r e v c o l o m b a n e s t e s i o l .

2 0 1 6;4 4(1):30–35

Revista Colombiana de Anestesiología

Colombian Journal of Anesthesiology

www.revcolanest.com.co

Review

Ultrasound and nerve stimulation-guided axillary

block夽

Luz María Lopera-Velásquez a,∗ , Carlos Restrepo-Garcés b,c

a Department of Anaesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
b Pain Relief Clinic, Surgery and Imaging Department, Hospital Pablo Tobón Uribe, Medellín, Colombia
c Pain Relief Unit & Anaesthesia Department, Clínica Las Américas, Medellín, Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The axillary block of the brachial plexus is widely used as an anaesthesia and
Received 17 July 2014 analgesia technique in upper limb surgery, specifically for hand, wrist and forearm pro-
Accepted 26 October 2015 cedures. The use of nerve stimulation and ultrasound guidance has increased the rate of
Available online 18 December 2015 success with this block.
Objective: This article presents a non-systematic review of the most recent literature on
Keywords: axillary block of the brachial plexus using ultrasound and peripheral nerve stimulation.
Ultrasonography Materials and methods: A search for a non-systematic review was conducted in the Cochrane,
Ultrasonics Pubmed/Medline, Embase and OVID databases.
Anesthesia, Conduction Conclusion: The axillary block of the brachial plexus is an anaesthetic and analgesic tech-
Nerve block, Analgesia nique for upper limb surgery that has a high percentage of success, with a low degree of
difficulty for the procedure.
© 2015 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier
España, S.L.U. All rights reserved.

Bloqueo axilar guiado por ultrasonido y neuroestimulador

r e s u m e n

Palabras clave: Introducción: El bloqueo axilar del plexo braquial es un bloqueo anestésico ampliamente
Ultrasonografía utilizado como técnica anestésica y analgésica en cirugía de miembro superior, específi-
Ultrasonido camente para mano, muñeca y antebrazo. El uso de neuroestimulador y ultrasonido ha
Anestesia de conducción aumentado la tasa de éxito de éste bloqueo.
Bloqueo nervioso Objetivo: El presente artículo hace una revisión no sistemática de la literatura más reciente
Analgesia relacionada con el bloqueo axilar del plexo braquial utilizando ultrasonido y estimulación
de nervio periférico.

夽
Please cite this article as: Lopera-Velásquez LM, Restrepo-Garcés C. Bloqueo axilar guiado por ultrasonido y neuroestimulador. Rev
Colomb Anestesiol. 2016;44:30–35.
∗
Corresponding author at: Department of Anaesthesia and Perioperative Medicine, University of Western Ontario, 339 Windermere Road,
London, Ontario, Canada.
E-mail address: lulopera@hotmail.com (L.M. Lopera-Velásquez).
2256-2087/© 2015 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier España, S.L.U. All rights reserved.
 r e v c o l o m b a n e s t e s i o l . 2 0 1 6;4 4(1):30–35 31

Métodos y Materiales: Se hizo una búsqueda en las bases de datos de Cochrane,

Pubmed/Medline, Embase y OVID para la realización de una revisión no sistemática.
Conclusión: El bloqueo del plexo braquial a nivel axilar es una técnica anestésica y analgésica
para cirugía de miembro superior con alto porcentaje de éxito y bajo grado de dificultad en
cuanto a realización del procedimiento.
© 2015 Sociedad Colombiana de Anestesiología y Reanimación. Publicado por Elsevier
España, S.L.U. Todos los derechos reservados.

of the smaller volume of local anaesthetic required to achieve

Introduction blockade,11–13 although there are reports in which the use of
ultrasound does not reduce the occurrence of complications
The axillary block is a regional anaesthesia technique, involv-
when compared to the nerve stimulator.14 Complications
ing blockade of the brachial plexus at the axillary level. It
associated with the axillary block include toxicity from the
is widely used as an anaesthetic and analgesic technique in
local anaesthetics15 and neurological and vascular injury,16,17
upper limb surgery, specifically for hand, wrist and forearm
although there is a paucity of reports in the literature on these
procedures. In the axillary block, the terminal branches of the
occurrences, supporting the theory that this block provides
brachial plexus are blocked. The use of nerve stimulation and
a high safety margin. Obesity increases the risk of vascular
ultrasound has increased the rate of success with this block1
puncture and failure rates with this type of block.18
and has reduced the incidence of complications. Unlike the
inter-scalene and supra and infraclavicular blocks, the risk of
Anatomy
injury to the stellate ganglion, pneumothorax or phrenic nerve
palsy is practically non-existent with this block because of the
The brachial plexus arises from the ventral branches of C5
site where the puncture is performed.2,3
to C8. At the level of the scalene muscles, these branches
regroup to form the superior, middle and inferior trunks, and
Methods when they leave the inter-scalene space, they form anterior
and posterior divisions at the supraclavicular level. The divi-
A search was conducted in the Cochrane, Medline/Pubmed, sions regroup again at an infraclavicular level to form the three
OVID and EMBASE databases using the words axillary block, lateral, posterior and medial cords which finally give rise to
ultrasound, nerve stimulator, regional anaesthesia. Included the five terminal branches at the axillary level: radial, axillary,
in the search were meta-analyses, systematic reviews, clini- musculocutaneous, median and ulnar nerves (Fig. 1).19
cal trials and non-systematic reviews, and articles in English, The radial nerve arises from the posterior cord. It runs
Spanish and French. together with the radial artery along its posterior aspect and
breaks away from the neurovascular bundle at the axillary
level in order to continue along the spiral humeral groove. It
Results provides sensation to the posterior and lateral aspects of the
arm and forearm down to the wrist, the lateral aspect of the
History dorsum down to the hand, the dorsal surface of the first three
digits and half of the fourth digit. It provides motor innervation
The first percutaneous axillary block was described by Hirschel
in 1911.4 In 1958, Burnham described how the axillary neu-
rovascular bundle was enveloped by a fascia that could be
“filled” with local anaesthetic.5 In 1961, De Jong referred to the
axillary space as a pyramid of 42 ml in volume, and described
that the nerves and blood vessels were surrounded individu-
ally by septae.6 In 1979, Eriksson and Skarby used a tourniquet
distal to the axillary injection site and, in 1984, Thompson and
Rorie identified the brachial plexus septae in the axillary space
as preventing the homogenous spread of the anaesthetic.7
Musculocutaneous nerve

More recently, cadaver studies using nuclear magnetic reso-

Median nerve
nance have concluded that the terminal branches are lined by Radial nerve Axillary artery
Ulnar nerve
connective tissue and fascial sheaths that prevent the anaes-
thetic from flowing homogenously after a single injection
and covering the entire plexus.8,9 The nerve stimulator was
introduced in the 1990s, and ultrasound has been introduced
in recent years10 ; their use has increased the rate of success Fig. 1 – Illustration of the terminal branches of the brachial
with the axillary block. The use of nerve stimulation and ultra- plexus at the axillary level.
sound has also reduced the number of complications because Source: Authors.
32 r e v c o l o m b a n e s t e s i o l . 2 0 1 6;4 4(1):30–35

Axillary nerve Supraclavicular

nerves
Radial nerve Axillary
Musculocutaneous nerve
Supraclavicular nerves
nerve
Radial nerve
Radial nerve
Musculocutaneous
Median nerve
nerve
Median
nerve
Intercostobrachial
nerve Intercostobrachial
Medial cutaneous nerve
nerve of the forearm Ulnar nerve
Medial cutaneous
nerve of the forearm
Ulnar
nerve
Fig. 2 – Dermatomes of the anterior aspect of the upper
limb.
Source: Authors. Fig. 3 – Dermatomes of the posterior aspect of the upper
limb.
Source: Authors.

to the triceps and brachioradialis muscles and to the extensors

of the posterior compartment of the forearm.
significant difference has been found with the two techniques;
The axillary nerve arises from the posterior cord at the level
ultrasound has allowed the use of a smaller local anaesthetic
of the coracoid process, forming an angle towards the deltoid
volume, although this affects the duration of the effect. One
muscle, which it innervates (Fig. 2).
of the advantages of ultrasound is the ability to visualize the
The median nerve traverses most of the time superior to
nerves – making blockade easier in patients with anatomic
the axillary artery, while the ulnar and axillary nerves are
variants23 – and the spread of the local anaesthetic as it is
found inferior to the axillary artery. The median nerve does
injected.24 Complications associated with the axillary block
not have cutaneous or motor branches in the arm, but in the
appear to be less when ultrasound is used.25
forearm it provides motor innervation to the anterior compart-
The patient is positioned in supine decubitus, with the arm
ment, except for the flexor carpi ulnaris and half of the flexor
in 90◦ of abduction and the forearm in flexion (Fig. 4). Asepsis
digitorum profundus. In the hand, it innervates the thenar
must be performed up to the distal portion of the arm. A high
eminence and the first two lumbrical muscles. It provides sen-
frequency linear probe is placed on the transverse axis, over
sation to the lateral half of the hand and the dorsum of the first
the axillary fold. The neurovascular bundle is localized 1–2 cm
three digits, and half of the fourth finger down to the nail bed.
underneath the skin.
The ulnar nerve arises from the medial cord and it does
The axillary artery must be localized first. It provides a
not provide branches to the arm. It provides motor innerva-
spherical, pulsatile hypoechoic image and it is not readily
tion to the flexor carpi ulnaris and the medial half of the flexor
compressible. It is found over the conjoined tendon, formed
digitorum profundus. In the hand, it innervates all the small
by the junction of the latissimus dorsi and teres major ten-
muscles except for the thenar eminence and the first two lum-
dons. It is important to identify the axillary vein, because it
bricals. It provides sensitive innervation to the middle third of
also provides a spherical and hypoechoic image, although it is
the palm, the dorsum of the fifth finger, and the medial aspect
not pulsating and is readily compressible. The median, ulnar
of the fourth finger.
and radial nerves are arranged around the artery. They appear
The musculocutaneous nerve arises from the lateral cord,
as spherical or oval-shaped, hyperechogenic, hypoechogenic
perforates the coracobrachialis muscle and leaves the neu-
or beehive-like structures. Their position around the artery
rovascular sheath usually at the level of the lateral edge of
the pectoralis major. It may be found outside the coraco-
brachialis muscle and joining the median nerve in 1 out of
5 individuals.20 It provides motor innervation to the cora-
cobrachialis, biceps and brachialis muscles. At the elbow, it
becomes a purely sensory nerve, innervating the anterior
portion of the forearm down to the wrist (Fig. 3).

Technique

The axillary block is used in hand, wrist and forearm surgery.

It is not as effective as other brachial plexus blocks in elbow
surgery.21
The axillary block may be performed using a nerve stimu-
lator, ultrasound or a combination of the two. With the use Fig. 4 – Axillary block of the brachial plexus at the level of
of the nerve stimulator, the failure rate is 5–30%, while the the axilla using a linear transducer and a nerve stimulation
two techniques combined increase the success rate by up to needle.
97%.22 As for the time required for performing the block, no Source: Authors.
 r e v c o l o m b a n e s t e s i o l . 2 0 1 6;4 4(1):30–35 33

delivered under the axillary artery. In the dual injection, part

of the dose is delivered under the artery and the other part
Biceps
is delivered around the musculocutaneous nerve.31 The most
MN effective technique with less associated complications but the
UN
most time consuming is the multiple injections.22 The time
AA
MCN to onset of the axillary block varies depending on the injec-
RN tion technique. In the study conducted by Lopez-Morales et al.
Coracobrachialis
comparing the axillary block with the inflaclavicular block,
CT
time to onset was significantly longer for the axillary block,
Triceps at a mean of 10.2 min.32 Blockade rate for the axillary, inter-
costobrachial and medial cutaneous nerves of the arm is lower
through the axillary approach.33
The choice of the local anaesthetic depends on the dura-
tion of the block and the availability in the Anaesthesia service.
Fig. 5 – Ultrasound image of the brachial plexus at the Reducing the local anaesthetic concentration and increasing
axillary level. UN = ulnar nerve, RN = radial nerve, the volume prolongs the duration of the block.34,35 Levobupi-
MN = median nerve, MCN = musculocutaneous nerve, vacaine and ropivacaine have been used in concentrations
AA = axillary artery, CT = conjoined tendon. of 0.375–0.75% and 0.25–0.5%, respectively. Compared to lev-
Source: Authors.
obupivacaine, ropivacaine has a faster onset of action (9 min
vs. 12 min) but blockade duration is shorter (9.2 h vs. 11.3 h).36
The total volume used ranges between 30 and 40 ml when
is not constant. The position of the radial and the median delivered in a single injection, and between 5 and 8 ml when
nerves in relation to the artery is usually constant.26 The radial each nerve is anaesthetized individually. González et al. found
nerve is located between 4 and 6 o’clock in 83% of cases, the that the MAC-90 of 1.5% lidocaine with epinephrine 5mcg/ml
median nerve is found between 9 and 12 o’clock in 88% of is 5.5 ml and 23.5 ml in the dual injection technique.37 The
cases, and the ulnar nerve is between 12 and 3 o’clock in 85% minimum effective volume (MEV90) of 0.5% bupivacaine is
of cases.27 The musculocutaneous nerve is usually separated 1.56 ml per nerve.38 The use of other additives to prolong the
laterally from the artery, between the short head of the biceps block, like using dexamethasone with the local anaesthetic,
and the coracobrachialis muscle (Fig. 5). has shown to be an effective way to increase motor and sen-
Once the structures have been identified under ultrasound, sory blockade.39,40 The use of clonidine as adjunct to the local
the skin is infiltrated with local anaesthetic and then, using a anaesthetic has not been shown to increase block duration,41
50 mm 22G nerve stimulator needle on an in-plane approach, different from dexmedetomidine which does appear to pro-
the nerves are localized with the nerve stimulator (Table 1). long axillary block duration.42,43 Magnesium sulphate has also
There is no significant difference in terms of success using been used as additive in axillary blocks, but has not been
the echogenic or non-echogenic needle in this type of block.28 shown to improve block duration or efficacy.44 Other adjuncts
It is recommended to use a 0.5–1.0 mA current in order to such as ketamine and tramadol have also been used, and some
reduce the risk of dysfunction or nerve injury. Stimulation studies have shown evidence that they prolong the action of
with a current of 0.3–0.5 mA increases the success of the the axillary block.45 There is recent evidence about the effect
block and shortens the onset time, but increases the risk of of hyaluronidase in shortening the time to onset of the axillary
nerve injury.29 When muscle stimulation is obtained with block in upper limb surgery.46
a 0.2 mA current or less, an intraneural injection must be Continuous infusion of the local anaesthetic using
suspected to be likely.30 Once the corresponding muscle con- catheters is not well documented in the literature.47,48 The
traction is obtained, syringe aspiration is done in order to rule axillary region is prone to catheter displacement and does not
out intravascular injection, and then the local anaesthetic is allow adequate fixation. The continuous infusion technique
injected, always under ultrasound guidance in order to visu- for the local anaesthetic has been used, but it is the surgeon
alize the deposition of the anaesthetic around the nerve. who places the catheter under direct vision.49
Three ways of injecting the local anaesthetic at the axillary It is recommended to add the intercostobrachial nerve
level have been described: a single injection, dual injection, block to the axillary block in order to increase tolerance of
and multiple injections to deliver the full volume of the anaes- the tourniquet during the surgical procedure.50 This nerve is
thetic. When a single injection is used, the anaesthetic is the cutaneous branch of the second intercostal nerve and pro-
vides sensory innervation to the upper portion of the medial
and posterior aspects of the arm.
Table 1 – Motor responses with nerve stimulation of
each nerve.
Radial nerve Arm or wrist extension
Conclusion
Median nerve Forearm pronation, thumb flexion
Ulnar nerve Flexion of the fifth finger The brachial plexus block at the axillary level is an anaesthetic
Musculocutaneous nerve Arm flexion and analgesic technique used with a high degree of success in
upper limb surgery, creating little difficulty for the procedure.
Source: Authors.
The use of nerve stimulation and ultrasound has increased
34 r e v c o l o m b a n e s t e s i o l . 2 0 1 6;4 4(1):30–35

the rate of effectiveness of this block and reduced the rate of 18. Hanouz J-L, Grandin W, Lesage A, Oriot G, Bonnieux D, Gérard
complications. J-L. Multiple injection axillary brachial plexus block: influence
of obesity on failure rate and incidence of acute
complications. Anesth Analg. 2010;111:230–3.
19. Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M.
Funding
Brachial plexus anesthesia: a review of the relevant anatomy.
Complications, and anatomical variations. Clin Anat.
None. 2014;27:210–21.
20. Remerand F, Laulan J, Couvret C, Palud M, Baud A, Velut S,
et al. Is the musculocutaneous nerve really in the
Conflict of interest coracobrachialis muscle when performing an axillary block?
An ultrasound study. Anesth Analg. 2010;110:1729–34.
The authors declare having no conflicts of interest. 21. Wada T, Yamauchi M, Oki G, Sonoda T, Yamakage M,
Yamashita T. Efficacy of axillary nerve block in elbow
arthroscopic surgery: a randomized trial. J Shoulder Elb Surg.
2014;23:291–6.
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