Chapter 28

Brachial plexus block at the level of the axilla is typically chosen for anesthesia of the distal upper limb. Axillary block is a basic regional anesthesia technique and perhaps the most common approach to brachial plexus blockade. Low risk of serious complications, superficial location, and good analgesia of the upper arm muscles make this block suitable for ambulatory procedures of longer duration that require a tourniquet.

The surgical technique of this block was first described by Hall1 in New York (Roosevelt Hospital) in 1884, and the percutaneous technique was described by Hirschel2 in 1911. While dissecting the axilla in a child in 1958, Burnham,3 recognized that filling the neurovascular sheath with local anesthetic could simplify the axillary block. He also described the characteristic fascial “click” felt on penetration by the needle. In 1961 while using the formula for a cylinder volume, De Jong4 calculated that in an average adult, 42 mL of local anesthetic (LA) was necessary to fill the fascial compartment to the level of the cords and block all terminal nerves to the arm. A year later, Eriksson and Skarby,5 in an effort to promote the proximal spread of LA, advocated wrapping a rubber tourniquet around the arm, distal to the needle. In 1979, Winnie and coworkers6 found the tourniquet ineffective and painful and recommended firm distal digital pressure on the neurovascular sheath instead. In addition, they also recommended arm adduction after LA injection, thinking that the head of the abducted humerus compressed the neurovascular sheath. Both maneuvers were later proved to be clinically ineffective.7–9 Thompson and Rorie,10 in 1983, studied brachial plexus using computed tomograms and suggested that the median, ulnar, and radial nerves lie in separate fascial compartments within the neurovascular sheath; this finding provided a rational explanation for incomplete blocks. However, anatomic studies by Lassale and Ang11 in 1984 and Vester-Andersen and coworkers12 in 1986 did not confirm the existence of a true neurovascular sheath. The interfascial space they found contained the median and the ulnar nerves, infrequently the musculocutaneous, and occasionally the radial nerves. Moreover, the space was suggested to communicate proximally only with the medial cord of the plexus. In 1987 Partridge and coworkers13 described the interneural septa, which were easily broken by injection of dyed latex. In 2002 Klaastad and coworkers14 were the first to investigate the spread of the LA through the axillary catheter in studies using magnetic resonance imaging (MRI) scanning. They found that in most patients the spread of LA was uneven and the clinical effect inadequate.

Until the 1960s, the prevalent block techniques were double or multiple axillary injections. After the concept of the neurovascular sheath had been established by De Jong4 in 1961, the single-injection technique, being the simplest, became standard. However, Vester-Andersen and coworkers15,16 demonstrated in 1983 and 1984, that despite high volumes of LA, analgesia was often inconsistent (“patchy”). In ...

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