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Chapter 7: Indications for Peripheral Nerve Blocks

INTRODUCTION

Peripheral nerve blocks (PNBs) are an important component in multimodal strategies for acute pain management. PNBs can be used as a sole anesthetic modality or as an adjunct to neuraxial or general anesthesia. The use of regional anesthesia confers many well documented clinical benefits. The wide availability of point-of-care ultrasound in clinical practice and the ubiquitous use of rapid recovery protocols increased the indications and utility of PNBs. A number of new regional anesthesia techniques have been introduced to facilitate early mobilization after surgery. The newer techniques tend to target specific distal sensory branches to decrease motor blockade. As an example, several truncal fascial plane blocks have been proposed as an alternative to epidural analgesia to avoid unwanted effects after thoracic and abdominal procedures (e.g., postural hypotension, motor weakness).

The proper choice of nerve blocks for specific procedures is essential for success. This chapter aims to provide guidance in decision-making for common clinical indications. Contraindications to PNBs are discussed in Table 7-1. Perioperative management protocols for patients having orthopedic surgical procedures are listed as an example for clinical context.

TABLE 7-1Contraindications to Peripheral Nerve Blocks
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TABLE 7-1 Contraindications to Peripheral Nerve Blocks
ABSOLUTE RELATIVE
Patient refusal Uncooperative or agitated patient
Documented allergy to multiple local anesthetics Vague history of allergy to local anesthetic (typically dental procedure)
Nerve/plexus trauma or evolving neuropathy History of neurologic deficits along the block distribution
Coagulopathy with deep blocks, especially blocks close to the neuraxis Coagulopathy or use of anticoagulants for peripheral perivascular blocks
Infection at the site of injection  

UPPER EXTREMITY BLOCKS

Regional anesthesia can be used as the main anesthesia and analgesia modality for many surgical procedures on the upper extremity because the brachial plexus innervates the entire upper extremity. The level (proximal-distal) at which the brachial plexus is blocked can be tailored to the specific surgeries from the cervical roots to the distal peripheral nerves. Table 7-2 lists common nerve block procedures and their indications.

TABLE 7-2Common Upper Extremity Blocks and Their Indications
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TABLE 7-2 Common Upper Extremity Blocks and Their Indications
PERIPHERAL NERVE BLOCK INDICATIONS ADVANTAGES DISADVANTAGES
Interscalene brachial plexus block

  • Shoulder surgery

  • Frozen shoulder mobilization

  • Upper arm and humerus surgery

  • Distal spread toward the supraclavicular nerves

  • May spare the lower trunk and partially preserve the mobility of the hand

  • Hemidiaphragmatic paralysis due to spread toward the phrenic nerve

  • Complex plexus architecture carries a higher risk of transient neuropathies compared to more distal blocks

  • Spares the lower trunk, therefore not recommended for surgery at the elbow and below

  • Side effects: Horner syndrome, recurrent laryngeal nerve block
Supraclavicular brachial plexus block

  • Shoulder surgery (if the upper trunk is blocked)

  • Surgery of the arm, forearm, and hand

  • Anesthesia of the whole arm including the shoulder with ...

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