Die supraklavikuläre Plexus brachialis-Blockade | Anatomie und Indikation

Moin! This is the fifth episode of the Plexus Brachialis. It's about the supra-clavicular level. Where is the difference to the inter-scalinary position? What is achieved against the infraclavicular blockade? And why does the blockade match at all? If you're interested, you're right here. You can hear Radio Megahertz, the podcast with blockbites over ultrashall in the Anesthesi. Nice that you're here. My name is Tim Mecken. My guest is Rainer Litz. Together we are Ustra Medical Education. For the understanding of this episode, the previous episodes are of no significant significance. If you need anything, you should listen to this first. I'd say we're going straight into it. Without a doubt how it was his journey and what's going through his head right now, right? Yes. The last time it was about the Truncus Superior. I've looked at the shoulder more effectively when I was licking heavy ultrashall devices. Daniel's question could be answered. And now something has happened to my upper arm. It's really broken. I've got a proximal humerus fracture. I'd like to expand this a bit. This is a clinical example. Does the supra-clavicular blockade feature, Rainer? Yes, it does. And we're back at the basis of the planning of the operation procedure. We have to figure out at the beginning what exactly is being operated and how does it look like. And here we do our standard again, that we consider ourselves in the foreground, what is the cut of the skin, that is, the dermatome, what are the underlying structures, muscles, bones and so on. What do we have to do to get a complete analysis? We know that the arm is supplied by Plexus brachialis with two overlaps. On the internal medial side we have an overlap of thoracic segment. The vertebrae is the nerve in the costum brachialis. And on the shoulder or on the head of the humerus, the nerve supra-clavicularis can be supplied from the Plexus cervicalis. The rest is Plexus brachialis. We need this, however, when we want to operate on the upper arm, as much as possible. In short, as a request, dear listeners, at least listen to episode 4 of the interscalinary blockade or episode 1 of the principle construction, anatomy and course of the Plexus brachialis. In the last episode we said that the Rami ventralis from C5 and C6 form the droncosuperior and supply all relevant structures of the nerve, which are, for example, necessary for a rotator cuff. Infraspinatus, supraspinatus, teresmino and subscapularis, including the capsule. The difference is now that the bone structures, i.e. from the capsule rotator cuff, clavicular or acromion, are expanded by an effective proximal humerus fracture or, I could also say, the installation of a shoulder tap. With this consideration, the bone supply of the humerus must now also be included, the musculature on the upper arm, on the proximal upper arm and, of course, the skin. Raina, you already mentioned it with the dermatome, myotome, sclerotome. Let's dive into it a little deeper. Well, in contrast to the classic shoulder surgery, of course, it has to be done according to the supply area on the upper arm of the nerve radialis. It did not play a role for the shoulder surgery for the first time. Furthermore, we need the Axilaris nerve for its components on the humerus. And now the question arises, where are these structures in which it is reliable to dive. In the scale, we had already described that the expansion to caudal, i.e. towards C7, C8, TH1, is uncertain. However, we look at the origin of the nerve radialis. Then it has parts from C5 to TH1. If we want to dive this nerve reliably, we have to dive in one place, where the Rami anterior is the spinal nerve of C5 to TH1. And that is at the height of the formation of the primar stem, i.e. the trunzi. And that is the supra-clavicular position. There are five and C6, the truncus superior, C7, the truncus medius, C8 and TH1, the truncus inferior, before dividing these primar stem into anterior and posterior divisions and then form the three fasciae in the height of the clavicular. So this is the perfect position to play a role in all parts of the Blexus brachialis, which plays a role in the supply of the arm with a function. Again, the analogy to previous episodes. The truncus superior blockade is more tactical than C5 and C6 to block further cranial. Theoretically, I could block all Rami ventralis from C5 to TH1, which are required, because we said that the nerve radialis is needed, also at the height of the neurophoramina. However, anatomically, it makes no sense at all and is much more risky than, for example, to find the arterial vertebralis at the height of the seventh vertebrae. So that's the ponder for a blockade above the clavecula, to ensure the supra-clavicular level when all Rami ventralis of the Blexus brachialis are reached. Are there nerves, Rainer, that go away beforehand and that we can't achieve? That's a very good question. Of course, there are those who, embryologically speaking, go for the departure for the supply of the rheumatism musculature in the gallinera ab, or the nerves. For the supply of the secondary rheumatism musculature, they go into the gallinera ab. But these are all nerves that we don't need for the operation on the arm. For example, the navus thoracicus longus or the navus thoracodorsalis, they are all not necessary for this. They will be related to the rheumatism musculature during operations. So there is no reason at all, that these insecure punctions, both the complications, the side effects and also the security, the predisposition of the expansion of the local anesthetics is to be chosen in the gallinera. The supra-clavicular position is the position where all structures with the exception of the entries described, two parts, from the Blexus cervicalis and from the upper thoracal segments can be achieved. For a complete regional anesthesiological cover, the nervous axilaris is needed. We also get infraclavicular and supra-clavicular. But it is not possible to leave a dent on the infraclavicular position due to the burden of supra-clavicular position, because we need the nerve supra-scarpularis. We are talking, for example, about the painless implantation of a shoulder prosthesis. The nerve supra-scarpularis therefore takes a significant position, which is necessary for this operation. You can detect the nerve supra-scarpularis if you follow the formation of the truncus superior, further to supra-clavicular Gs. This is the first step, the nerve that is placed laterally in its target area. And the beautiful thing is that there is a hearing question that I will briefly answer. Hello Tim, hello Radio Megahertz. Listen, one question for you. Maybe you can answer the short and tricky one. We are currently looking at the division of the Blexus cervicalis. I would like to leave the supra-scarpularis, which actually goes away from the truncus superior earlier. Now my question is, how can I be sure that it is still in there or do I just have to drive the whole way up again to be sure that it is still in there? Maybe you can answer the question quickly and briefly or if there is a leading structure that I can use. Thank you very much. The question is interesting and really good how the nerve supra-scarpularis can be reliably achieved. There is indeed a leading structure. This is the musculosomal hyoidius, which covers the Blexus in supra-clavicular position and the nerve descent usually takes place in a high state where the muscle exactly overlaps the Blexus. Otherwise, the reliable path is really coming from the truncus superior to follow the nerve to the lateral. The path is not far. If the protrusion is already in the height of the division, it usually takes a few degrees to detect the nerve. But as a leading structure, I would recommend the musculosomal hyoidius. Which techniques are available to block us on supra-clavicular level? There is of course, as always, the out-of-plane technique and there is also the in-plane technique. Both techniques have their leading. I advance as always, that we take the CTUS and after the local conditions that we find, then the more promising techniques of both choices. There is no forcing reason to prefer one or the other. In both cases, both with an in-plane and an out-of-plane nerve lead, the CTUS is reliably predictable. We see the vulnerable punctured structures. Of course, they are in supra-clavicular position. Regularly promising vessels, both arteries as well as veins. As always, the representation of the pleura is recommended to be able to avoid any shortcomings here. And that is possible. With a secure representation, a pneumotorax is avoidable in this position. On the website, I will show a picture where arterial departures from the arterial supra-clavicular are recognized, which run through the plexus prarialis and as well as prominent veins from the venous supra-clavicular that run to the lateral. In both cases, you have to be able to move between these vessels safely. And there is an analog, like with any in-plane technique, the question or at least the knowledge, a role that you know in the thick layer. The nervous supra-scarpularis, the question goes back to the call of Severin again, can go off relatively early and can be overlooked with a cannula lead from lateral to medial. If these gorgeous images, lateral to arterial supra-clavicular, are focused and you do not use the technique of tracing and definitely determine the departure of the nervous supra-scarpularis from the venous ventralis C5 identified. Basically, the possibility is there for the function to store the arm sonographically, which in my approximate upper arm fracture would now do us good. If you pull the arm so that the shoulder comes down, you can make it so that the first rib is deep into the plexus prarialis and thus the bone r-back for an in-plane function with the cannula lead from lateral to medial could be. Rainer, again briefly about the cannula lead, if we talk about in-plane, it's probably the most common for you from lateral to medial. I know, but the principle could also go from medial to lateral. How do you see that? Yes, well, that's a technique that we have in the exception case corresponding to anatomical conditions back and forth again from medial to lateral. Of course, here, too, all vulnerable structures that can run here can be identified. That's clear. I have the out-of-plane technique in advance, which is a bit more difficult for the untapped angle of the shoulder, of course, it has the shortest function path. That's one thing, but it comes with me, of course, that I traditionally made the plomb-block out of the stimulation technique super-glavicular and that's why the function direction was simply reliable. To find out the supra-glavicular position, there is a little trick. Maybe you already read the presentation of the Venabrachiocephalica from the season 1, the block contribution or the podcast. If you have clearly presented the Venabrachiocephalica, the head of the glavicular is connected, and everything you have to do at the moment is to guide the probe to the lateral, and you automatically get into the supra-glavicular position. If it is presented in a round shape, then that corresponds to the corresponding position and through slight hip movement, the change of the probe impression optimizes your representation. Rainer, let's talk briefly about the position of the device, because it is different from my point of view for in-plane and out-of-plane. Well, the basic principle of an intervention is the direction of view and guide in an axis. Compare it to a biathlete, who also looks in the direction in which his target is focused and has also set up his rifle, and that is no different with the guide. For example, it is not aimed to look to the left and to point to the right, which we always see in the OP, but to set everything strictly in an axis, because it is much easier here to keep the exact guide. That means I choose a function direction from lateral to medial, I would position the ultrasonic device on the contralateral side, I point out-of-plane, then it is on the y-lateral side in torax height. With this, I can select a vertical view axis direction. You have to note that if you point from lateral, that is close to a function direction from posterior. There are clinics where the patients are stored on the side for this technique. For me it is so cumbersome, I take a head case or a ring and put the head on the edge, and I manage the space with it. I don't need a longer barrel than 50 mm. Now, set the case, I want to block the tronco superior, but it is not possible for me in the classic inter-scalinary position. For what reasons always, Reiner, can I also direct this to supra-clavicular levels? Yes, of course, you can distinguish the three troncs from each other. Here it is exactly the same as in other positions as well. There are no narrow gaps between these troncs, there are binding wavelengths, there are variations, also depending on the habit of fat wavelengths. You can simply set the tronco superior here, you can differentiate from the other two troncs. However, the selective blockade, as above the clavicular, as above the classical function, cannot be obtained, you will not be able to prevent the local anesthetic from reaching the other troncs. Of course, this also plays a role in the clinical blockade. If all three troncs are too reliable, of course you have to calculate a complete blockade in this position. So, together with the disadvantages, supra-clavicular can very well block the tronco superior, not to prevent the other parts from being blocked, but supra-clavicular has the opportunity to reach all nerve parts, i.e. for example from the nervous radialis, parts from C5 to Th1. Away from the plexus brachialis to the nerve supra-clavicularis, purely analog to the interscalinal region, we would have to be able to cover the skin of the shoulder roof sensitively for some operations. We are close to the clavicular here. That is, the nerve supra-clavicularis have usually broken through the fascia pre-vertebralis and are subcutaneous. Here, the cannula is enough to pull back the fascia pre-vertebralis. And I call it a small volume block without a single representation of the nerves. I think that at 2-3 milliliters, which can be placed above the fascia, the nerves can reach the shoulder area reliably. We have already discussed the restriction with the interscalinal blockade, that high-definition medial components are not reached to the standard clavicular joint. To do this, the blockade has to be carried out higher, at this point, where the nerves break through the fascia pre-vertebralis. But that is not necessary for operations. Thus, the supra-clavicular region is a real key position, because it offers many options. And I am happy that Axel has sent me a hearing question, which I will play now. Hello, here is Axel from the Klinghausen. I am on my way to the orthopedic clinic, and I recently got the patients with supra-clavicular plexus for lumbar prosthesis. And you still do the mis-innovation of the arm to make sure that I did not get everything. And my question is, what is better, to put supra-clavicular plexus or infraclavicular for lumbar prosthesis? That would interest me. I look forward to the next podcast. Thank you very much. Reiner, would you like to answer that? Yes, I can do that. Basically, the transition from supra-clavicular to infraclavicular is smooth. Tim has already described the main difference between the two blockades, that supra-clavicular, the nerve supra scapularis, is achieved. Otherwise, the distribution areas or supply areas are very comparable to supra-clavicular. What both blocks have as weaknesses, which can only be solved by the axillary blockade, is the blockade of the nerve in the scapularis, which can supply a variable area on the inside of the upper arm. Otherwise, the supra-clavicular blockade should be equal just for a lumbar fracture or prosthesis. Since I do not know exactly, I cannot answer the question, where the gaps were intra-operative, there is also the possibility that the blockade of the flexus in supra-clavicular was not complete. We had already noticed that there is a fat tissue between the truncate and it stays the same until it goes down to the fascicle. The truncate has its own gaps. In order to achieve a reliable effect, both infra- and supra-clavicular, it is necessary that we always reach all three core structures, i.e. the truncate or the fascicle, which stays the same. If the local anesthetic is not distributed to one of the corresponding fascicles, then I have to assume that the blockade can be incomplete. And possibly that was the case, but I cannot take that from the data. So here again, please make sure that the local anesthetic is spread between all three truncates and that all these structures are reached. That means that a needle repositionation is necessary in all cases, so that the local anesthetic does not flow off the lateral injection. Axel, I hope your question is answered. If not, just write to us again. Rainer, if I now look at how much we have already talked about the Plexus brachialis, from my point of view, we can keep up with this episode very briefly. And I would directly address the summary of the typical features, the anatomical features and features of the supra-clavicular position, before the ultimate summary comes, you probably already know what it is. Rainer, do we just want to make the summary as usual here? Supra-clavicular plexus brachialis blockade. Typical OP indications and OP areas are operations on shoulder and arm, so everything that is supplied by the RAMI Ventralis C5 and TH1. Yes, and that can go down to the hand. Right. The Drunkosuperior can be completely blocked. Yes, that is a very good way for, I would say, smaller shoulder operations or shoulder repositions, because nothing else is involved than necessarily involved. The blockade can be expanded by blocking all the drunks. Of course, this is best done in a supra-clavicular position, where the drunks are arranged neatly next to each other on the lateral artery. In addition, I have access to the nerve supra-clavicularis, which lie above the fascia-prevente brales. Yes, they are individually imaginable, as you would like to do in clinical practice. Usually enough, the injection of 2-3 milliliters above the fascia-prevente brales may be helpful in many cases, the vena-jugularis externa. The nerve supra-scarpularis is achieved. Yes, this is the first step to the lateral, from the Drunkosuperior, and it is of course reachable in this position. In the supra-clavicular position there is, principally, the possibility to cause a Pneumotorax. Yes, but only with non-visible cannules and if the pleura is not presented. The Pneumotorax is definitely comparable to corrective technology. A nerve supra-scarpularis is, in contrast to the intascalinary position, more unlikely. That is correct, it is more unlikely, but not excluded. The nerve supra-scarpularis lies at the point of time on its way to the mediastinum, already significantly further media. However, it has a anatomic close to the arterial subclavicularis, like the plexus as well, that is, with certain volume and high injection pressure from the lateral to the medial, the nerve can of course be reached. And that is why it remains, no more volume induces than necessary and, above all, slowly induces. In contrast to other positions of the plexus brachialis blockade, the risk of atrial infarction, at least from anatomical point of view, is higher. Good, that can be discussed controversially. Of course, the plexus here lies lateral to the arterial subclavicularis, which, of course, can be injured by incorrect technology. On the other hand, the visible function of the arterial brachialis is in the intascalinary position, and one must not be alarmed. The arterials appear to be relatively large in the ultrasonic field of view. You can see that the arterial brachialis is often the diameter of one to two millimeters, which does not usually lead to a malfunction in careful cannules, because the needle is softened at the arterial brachialis. It is strictly advised that the needle should not be pushed back in the same way as in the past, but with a feeling, i.e. with the fingertips and not with the upper arm or elbow. Finally, the nervous intercostal brachialis is not reached. There is nothing to add. There is a completely different course and it is not reachable in these two positions, also not with high volume. It is only reachable over the axial access path, or over the blockades on the thorax wall. But the operation on the arm is not necessary at all. The axillary blockade is completely enough. Rainer, and now we come to a question. Have you memorized it in episode one of the second season? Can you still remember it and can you introduce it again, please? That was probably the question. Which two blocks would we take on a single island if we were only allowed to take two? And the answer is, if we take the anatomy of the brachialis from the stem to the finger group, this question is clearly to be answered. Which two techniques are the anesthesis or the anesthesis needed? I did an education here. The KI helped me to draw a single island. There is a guy with an usra shield and a guy with a radio mega-head shield. Rainer, you can choose one now, I'll tell the others. Yes, after all, I hold the axillary blockade of the plexus brachialis for most operations on the arm for the king's block. Because you also have access to the intercostal brachialis? That's the point. For the second blockade, which I take to the island, we would add the supra-clavicular blockade. Because I would get the nerve supra scapularis and the nerve supra-clavicularis, which you would not get against. That's how it is. And the further blockade possibility, that is, the interscalinary blockade, we could not take it from space on the island. We would have needed it if we wanted to attack the Torax wall. Right, but we don't take it through the island. That's right. Rainer, I would like to thank you very much for five episodes of plexus brachialis. And because that's something special for me, I made you a little present. And I have to take it out for a moment. The last time I was in Augsburg, you gave me a drink. There was Augsburg on it. I'm going to get revenge now. You get the same drink guy. However, he doesn't mean Augsburg, but Louvre and Lé. I would like to name him as "Bagboard" and "Steuerboard" as a phrase. Let it taste you and maybe there will be a report as it was. Again, thank you very much for being there. I think that's great, Rainer. Yes, I'd love to. So, dear Radio Mega-Härzlerin, dear Radio Mega-Härzler, that was the fifth and first last episode of plexus brachialis. Go to radiumegaherz.de. You have five full blog entries with many contents. Subscribe to our newsletter to get regular sonographic texts. And I look forward to seeing you if you stay loyal to us. And I'm looking forward to the next episode. Ciao!