First peripheral block was performed by William Halsted with cocaine in 1885

Over the past 30 years there has been an increasing trend in the use of peripheral nerve blocks for postoperative pain management

Adequate pain control via peripheral block:

1. 
   

   Decreases hospital length of stay

   
   
2. 
   

   Allows transition from traditional inpatient surgery to outpatient

   
   
3. 
   

   Decrease opioid use and associated opioid side effects

   
   
4. 
   

   Enhances participation in rehabilitation

   
   
5. 
   

   Improve functions and patient satisfaction outcomes

   
   
6. 
   

   Enhance cost-effectiveness.

Vital to understand the indications and potential complications associated with regional anesthesia.

Brachial plexus (▶ Fig. 22.1 ):

1. 
   

   Five roots: C5, C6, C7, C8, and T1

   
   
   
   
   1. 
      

      Level of intrascalene block.

   
   
2. 
   

   Three trunks: Upper, middle, and lower

   
   
   
   
   1. 
      

      Level of supraclavicular block.

   
   
3. 
   

   Six divisions: Anterior and posterior divisions of three trunks

   
   
4. 
   

   Three cords: Posterior, lateral, and medial

   
   
   
   
   1. 
      

      Level of intraclavicular block.

   
   
5. 
   

   Five branches: Median, axillary, radial, musculocutaneous, and ulnar nerves

   
   
   
   
   1. 
      

      Level of axillary block.

      

Shoulder sensory innervation:

1. 
   

   Superior region:

   
   
   
   
   1. 
      

      Superficial cervical plexus (C3–C4):

      
      
      
      
      • 
        

        i. Supraclavicular nerve.

   
   
2. 
   

   Axillary region:

   
   
   
   
   1. 
      

      T2 nerve root.

   
   
3. 
   

   Shoulder capsule, subacromial bursa, acromioclavicular joint, cutaneous tissue:

   
   
   
   
   1. 
      

      Suprascapular nerve—primarily C5, C6 with some C4.

Four anatomic regions pertinent to peripheral nerve blocks (▶ Fig. 22.2 ):

1. 
   

   Intrascalene:

   
   
   
   
   1. 
      

      Potential space between anterior and middle scalenes

      
      
   2. 
      

      Targets brachial plexus at root-trunk level

      
      
   3. 
      

      Most commonly preformed

      
      
   4. 
      

      Effective for shoulder, proximal humerus, and distal clavicle

      
      
   5. 
      

      Ulnar sparing:

      
      
      
      
      • 
        

        i. C8 frequently not covered

        
        
      • 
        

        ii. Additional block required for surgery around the elbow.

        

   
   
2. 
   

   Supraclavicular:

   
   
   
   
   1. 
      

      Superior to clavicle at the level of plexus trunks

      
      
   2. 
      

      Between anterior and middle scalenes at the first rib

      
      
   3. 
      

      Apical lung vulnerable

      
      
   4. 
      

      Suitable for shoulder; theoretically does not cover superior aspect of shoulder, arm, and elbow: forearm hand adequately covered.

   
   
3. 
   

   Infraclavicular:

   
   
   
   
   1. 
      

      Boarders consist of:

      
      
      
      
      • 
        

        i. Superior—posterior aspect of clavicle

        
        
      • 
        

        ii. Inferior—soft tissues of axilla

        
        
      • 
        

        iii. Anterior—pectoralis minor

        
        
      • 
        

        iv. Posterior subscapularis.

      
      
   2. 
      

      Level of the cords before axillary and musculocutaneous nerves exit

      
      
   3. 
      

      Shoulder not covered; arm, elbow, and forearm hand adequately covered.

   
   
4. 
   

   Axillary and suprascapular:

   
   
   
   
   1. 
      

      In combination similar shoulder coverage compared with intrascalene block

      
      
   2. 
      

      Axillary:

      
      
      
      
      • 
        

        i. Located beneath glenohumeral joint between the chest wall and medial upper arm

        
        
      • 
        

        ii. In isolation may be adequate for elbow surgery.

      
      
   3. 
      

      Suprascapular:

      
      
      
      
      • 
        

        i. Level of the suprascapular notch.