Upper Body

Surgical Indications: Distal clavicle, shoulder, proximal humerus

Target Nerves: C5, C6, C7 spinal nerve roots

Complications: Horner’s syndrome, hemidiaphragm, pneumothorax, hoarseness (RLN blockade)

Procedure Steps:

• Place probe on supraclavicular fossa; identify subclavian artery and brachial plexus
• Scan superiorly to find nerve roots in “stoplight” pattern at cricoid level
• Advance needle from posterior to anterior in-plane
• Motor response to stimulation: deltoid, pectoralis, biceps, triceps, forearm, hand

Equipment:

• High-frequency linear ultrasound probe
• Short to medium-length, insulated, short-bevel needle
• Local anesthetic volume: 5–15 mL

Surgical Indications: Lateral shoulder, upper arm, elbow, forearm, hand

Target Nerves: Upper, middle, and lower trunks of the brachial plexus

Complications: Horner’s syndrome, hemidiaphragm, pneumothorax

Procedure Steps:

• Place probe on supraclavicular fossa; identify subclavian artery, first rib, and pleura
• Identify brachial plexus lateral to artery
• Advance needle posterior to anterior in-plane
• Inject near lower trunks (deep), then withdraw and redirect to inject middle and upper trunks (superficial)
• Motor response to stimulation: biceps, triceps, forearm, hand

Equipment:

• High-frequency linear ultrasound probe
• Short to medium-length, insulated, short-bevel needle
• Local anesthetic volume: 10–20 mL

Surgical Indications: Elbow, forearm, wrist, hand

Target Nerves: Radial (RN), ulnar (UN), median (MN), musculocutaneous (MC)

Complication: Intravascular injection

Procedure Steps:

• Place probe on axillary crease and identify the axillary artery
• Identify surrounding nerve branches, including musculocutaneous nerve (MC) in lateral muscle
• Advance needle from cephalad to caudad in-plane
• Inject deep to the artery (targeting RN), then superficial (MN, UN)
• Withdraw slightly to inject around MC
• Motor response to stimulation: biceps, forearm, hand, fingers

Equipment:

• High-frequency linear ultrasound probe
• Short to medium-length, insulated, short-bevel needle
• Local anesthetic volume: 20–30 mL