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C OPYRIGHT 2013
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Exhibit Selection
Upper-Extremity Peripheral Nerve Blocks

in the Perioperative Pain Management
of Orthopaedic Patients
AAOS Exhibit Selection
Umasuthan Srikumaran, MD, Benjamin E. Stein, MD, Eric W. Tan, MD, Michael T. Freehill, MD, and John H. Wilckens, MD
Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
Background: Over the past twenty-five years, peripheral nerve blocks have become increasingly common for the management of perioperative pain of the upper extremity. Several factors have led to increasing acceptance and use of these
peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on
decreasing the duration of hospital stays and associated costs.
Methods: We present a review of peripheral nerve blocks for procedures involving the upper extremity, including indications, contraindications, anatomy and technique, expected clinical outcomes and the associated levels of evidence,
cost-effectiveness, and complications. We reviewed the scientific literature for studies on the effectiveness of peripheral nerve
blocks for orthopaedic procedures involving the upper extremity. Particular attention was directed at the most commonly used
nerve blocks, the levels of evidence supporting their use, and emerging technologies such as ultrasonographic guidance.
Results: Peripheral nerve blocks for upper-extremity procedures improve postoperative pain control and patient satisfaction, can be administered safely, and have a low complication rate. They are also associated with enhanced participation in postoperative rehabilitation, decreased hospital stays, and decreased costs. There are increasingly higher levels
of evidence in the literature to support the use of peripheral nerve blocks in a wide variety of orthopaedic procedures
ranging from the shoulder to the hand.
Conclusions: The use of peripheral nerve blocks in upper-extremity surgery is common. To actively participate with the
patient and anesthesiologist to ensure the best possible outcomes, the orthopaedic surgeon must be well informed
regarding the benefits and limitations of this modality.
ver the past twenty-five years, peripheral nerve blocks

of the upper extremity have become increasingly
common for the management of perioperative pain.
Several factors have led to the increasing acceptance and use of

these peripheral nerve blocks, including a greater awareness
and measurement of patient pain and a greater emphasis on
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.
The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2013;95:e197(1-13)
http://dx.doi.org/10.2106/JBJS.L.01745
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decreasing the duration of hospital stays and associated costs.

This increased focus on the evaluation and management of
pain is shown by the distinction of pain as the fifth vital sign by
the American Pain Society in 19951,2. In addition, The Veterans
Health Administration made this concept the central component of their pain management strategy in 1998-19993, and the
Joint Commission on Accreditation of Healthcare Organizations4 made appropriate pain assessment and management the
standard of care in 2000, mandating compliance with this
initiative by all health-care providers.
The prevalence and severity of postoperative pain after
orthopaedic procedures are higher than those after nonorthopaedic procedures5-8, making adequate pain control difficult. Traditional pain management includes general anesthesia
and narcotic medication for surgery, followed by oral and intravenous pain medications, including patient-controlled analgesia,
after surgery. The use of peripheral nerve blocks for upperextremity procedures has led to improved postoperative pain
control, decreased narcotic use, and decreased narcotic-associated
side effects such as nausea and vomiting9-20. Accordingly, the
duration of hospital stays has been reduced, and procedures
previously performed in an inpatient care setting are being
performed on an outpatient basis20. Peripheral nerve blocks
also allow enhanced participation in postoperative rehabilitation, improving overall patient satisfaction and functional
outcomes21,22. Conversely, the use of peripheral nerve blocks
U P P E R -E X T R E M I T Y P E R I P H E R A L N E R V E B L O C K S
I N P E R I O P E R AT I V E P A I N M A N A G E M E N T
introduces an additional set of potential complications and

concerns, such as a pneumothorax or peripheral neuropathy.
However, patients are becoming increasingly aware of
these pain management options, and they often have related
questions for the orthopaedic surgeon. A well-informed surgeon will be able to address these questions and actively participate with the patient and anesthesiologist to ensure the best
possible outcomes. To provide such information, we review the
relative anatomy, techniques, indications, contraindications,
expected clinical outcomes, and potential complications of the
four major peripheral nerve blocks for procedures involving
the upper extremity.
General Brachial Plexus Anatomy
he brachial plexus innervates all of the muscles of the
upper extremity and is responsible for most, but not all, of
its sensory function (Fig. 1). Although the superior aspect of
the shoulder receives sensory innervation by the superficial
cervical plexus (C3-C4) via the supraclavicular nerves (Figs.
2-A and 2-B) and the axilla is innervated by the second thoracic
nerve root, the brachial plexus provides the remaining sensory
innervation to the upper extremity. Cervical nerve roots C5
through T1 join to form the upper, middle, and lower trunks.
The anterior and posterior divisions of these trunks form the
medial, lateral, and posterior cords, which ultimately branch
and terminate in the peripheral nerves of the upper extremity
Fig. 1
Brachial plexus anatomy. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia and Analgesia
Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical Center; 2008.)
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prascapular nerve, with most of the contributions being from

the C5 and C6 nerve roots and some from the C4 nerve root23.
The sensory innervation to the skin is variable because the
axillary nerve, originating from C4, C5, and C6 via the posterior cord and superior lateral brachial cutaneous nerve, supplies most of the skin over the lateral upper arm.
Brachial plexus blockade is most commonly performed
at four distinct levels: the space between the anterior and
middle scalene muscles (interscalene block), the areas above
and below the clavicle (supraclavicular and infraclavicular
blocks), and the axilla (axillary block). An understanding of
brachial plexus anatomy and the level of the peripheral nerve
block can help the surgeon determine whether the surgical
field will be adequately covered by a particular block. In turn,
decisions can be made regarding whether additional local anesthetic infiltration is indicated.
Localization Techniques for Upper-Extremity Nerve
Blocks
he methods used for accurate localization of a nerve
or plexus to successfully administer an upper-extremity
nerve block have been a topic of much controversy. Early
methods used for localization involved elicitation of paresthesias from the patient to guide needle placement and a
tactile response on the part of the operator. Over time, new
technologies emerged, including neurostimulation and ultrasonographic guidance, which have improved the accuracy
of localization.
In the recent literature, there has been an increasing
focus on comparing ultrasonographic guidance and neurostimulation. A number of randomized and double-blinded
studies involving infraclavicular and axillary nerve blocks
have shown that ultrasonographic guidance is superior in
terms of faster performance of the block, faster block onset,
and improved block success24-26. In a meta-analysis of randomized studies comparing ultrasonographic guidance and
neurostimulation, fifteen of nineteen studies showed that
ultrasonographic guidance had significant benefits for supraclavicular nerve, infraclavicular nerve, and axillary nerve
blocks 27 . Another meta-analysis of thirteen randomized
controlled studies comparing ultrasonographic guidance
with neurostimulation found that the ultrasonographically
guided blocks took less time to perform, were more successful, and had a lower risk of vascular puncture28. Despite this
mounting evidence of the superiority of ultrasonographic
over neurostimulation guidance, however, one recent metaanalysis found that the data were insufficient for drawing this
conclusion29.
Ultimately, there remains a large variability in the localization techniques used in different centers. The associated
operative delay remains largely contingent on the operative
setting (ambulatory center versus hospital) and experience
level of the operator. Whether or not a dedicated block physician or room is available, time savings are often achieved
at the end of the case because the patient can be gradually
awakened without affecting surgical wound closure.
Fig. 2-A
Fig. 2-B
Figs. 2-A and 2-B The cervical plexus. (Reproduced, with permission, from:
Buckenmaier C III, Bleckner L. The Military Advanced Regional Anesthesia
and Analgesia Handbook. Washington, DC: The Office of The Surgeon
General at TMM Publications, The Borden Institute, Walter Reed Medical
Center; 2008.) Fig. 2-A The dermatomes anesthetized are shown in
dark blue. Fig. 2-B Surface anatomy of the neck showing the relative
midpoint (x) of the posterior border of the sternocleidomastoid muscle
(solid line).
(Fig. 1). Seventy percent of the sensory innervation to the

shoulder capsule, subacromial bursa, acromioclavicular joint,
and overlying skin comes from the superior trunk via the su-
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Fig. 3-A
Fig. 3-B
Figs. 3-A, 3-B, and 3-C Interscalene nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional
Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical
Center; 2008.) Fig. 3-A The dermatomes anesthetized are shown in dark blue. Fig. 3-B The highlight shows the region of the brachial plexus (nerve roots
and root-trunk transition) targeted by an interscalene nerve block.
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TABLE I Level of Evidence, Anesthesia Type, and Identified Complications for Studies Involving Upper-Extremity Peripheral Nerve Blocks*
Study
Level of Evidence (Study Design)

39
Bishop et al.
40
Brull et al.
Borgeat et al.
42
Misamore et al.
Block Type
Complications
IV
ISB
2.3% sensory neuropathy
III (meta-analysis)
ISB
2.84% sensory neuropathy
II (RCT)
CISB
Decreased diaphragmatic excursion
III (prospective)
ISB
Immediate paresthesias in 16%;

persistent neuropathy in 4.4%;
long-term neuropathy in 0.8%
41
Liu et al.
III (prospective)
ISB, SCNB
Hoarseness: 31% (ISB), 22% (SCNB).
III (prospective)
ICNB
0.7% prevalence pneumothorax
III (prospective)
SCNB
50% complete hemidiaphragmatic paresis;
Dyspnea: 10% (ISB), 7% (SCNB)

37
Desroches
38
Mak et al.
17% partial hemidiaphragmatic paresis

*ISB = interscalene nerve block, RCT = randomized controlled trial, CISB = continuous interscalene nerve block, SCNB = supraclavicular nerve
block, and ICNB = infraclavicular nerve block.
Single-Injection Blocks Versus Continuous Perineural

Catheters
he single-injection nerve block for improved postoperative
pain control is currently the most commonly used modality for regional anesthesia in upper-extremity surgery. The
duration of analgesia provided by these blocks ranges from
twelve to twenty-four hours13,16. As technology has advanced,
the use of indwelling continuous nerve catheters to provide
primary anesthesia and prolonged management of postoperative pain has increased. In two comparison studies of singleinjection compared with continuous interscalene nerve blocks,
the results showed that a continuous interscalene nerve block
provided better pain relief, better sleep quality, and lower
narcotic requirements18,30.
Several studies have also suggested that the use of continuous nerve catheters may lead to shorter hospital stays and
improved postoperative shoulder mobilization14,31,32. Furthermore, the authors of one pilot study reported the successful use
of nerve catheters for total shoulder arthroplasties performed
in an outpatient setting33. However, to implement models involving nerve catheters in the ambulatory setting, there has to
be a great deal of focus on patient education and a safe and
effective follow-up system. With the growing emphasis on costeffectiveness in the surgical setting, there will undoubtedly be a
continued focus on studying the use of continuous nerve
catheters to allow for earlier patient discharge.
Peripheral Nerve Blocks

Interscalene Nerve Block
he interscalene nerve block, the most commonly performed nerve block, targets the brachial plexus at the roottrunk level (Figs. 3-A, 3-B, and 3-C). The localization of this
block makes it effective for procedures involving the shoulder,
proximal aspect of the humerus, and distal aspect of the clavicle. The supraclavicular and suprascapular nerves are affected
by the block, and therefore the superior aspect of the shoulder

is adequately covered34. However, the C8 dermatome and inferior trunk are often incompletely covered, an effect that is
called ulnar sparing. Procedures at or distal to the elbow are not
adequately covered with an interscalene nerve block alone and
require an additional ulnar nerve block.
Since the first description of the direct anterior technique
for interscalene nerve blockade by Winnie35 in 1970, several
modifications have enhanced its safety and effectiveness. Meier
et al.36 and Borgeat et al.9 described a lateral approach with a
more caudal trajectory to help avoid central neuraxial complications. The use of nerve stimulation or ultrasonography for
guidance has further increased its safety (Table I9,37-42). However, complications can occur.
Fig. 3-C
Surface anatomy. The typical needle entry point (x) for an interscalene
nerve block is shown in relation to the sternocleidomastoid muscle and its
clavicular and sternal heads (solid lines) as well as the course of the
external jugular vein (dotted line) and the ends of the clavicle.
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Fig. 4-A
Fig. 4-B
Figs. 4-A, 4-B, and 4-C Supraclavicular nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional
Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed Medical
Center; 2008.) Fig. 4-A The dermatomes anesthetized are shown in dark blue. Fig. 4-B The highlight shows the region of the brachial plexus (trunks)
targeted by a supraclavicular nerve block.
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TABLE II Anesthesia Type, Level of Evidence, and Outcome Parameters for Studies Involving Open and Arthroscopic Shoulder Surgery*
Study
10
Brown et al.
16
Kinnard et al.
19
Singelyn et al.
12
Ciccone et al.
17
Lee et al.
13
Gohl et al.
20
Wu et al.
Level of Evidence
(Study Design)
Anesthesia
Patient
Satisfaction
Pain
Duration
of Stay
Rehabilitation
II (RCT)
CISB
II (RCT)
ISB
)
/
II (RCT)
ISB
YY
SSNB
)
/
)
/
Adverse Effects
IA
)
/
)
/
)
/
II (RCT)
ISB
)
/
)
/
II (RCT)
ISB
)
/
)
/
III
ISB
)
/
IV
ISB
)
/
*CISB = continuous interscalene nerve block, RCT = randomized controlled trial, ISB = interscalene nerve block, SSNB = suprascapular nerve
block, and IA = intra-articular analgesia. Arrows indicate whether the outcome is no different ()
/), better (Y), or worse ([). Multiple arrows (YY)
indicate a better outcome compared with the other listed peripheral nerve block modalities for the same study. Dashes indicate not reported.
Each group was compared with intravenous patient-controlled analgesia.
Complications of the interscalene nerve block include

phrenic blockade, spinal cord damage, sympathetic chain
blockade, recurrent laryngeal nerve blockade, and peripheral
neuropathy34. The reported rates of neuropathy after an interscalene nerve block vary: the neuropathy most commonly takes
the form of a sensory neuropathy (in <5% of cases); long-term
peripheral neuropathy occurs in <1% of patients43 (Table I).
Severe pulmonary disease is a contraindication to the use of an
interscalene nerve block because respiratory compromise can
occur secondary to phrenic nerve blockade, which occurs
nearly 100% of the time44. Despite hemidiaphragmatic paresis
from phrenic nerve blockade, dyspnea is reported only 3% of the
time for ultrasonographically guided interscalene nerve blocks41.
Vocal cord paresis can occur because of recurrent laryngeal nerve
blockade; it is reported as hoarseness in 11% of ultrasonographically guided interscalene nerve blocks41. In addition to
severe pulmonary comorbidities, another relative contraindication is a body mass index of 30 kg/m2 because the complication
and failure rates are more substantial in obese patients45. However, the use of ultrasonographic guidance can yield similar results and complication rates in nonobese and obese patients46.
Supraclavicular Nerve Block
The supraclavicular nerve block targets the brachial plexus
superior to the clavicle at the level of the trunks and their
anterior and posterior divisions (Figs. 4-A, 4-B, and 4-C). This
approach involves the injection of local anesthetic between the
anterior and middle scalene muscles at the level of the first rib.
The superior aspect of the shoulder theoretically is not covered
by this block (Fig. 4-A), but local anesthetic can travel more
cephalad within the prevertebral fascia, covering the nerves
to the level of the trunk and roots41, making a supraclavicular
nerve block an option for various shoulder procedures. In addition, supraclavicular nerve blocks can be used for procedures
involving the arm, elbow, forearm, and hand.
The localization of the supraclavicular nerve block makes

the apical pleura of the lung vulnerable to injury; however,
ultrasonographic guidance has helped reduce the prevalence of
pneumothorax and nerve injury47-50. Phrenic nerve blockade
and hemidiaphragmatic paresis are less common (17% to 50%)38
with supraclavicular nerve blocks than with interscalene nerve
blocks, and the prevalence of dyspnea is only 7%41. Perlas et al.50
reported that the prevalence of pneumothorax in their series
of 510 supraclavicular nerve blocks ranged from 0.6% to 6.1%
with various procedures, but that the prevalence could approach 0% with ultrasonographic guidance and experienced
operators. Recurrent laryngeal nerve blockade can lead to
hoarseness in 22% of cases41.
Fig. 4-C
Surface anatomy. The typical needle entry point (x) for a supraclavicular
nerve block is shown in relation to the sternocleidomastoid muscle and
its clavicular and sternal heads (solid lines) as well as the ends of the
clavicle.
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Fig. 5-A
Fig. 5-B
Figs. 5-A, 5-B, and 5-C Infraclavicular nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional
Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed
Medical Center; 2008.) Fig. 5-A The dermatomes anesthetized are shown in dark blue. Fig. 5-B The highlight shows the region of the brachial plexus (cords)
targeted by an infraclavicular nerve block.
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TABLE III Anesthesia Type, Level of Evidence, and Outcome Parameters for Studies Involving Shoulder Arthroplasty and Elbow
and Hand Procedures*
Level of Evidence
(Study Design)
Study
9
Borgeat et al.
Anesthesia
Procedure
Patient
Satisfaction
Pain
Adverse
Effects
Duration
of Stay
Rehabilitation
II (RCT)
CISB
TSA
14
II (RCT)
CISB
TSA
)
/
15
III
CISB
TSA
II (Meta-RCT)
ICNB
Elbow, hand
)
/
II (Prospective)
CICNB versus
CSCNB
Elbow, hand
Ilfeld et al.
Ilfeld et al.
11
Chin et al.
18
Mariano et al.
*CISB = continuous interscalene nerve block, RCT = randomized controlled trial, TSA = total shoulder arthroplasty, ICNB = infraclavicular nerve
block, CICNB = continuous infraclavicular nerve block, and CSCNB = continuous supraclavicular nerve block. Arrows indicate whether the outcome
is no different ()
/), better (Y), or worse ([). Dashes indicate not reported. Each group was compared against intravenous patient-controlled
analgesia unless otherwise specified.
Infraclavicular Nerve Block

The infraclavicular nerve block targets the brachial plexus at
the level of the cords before the exit of the axillary and musculocutaneous nerves (Figs. 5-A and 5-B). The shoulder is not
covered by this block, but the remaining arm, elbow, forearm,
and hand are adequately covered without the need for additional distal nerve blocks (Fig. 5-A). The surface landmarks for
injection are shown in Figure 5-C. Infraclavicular nerve blocks
have classically had a low pneumothorax prevalence (0.7%)37
but, as noted above, the increasing use of ultrasonographic
guidance has increased the safety profile of brachial plexus
blocks in general, including periclavicular blocks11.
Suprascapular and Axillary Nerve Blocks
The suprascapular and axillary nerves provide most of the innervation to the shoulder. A suprascapular nerve block in
combination with an axillary nerve block (Figs. 6-A, 6-B, and
6-C) is an effective option for intraoperative and postoperative
pain control for shoulder procedures. Several techniques have
been described to block the suprascapular nerve, but injection
at the level of the suprascapular notch provides the best
coverage51,52. As with other peripheral nerve blocks, ultrasonographic guidance can improve injection localization53.
The coverage is similar to that of an interscalene nerve
block, but analgesia may not be complete, although there is
a decreased rate of complications with this combination
block52,54. In addition, a suprascapular nerve block in combination with an axillary nerve block can be used in patients with
pulmonary comorbidities because the phrenic nerve is not
blocked, and hemidiaphragmatic paresis does not occur. This
combination block is ideal for shoulder procedures such as
simple arthroscopy. Procedures involving more substantial
surgery that may generate moderate to severe pain are likely
better served by an interscalene nerve block. Isolated axillary
blocks are very effective for procedures involving the elbow
even when compared with interscalene nerve blocks and supraclavicular nerve blocks55 (Figs. 6-A, 6-B, and 6-C). An axillary nerve block is also technically easier to perform than
those mentioned previously because of the palpability of the

axillary artery.
Clinical Outcomes
eripheral nerve blocks are an effective modality for pain
control during and after procedures involving the upper
extremity. Shoulder and elbow reconstruction, open soft-tissue
procedures, and arthroscopic interventions can all result in
severe pain. The use of peripheral nerve blocks can improve
patient satisfaction, minimize associated perioperative complications related to narcotic use, increase surgical efficiency,
shorten hospital stays, and enhance overall cost-effectiveness
(Tables II10,12,13,16,17,19,20 and III9,11,14,15,18).
Fig. 5-C
Surface anatomy. The typical needle entry point (at end of purple arrows) for
an infraclavicular block is shown in relation to the sternocleidomastoid
muscle and its clavicular and sternal heads (dotted lines) as well as the
deltopectoral groove (dotted line), the ends of the clavicle, and the coracoid
process (circle). The entry point is below the clavicle, 2 cm medial and
2 cm inferior to the coracoid.
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Fig. 6-A
Fig. 6-B
Figs. 6-A, 6-B, and 6-C Axillary nerve block. (Reproduced, with permission, from: Buckenmaier C III, Bleckner L. The Military Advanced Regional
Anesthesia and Analgesia Handbook. Washington, DC: The Office of The Surgeon General at TMM Publications, The Borden Institute, Walter Reed
Medical Center; 2008.) Fig. 6-A The dermatomes anesthetized are shown in dark blue. Fig. 6-B The highlight shows the region of the brachial plexus
(terminal branches) targeted by an axillary nerve block.
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Fig. 6-C
Surface anatomy. The course of the axillary artery (solid line) below the
border of the pectoralis major is shown.
The interscalene nerve block, considered the gold standard for regional anesthesia of the shoulder, has been the most
widely studied with regard to outcome measures. Although the
interscalene nerve block with neurostimulation guidance is
considered effective and safe, ultrasonographic guidance has
improved the clinical results and enhanced its safety. Kapral
et al.56 showed successful surgical anesthesia in 99% of ultrasonographically guided interscalene nerve blocks compared
with 91% of neurostimulation-guided interscalene nerve
blocks (p < 0.01) in a randomized, blinded study. That study
also showed that ultrasonographic guidance provided better
sensory blockade, motor blockade, and extent of blockade56.
Others have shown that ultrasonographic guidance can achieve
similar clinical effects with a lower anesthetic volume and
therefore a greater safety profile57,58.
Compared with general anesthesia alone, interscalene
nerve blocks provide greater patient satisfaction and lower
postoperative side effects for arthroscopic shoulder procedures10. Kinnard et al.16 and Brown et al.10 reported that use of
an interscalene nerve block in outpatient shoulder procedures
resulted in effective pain control, a lower rate of hospital admission, and shorter hospital stays. An interscalene nerve block
provides greater pain relief for subacromial acromioplasty than
a suprascapular nerve block or a bursal injection of local
anesthetic19,59.
Although single-injection interscalene nerve blocks are
effective compared with traditional methods, continuous interscalene nerve blocks may provide additional benefits to
patients undergoing procedures that result in severe postoperative pain9,14,15,18,30-32,60. In a prospective study, Mariano et al.18
showed lower opioid need, better sleep, and overall greater
patient satisfaction after outpatient shoulder procedures when
pain management involved a two-day continuous interscalene
nerve block (using a portable infusion device) compared with a

single injection. Others have argued that a single-injection
interscalene nerve block is likely adequate for most moderately
painful arthroscopic shoulder procedures61. For total shoulder
arthroplasty, Ilfeld et al.14 showed a shorter time to hospital
discharge and a greater tolerance for shoulder motion and
therapy with use of a continuous interscalene nerve block
beyond the morning after surgery. Some patients have been
discharged in the afternoon of the day of surgery with a continuous interscalene nerve block14,33. Whether a continuous
interscalene nerve block can achieve shorter hospital stays after
total shoulder arthroplasty for most patients in a safe manner
remains to be seen.
Alternatives to the interscalene nerve block, such as
the periclavicular blocks (supraclavicular nerve block and/or
infraclavicular nerve block) and the combination of a suprascapular nerve block and an axillary nerve block, have
also shown effectiveness for procedures involving the upper
extremity 11,18,41,52,54. Checcucci et al.54 described the latter
shoulder block (a suprascapular nerve block in combination with an axillary nerve block) as an alternative to
an interscalene nerve block for arthroscopic procedures and
reported 100% patient satisfaction. The enhanced safety of
this combination block makes it an attractive alternative
to more proximal brachial plexus blocks, but to our knowledge there have not yet been any direct clinical effectiveness
trials.
The ongoing focus on cost-conscious health care has
driven research into the possible cost savings associated with
peripheral nerve blocks. Fredrickson and Stewart62 retrospectively reviewed more than 200 patients who were undergoing
rotator cuff repair in a multiprovider private practice setting;
those investigators did not find a substantial increase in cost
associated with the continuous interscalene nerve block
method. Not all studies have shown cost savings with this
block63, but one has shown not only cost savings but greater
time efficiency as well64. Gonano et al.64 showed that, compared
with general anesthesia, an interscalene nerve block for arthroscopic shoulder surgery provided lower cost and better
overall work-flow times, including the time from block
placement to the time the patient is ready for surgical preparation, emergence time (the time needed for the patient to
awaken after completion of the surgical procedure), anesthesia control time (the time from entry into the operating
room until the beginning of the surgical preparation plus the
time from the completion of the surgical procedure until exit
from the operating room), and post-anesthesia care unit time.
Clearly, the cost-efficiency and clinical efficiency of peripheral
nerve blocks depend on many factors, including the experience of the operating center and surgeon, the experience of
the anesthesiologist, the pain control technology and modality used, and commitment to overall workflow efficiency
(block room availability, staffing availability, etc.). Further
investigation is needed to determine and define the most efficient practices as they relate to the use of peripheral nerve
blocks.
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Discussion
he first brachial plexus block was performed with cocaine
by William Halsted in 188565. Over the last century,
marked advancements have occurred in the techniques and
agents that are used to achieve adequate anesthesia. Technological innovation and a focus on patient pain, in addition to
patient-measured outcomes, have driven the popularity of
peripheral nerve blocks over the past two decades. Furthermore, the recent recognition of chondrotoxicity as a complication of intra-articular anesthetic agents66 has limited their use
in postoperative pain management. Peripheral nerve blocks are
a clinically effective and cost-effective modality for pain management after upper-extremity procedures. Ultrasonographic
guidance has enhanced the safety of peripheral nerve blocks as
well. The use of peripheral nerve blocks for upper-extremity
surgery continues to increase and will likely become even more
important in delivering cost-effective care. An adequate understanding of the risks, benefits, and limitations of peripheral
nerve blocks will help the orthopaedic surgeon play an active role
in managing perioperative pain. The best practices with respect

to peripheral nerve blocks will continue to evolve with additional
research efforts; keeping up to date with these advances will
allow orthopaedic surgeons and anesthesiologists to work together to deliver the highest-quality care to their patients. n
Umasuthan Srikumaran, MD
Benjamin E. Stein, MD
Eric W. Tan, MD
Michael T. Freehill, MD
John H. Wilckens, MD
c/o Elaine P. Henze, BJ, ELS,
Medical Editor and Director, Editorial Services,
Department of Orthopaedic Surgery,
The Johns Hopkins University/Johns Hopkins Bayview Medical Center,
4940 Eastern Ave. #A665,
Baltimore, MD 21224-2780.
E-mail address for E.P. Henze: ehenze1@jhmi.edu
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e197(1)

Upper-Extremity Peripheral Nerve Blocks

ver the past twenty-five years, peripheral nerve blocks

Several factors have led to the increasing acceptance and use of

J Bone Joint Surg Am. 2013;95:e197(1-13)

decreasing the duration of hospital stays and associated costs.

introduces an additional set of potential complications and

prascapular nerve, with most of the contributions being from

(Fig. 1). Seventy percent of the sensory innervation to the

Level of Evidence (Study Design)

2.3% sensory neuropathy

2.84% sensory neuropathy

Decreased diaphragmatic excursion

Immediate paresthesias in 16%;

Hoarseness: 31% (ISB), 22% (SCNB).

0.7% prevalence pneumothorax

50% complete hemidiaphragmatic paresis;

Dyspnea: 10% (ISB), 7% (SCNB)

17% partial hemidiaphragmatic paresis

Single-Injection Blocks Versus Continuous Perineural

Peripheral Nerve Blocks

by the block, and therefore the superior aspect of the shoulder

Complications of the interscalene nerve block include

The localization of the supraclavicular nerve block makes

Infraclavicular Nerve Block

those mentioned previously because of the palpability of the

nerve block (using a portable infusion device) compared with a

in managing perioperative pain. The best practices with respect

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