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LETTER TO THE EDITOR

Is the Interscalene Brachial Plexus Block the Best Approach?

Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland, stephan.blumenthal{at}balgrist.ch

To the Editor:

We read with interest the article of Altintas et al. (1), who performed interscalene brachial plexus block for surgery at the forearm. We question some aspects of their methods. Vester-Andersen et al. (2) described, more than two decades ago, that after an interscalene block the nerve distribution areas of the medial antebrachial ulnar nerve and the cutaneous nerve are only reliably blocked in 70% and 90%, respectively. This is emphasized by the limited success rate of 81% obtained by Altintas et al. It is generally accepted that an infraclavicular blockade of the brachial plexus is the most appropriate technique in this surgical context (3). Weller and Gerancher (4) nicely compared different approaches to the brachial plexus in the infraclavicular region. Of these, the modified approach of the Raj techniques (5,6) has been described with a high success rate for single-shot block and for continuous block. The reported risk of vascular puncture was 2%. No pneumothorax has been reported until now. Performing an interscalene block using the Winnie (7) method is questionable when fear of pneumothorax is the reason for avoiding an infraclavicular block. Four years after Winnie’s publication, Ward (8) reported a 3% risk of pneumothorax with this technique. Unfortunately, the authors experienced another severe complication of the Winnie technique: the spinal injection. Moreover, it has been shown that interscalene block using the modified lateral approach, particularly when performing the block through the catheter, decreases the severity of the phrenic nerve blockade (9). The low success rate found in this study should lead the authors to look for a more accurate peripheral nerve block for creation of arteriovenous fistulas and to encourage the authors to familiarize themselves with another method of blocking the brachial plexus by using, for example, the modified Raj technique, which is much safer (10,11). Finally, considering the small group of patients included in this study, the lack of a power analysis raises some doubts for us on the validity of their conclusions.

References

1. Altintas F, Gumus F, Kaya G, et al. Interscalene brachial plexus block with bupivacaine and ropivacaine in patients with chronic renal failure: diaphragmatic excursion and pulmonary function changes. Anesth Analg 2005;100:1166-71.[Abstract/Free Full Text]
2. Vester-Andersen T, Christiansen C, Hansen A, et al. Interscalene brachial plexus block: area of analgesia, complications and blood concentrations of local anesthetics. Acta Anaesthesiol Scand 1981;25:81-4.[Medline]
3. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia. Anesthesiology 2004;100:395-402.[Web of Science][Medline]
4. Weller RS, Gerancher JC. Brachial plexus block: "best" approach and "best" evoked response: where are we? Reg Anesth Pain Med 2004;29:520-3.[Web of Science][Medline]
5. Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001;93:436-41.[Abstract/Free Full Text]
6. Dullenkopf A, Blumenthal S, Theodorou P, et al. Diaphragmatic excursion and respiratory function after the modified Raj technique of the infraclavicular plexus block. Reg Anesth Pain Med 2004;29:110-4.[Medline]
7. Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970;49:455-66.[Free Full Text]
8. Ward ME. The interscalene approach to the brachial plexus. Anaesthesia 1974;29:147-57.[Web of Science][Medline]
9. Borgeat A, Perschak H, Bird P, et al. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: effects on diaphragmatic and respiratory function. Anesthesiology 2000;92:102-8.[Web of Science][Medline]
10. Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003;99:436-42.[Web of Science][Medline]
11. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology 2001;95:875-80.[Web of Science][Medline]

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