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Anesth Analg 2001;92:194-198
© 2001 International Anesthesia Research Society

REGIONAL ANESTHESIA AND PAIN MEDICINE

An Evaluation of the Brachial Plexus Block at the Humeral Canal Using a Neurostimulator (1417 Patients): The Efficacy, Safety, and Predictive Criteria of Failure

Michel Carles, MD, Alphonse Pulcini, MD, Philippe Macchi, MD, Patrick Duflos, MD, Marc Raucoules-Aime, MD, and Dominique Grimaud, MD

Department of Anesthesiology, Hôpital St Roch, Nice, France

Address correspondence and reprint requests to Michel Carles, MD, Département d’Anesthésie-Réanimation, Hôpital St Roch 5 rue Pierre Dévoluy 06006 Nice cédex 1, France. Address e-mail to michel.carles{at}biosys.net


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
To evaluate the efficacy and safety of the multiple peripheral nerve block technique at the humeral canal (humeral block) with the use of a neurostimulator, we prospectively studied 1417 patients undergoing upper limb surgery with a brachial plexus block at the humeral canal (1468 blocks). The success rate (defined as sensory block [in all nerve distributions] and/or the absence of another anesthetic technique required to allow surgery) was 95%. The threshold of minimal stimulation used to locate each nerve before injecting the anesthetic solution was the unique predictive factor for identified failure. For the median nerve, the threshold was 0.8 mA with a relative risk of failure (RRf: relative risk evaluated by series of Taylor with a 95% confidence interval) = 1.49 (P = 0.04), for the radial nerve the threshold was 0.6 mA (RRf 1.3, P = 0.02), and 0.7 mA for the ulnar nerve (RRf 1.36, P = 0.04). For any equal or higher stimulation level, the risk of failure of the humeral block increased. For the musculocutaneous nerve, we did not observe a significant stimulation threshold for the risk of failure; although beyond 0.7 mA, the RRf was always more than 1.3. Adverse events occurred in 7% of all cases and were usually minor (nausea/vomiting, anxiety, local pain). Our study provides supplementary information on the efficacy and safety of this technique. Stimulation thresholds are clinically identified for the first time as the main factor linked to the failure of a technique using a neurostimulator. We conclude that the humeral block is a reliable peripheral block allowing good success rates results with minor complications, which can be used as an alternative to the axillary block.

Implications: We prospectively evaluated the feasability and the factors causing failure of a peripheral nerve block technique (humeral block) using neurostimulation in a large number of patients. The importance of the level of stimulation for the success of the block was evaluated for the first time.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Brachial plexus blocks are often used to perform anesthesia for upper limb surgery. Interscalene, supraclavicular, axillary, and humeral canal approaches, with or without the use of a neurostimulator, have various failure and complication rates (1). The technique of multiple peripheral nerve blocks at the humeral canal with a neurostimulator (humeral block) was described in 1994 by Dupré (2). This approach provides a selective block of each major nerve from the brachial plexus. Such a selective approach results in an increased success rate of axillary blocks (3). Since its description, the humeral block has not been evaluated prospectively in a large series of patients for complications and failures, unlike the axillary block (4,5). The aim of our study was to evaluate the efficacy and safety of this technique. Moreover, although the multiple-injection technique with the use of a neurostimulator has been reported (6,7) the importance of the level of stimulation for the success of the block has not been defined. We analyzed the statistical link between the occurrence of nerve block failures and each variable recorded, especially stimulation thresholds.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
From January 1995 to January 1998, 1417 patients scheduled for surgery on the upper limb with brachial plexus block, using the humeral block according to the technique of Dupré (2), were prospectively included in the study after approval by our IRB. Surgery included all injuries to the upper limbs, except those involving the shoulders. A tourniquet was used in all cases. All patients received preliminary information on the anesthetic technique and agreed to undergo brachial plexus block at the humeral level.

Blood pressure, oxygen saturation monitoring, and a peripheral venous access were done before the beginning of the anesthetic procedure. After premedication with midazolam 5 mg sublingually administered 1 h before the arrival in the operating room and midazolam 1 mg IV bolus for sedation to reach a Ramsay score of 2 (cooperating, oriented, and still patient), humeral blocks were performed on all patients while they were in a supine position. Upper limbs were positioned in abduction (80°), and external rotation and the course of the brachial artery on the medial side of the arm was marked. A BraunTM neurostimulator with a 22-gauge 50-mm needle was used for all patients (Stimuplex® B-Braun, Melsungen AG, Germany). The puncture site was at the junction between the upper and middle thirds of the arm, immediately above the brachial artery. The needle was introduced following the direction of the brachial artery, toward the axilla. After crossing the brachial fascia, the neurostimulator was started. The initial current was 3 mA, rapidly decreased when motor response was noted. Nerve location was performed in the following order: median, ulnar, radial, and musculocutaneous, according to the initial description (2). After reaching the minimal level for each nerve stimulation with an adequate motor response, an aspiration test was done and finally, 8–10 mL of anesthetic solution was injected for each of the three nerves: median, radial, and ulnar. For the musculocutaneous nerve, 6–8 mL of solution was injected and 2–4 mL for the medial cutaneous nerve. The usual anesthetic solution injected contained 1.5% lidocaine with epinephrine (1:200,000) in combination with an opioid (sufentanil or nalbuphine), and with clonidine if required to prolong the block duration.

The gathered data included age, weight, sex, ASA physical status, surgical procedures, training level of anesthesiologists for this technique (recognized as experienced if at least 50 humeral blocks had been performed and considered as inexperienced if in training), anesthetic solution, time between humeral block and surgical incision, duration of surgery, threshold level reached for each nerve with the injection of the anesthetic solution, and volume injected for each nerve. Adverse events were noted during humeral block or surgery, and block failure was defined as the absence of sensory block in at least one neural distribution and/or the need of another anesthetic technique to allow surgery. The sensory block was evaluated by sensitivity to cold (ether test).

To evaluate the time spent while performing the humeral block and the delay for the anesthetic solution to become effective, a subgroup of patients was studied. Over a period of 4 mo (October 1997–January 1998), only the patients anesthetized by an "experienced" anesthesiologist (as defined) using the same anesthetic technique (40 mL of 1.5% lidocaine with epinephrine 1:200,000 and sufentanil 25 µg) were included. The procedure time was measured between the skin puncture and the withdrawal of the needle; the onset period was measured between the end of the humeral block (withdrawal of the needle) and a complete sensory block in each neural distribution (ether test). A physical examination was planned at 1 mo for all patients to detect adverse neurological events.

Results are expressed as mean ± SD and range. The analysis of data was performed with EpiInfoTM software (Centers for Disease Control, Atlanta, GA). Relative risk (RR) with 95% confidence interval (CI95) evaluated by series of Taylor, {chi}2, Fisher’s exact test, analysis of variance, and Kruskall-Wallis nonparametric analysis were used if required. Relative risk of failure was expressed as RRf, indicating for each level of stimulation the calculated RR with CI95. A value of P < 0.05 was considered significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Thirteen anesthesiologists (3 experienced, working in the plastic surgery department, and 10 inexperienced) performed 1468 humeral blocks on 1417 patients (1044 humeral blocks by experienced and 424 by inexperienced anesthesiologists). Demographic data and data concerning the surgery are reported in Table 1. Characteristics of the humeral block technique are described in Table 2. For the subgroup created to evaluate procedure time and delay of block installation, we included 155 patients: the mean time to perform the humeral block was 10 ± 5 (range 5–30) min, and the delay of onset of sensory block (with 1.5% lidocaine + epinephrine + sufentanil) was 15 ± 7 min for the median nerve, 13 ± 5 min for the radial nerve, 12 ± 4 min for the ulnar nerve, 10 ± 2 min for the musculocutaneous nerve, and 9 ± 2 min for the medial cutaneous nerve.


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  		Table 1. Demographic and Surgical Data
 

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  		Table 2. Data on the Humeral Block Technique
 
There were 72 humeral block failures, representing 5% of the cases. Failure was linked to the lack of nerve stimulation (33 cases, 2%) or to a partial or absent sensory block in at least one nerve distribution despite a complete procedure (39 cases, 3%). In these cases, supplementation with local anesthesia or distal block allowed surgery except in five cases (i.e., 0.3%). Age, weight, sex ratio, surgery, and nerve distribution involved in the surgery were similar regarding failure occurrence. Focusing on failure frequency, the most frequent failure was the ulnar nerve (n = 19, i.e. more than half of the failures), then the radial nerve (n = 7), the musculocutaneous nerve (n = 4), and the median nerve (n = 3). Only one failure was recorded on the medial cutaneous nerve (detected by sustained pain caused by the tourniquet despite its normal position). Failure of sensory blocks was not related to the injected volume (44 ± 5 mL in case of failure versus 43 ± 6 mL) or to the dose of lidocaine (622 ± 107 mg in case of failure versus 641 ± 103 mg). The risk of a failure was similar regardless of whether the anesthesiologist was trained for the humeral block technique (5% versus 6%).

The threshold of stimulation used to locate the nerve before injecting the anesthetic solution was found to be a predictive factor of failure (Figure), with a threshold value of 0.8 mA for the median nerve (RRf 1.49, P = 0.04), 0.6 mA for the radial nerve (RRf 1.3, P = 0.02), and 0.7 mA for the ulnar nerve (RRf 1.36, P = 0.04). For any injection using this intensity of stimulation or higher, the risk of failure of humeral block increased. With a stimulation level >=1 mA, RRf was always at least 4 times more than the success rate of humeral block. For the musculocutaneous nerve, we did not find a minimum threshold stimulation representative of the risk of failure, although beyond 0.7 mA the RRf was always more than 1.3.



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  		Figure 1. Relative risk of failure (RRf) of humeral block with 95% confidence interval (CI95) for each level of stimulation with the first step of a significant threshold reached for median, radial, and ulnar nerves (logarithmic scale): investigation of the stimulation threshold under which the risk of failure is not linked to the stimulation level (CI95 including 1, RRf not significant).

 
Adverse events were observed in 102 cases (7%) of humeral block including 60 cases of nausea and/or vomiting, 17 cases of anxiety, and 7 cases of local pain (tourniquet or pain during nerve blockade). We also observed two cases of seizure during the block which were caused by the anesthetic solution being injected too quickly (negative aspiration test). A third patient became confused with loss of verbal contact during the surgical procedure, 90 min after the block. The anesthetic solution (lidocaine, epinephrine, and sufentanil) may have contributed, although the toxic dose was not reached. For this patient, a postoperativeneurological checkup was noncontributive. Two local hematomas were reported during the humeral block, caused by venous puncture. No arterial puncture occurred in the series.

Complications were more frequent with an anesthesiologist not trained to this technique than with a trained specialist (9% versus 6%, P = 0.03). Even if complications such as nausea and vomiting, which can be attributed to the adjunctive therapy, were excluded, the difference remained significant (5% versus 3%, P = 0.02).

During the 1-mo follow-up (1247 surveyed patients representing 85% of the patients), hematomas were reported in 3% of cases at the puncture site of the humeral block in the first 10 days after surgery. There were no cases of persisting paresthesia and no other adverse events requiring further investigation.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
This prospective study of 1468 humeral blocks allowed us to evaluate the feasibility of this technique and to perform an analytic assessment of the complications and failures. Our results confirm previous available data on the subject (2) and offer new information.

The success rate of this technique is good (95%), even for anesthesiologists with no training (94%); these results are in agreement with those of Dupré (2). Compared with other approaches to the brachial plexus (mostly the axillary block using the transarterial approach or neurostimulation) having the same indications for upper limb surgery (1), the success rate of this procedure is better (8). Indeed, for the axillary block, Schroeder et al. (9) report a success rate of 89%, reaching 94% when combining the transarterial approach, neurostimulation, and eliciting paresthesia. Urban and Urquhart (10) report 93% of successful blocks using the transarterial approach or by eliciting paresthesia. Finally, Stan et al. (5), obtained a complete block in 89% of cases in a series of 1000 patients having an axillary block using the transarterial approach.

The average time spent to perform the humeral block was 10 minutes. This short delay is well adapted to ambulatory or emergency surgery. After the humeral block has been performed, the mean time for completion of the sensory block in all neural distributions was 15 minutes. Thus, for an anesthetic solution including 1.5% lidocaine with epinephrine, a minimal time interval of 25 minutes is required between the beginning of humeral block and the surgical incision. The order in which nerve blocks are achieved depends on the time required for the block to become effective. This delay is related to specific nerve characteristics: diameter and length of nerves and nerve fiber type (11). In our experience, the order should be the median nerve first for anatomical reasons (it is the most superficial) and because the delay for sensory block is the longest. The musculocutaneous nerve and the medial cutaneous nerve should be the last to be blocked because the delay of block is very short, confirmed by recently published data (6).

Failure is not linked to the experience of the anesthesiologist, to the physical characteristics of patients, or to the injected volume. Indeed, a total volume of 38–40 mL is sufficient to insure a complete sensory block of the four nerves. A smaller volume may result in a sensory block of poorer quality in some nerve distributions (12).

Anatomical considerations and the use of neurostimulation are two important variables to reduce the risk of failure. The most frequent stimulation failures have occurred with the ulnar and the radial nerves. These facts are in agreement with the anatomical knowledge on variations in the location of the radial nerve and the possibility of a Martin Gruber anastomosis (the main neural anastomosis at this level [i.e., humeral canal] between the median and ulnar nerves, with a motor response of ulnar type after the stimulation of the median nerve) that may make it harder to locate the ulnar nerve by neurostimulation (2). As explained by other authors (13), the humeral block is not a "midhumeral block" but a block of the upper third-middle third junction of the arm. A too distal site of puncture can explain some stimulation failures on the radial nerve. Neurostimulation has allowed an anatomical approach to regional anesthesia, leading to a more reliable injection and a possibly decreased risk of nerve trauma (2,7). The level of stimulation is a predictive factor of failure. This is clearly demonstrated in our study for the three nerves: median, radial, and ulnar. A stimulation level under a threshold of 0.6 to 0.8 mA is recommended for the humeral block. Values under this threshold are associated with a high rate of success. The lack of relationship reported between failure and level of neurostimulation for the musculocutaneous nerve can be explained by its anatomical course along the humeral bone, within the brachial biceps muscle. Despite a too distant injection, a fast and wider diffusion of the anesthetic solution in the muscle can partially explain this fact. In our study, stimulation thresholds to avoid a failure caused by an injection too distant from the nerve, are in agreement with the data reporting an average stimulation level of 0.7 mA as a "reliable, consistent marker of needle tip proximity to the brachial plexus" (14).

The complication rate is low (7%). Adverse events are minor and often related to the side effects of opiates used in the anesthetic solution. No vascular puncture or intraneural injection and no paresthesias were observed, confirming the safety of this technique (2,6). Nevertheless, because of the possibility of occurrence of adverse events (6), a systematic investigation of signs or symptoms linked to neural or vascular injury is required. These results emphasize the use of neurostimulation compared with techniques relying on eliciting paresthesias or the transarterial approach carrying serious complications (paresthesia, regressive hematoma) (5,15). The two seizures observed during the humeral block occurred with a frequency of 1.3 in 1000 blocks. To avoid this type of complication, it is important to inject the anesthetics slowly (this was not done in the two cases). The infrequent incidence of major complications is also found in recent regional anesthesia literature (7,16).

Our study provides confirming information on the reliability and safety of this technique. In our study, stimulation thresholds were clinically evaluated for the first time and recognized as the main factor linked to the failure of a procedure using a neurostimulator. The humeral block is a reliable peripheral block giving good results with minor complications, even with untrained anesthesiologists. This technique offers the major advantage of a unique site of injection (humeral canal) to reach the four major nerves in the upper extremity in a selective approach. It opens the way to a more specific use of regional anesthesia, especially in ambulatory surgery because it provides postoperative analgesia targeted to the specific nerve distribution involved in the surgery, while obtaining a complete block of the upper limb during surgery (17). Excluding the usual contraindications, the humeral block is a peripheral block technique for upper limb surgery (with or without a tourniquet) representing an attractive alternative to the axillary block. According to our results, stimulation level is a good predictive criterion of failure.


   Acknowledgments
 
We thank Dr. X. Capdevilla for his advice and corrections and Dr. A. Haddad for his assistance in the translation of this article.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Dupré LJ. Blocking of the brachial plexus: which technique(s) should be chosen? Cah Anesthesiol 1995; 43: 587–600.[Medline]
  2. Dupré LJ. Brachial plexus block through humeral approach. Cah Anesthesiol 1994; 42: 767–9.[Medline]
  3. Lavoie J, Martin R, Tétrault JP, et al. Axillary plexus block using a peripheral nerve stimulator: single or multiple injections. Can J Anaesth 1992; 39: 583–6.[Web of Science][Medline]
  4. Davis WJ, Lennon RL, Wedel DJ. Brachial plexus anesthesia for outpatient surgical procedures on an upper extremity. Mayo Clin Proc 1991; 66: 470–3.[Web of Science][Medline]
  5. Stan TC, Krantz MA, Solomon DL, et al. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach: a prospective study of 1,000 consecutive patients. Reg Anesth 1995; 20: 482–5.[Web of Science][Medline]
  6. Gaertner E, Kern O, Mahoudeau G, et al. Block of the brachial plexus branches by the humeral route: a prospective study of 503 ambulatory patients—proposal of a nerve blocking sequence. Acta Anaesthesiol Scand 1999; 43: 609–13.[Web of Science][Medline]
  7. Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications—study group on regional anesthesia. Anesth Analg 1999; 88: 847–52.[Abstract/Free Full Text]
  8. Bouaziz H, Narchi P, Mercier FJ, et al. Comparison between conventional axillary block and a new approach at the midhumeral level. Anesth Analg 1997; 84: 1058–62.[Abstract]
  9. Schroeder LE, Horlocker TT, Schroeder DR. The efficacy of axillary block for surgical procedures about the elbow. Anesth Analg 1996; 83: 747–51.[Abstract]
  10. Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth 1994; 19: 175–82.[Web of Science][Medline]
  11. Peter JD. Anatomie et histologie des fibres et des troncs nerveux: effets secondaires des anesthésiques locaux sur les fibres nerveuses. In: Lafaye G, ed. Précis d’anesthésie loco-régionale. Paris: Masson, 1994: 39–50.
  12. Martin R, Dumais R, Cinq-Mars S, Tétrault JP. Axillary plexus block by simultaneous blockade of several nerves. I. Influence of the volume of the anesthetic solution. Ann Fr Anesth Reanim 1993; 12: 229–32.[Web of Science][Medline]
  13. Frizelle HP, Moriarty DC. The "midhumeral" approach to the brachial plexus. Anesth Analg 1998; 86: 447–8.
  14. Riegler FX. Brachial plexus block with the nerve stimulator: motor response characteristics at three sites. Reg Anesth 1992; 17: 295–9.[Web of Science][Medline]
  15. Cooper K, Kelley H, Carrithers J. Perceptions of side effects following axillary block used for outpatient surgery. Reg Anesth 1995; 20: 213–6.
  16. Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia: results of a prospective study in France. Anesthesiology 1997; 87: 479–86.[Web of Science][Medline]
  17. Bouaziz H, Narchi P, Mercier FJ, et al. The use of a selective axillary nerve block for outpatient hand surgery. Anesth Analg 1998; 86: 746–8.[Abstract]
Accepted for publication September 1, 2000.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press