Anesth Analg 2001;93:1618-1620
© 2001 International Anesthesia Research Society
REGIONAL ANESTHESIA
The Use of a "Reverse" Axis (Axillary-Interscalene) Block in a Patient Presenting with Fractures of the Left Shoulder and Elbow
Anthony R. Brown, MBChB, and
G. C. Parker, MD
College of Physicians & Surgeons, Columbia University, New York, New York
Address correspondence to Anthony R. Brown, MBChB, Columbia University College of Physicians & Surgeons, Department of Anesthesia, P + S Box 46, 630 West 168th Street, New York, NY 10032. Address e-mail to arb6{at}columbia.edu
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Abstract
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IMPLICATIONS:A patient presented for surgery to repair a fractured left shoulder and elbow and requested regional anesthesia. Most upper extremity operations require a single brachial plexus nerve block. The position of the two fractures however required the use of two separate approaches, an interscalene and an axillary approach.
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Introduction
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The objective of regional anesthesia is to use a technique that is appropriate for the surgical procedure (1,2) and is associated with a high degree of success and an infrequent complication rate. Shoulder surgery is traditionally performed under interscalene blockade (ISB) (3). Brachial plexus blockade for procedures involving the elbow can be especially challenging. The supraclavicular or infraclavicular ("periclavicular") approaches to the brachial plexus have traditionally been recommended for elbow surgery, although this has been questioned (4). We recently encountered a patient requiring shoulder as well as elbow surgery on the same arm. The patient requested regional anesthesia as a result of the enthusiastic support of this technique by the surgical team. As neither an interscalene nor a "periclavicular" block alone would guarantee complete anesthesia for both procedures, we decided to perform an axis (axillary-interscalene) block.
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Case Report
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An 80-yr-old, 6-ft, 185-lb male presented for open reduction and internal fixation of a left elbow (olecranon) fracture as well as a nondisplaced surgical neck fracture of the left humerus. Medical evaluation was negative for a history of a syncopal episode causing his fall and injury, and no head injury was noted after the fall. His medical history was significant for myocardial infarction, congestive heart failure, and coronary artery bypass surgery in 1976, with subsequent pacemaker placement in 1995. He reported no recent dyspnea on exertion, chest pain, or palpitations. In addition, the patient suffered from gout. His medications included Aldactone (Searle, Chicago, IL), Lanoxin (GlaxoSmithKline, Research Triangle Park, NC), Furosemide (Mylan Laboratories, Pittsburgh, PA), Capoten (Bristol-Myers-Squibb; Princeton, NJ), and Colchicine (Westwood; Buffalo, NY).
After placement of the appropriate monitors, an IV line, and the administration of oxygen at 3 L/min via a nasal cannula, the patient was positioned and prepared for an ISB. Winnie’s technique was modified with the aid of a peripheral nerve stimulator (Digistim II, Neuro Technology, Houston, TX) and an insulated needle (Stimuplex, B. Braun, Bethlehem, PA). A deltoid twitch at 0.3 mA was achieved followed by the administration of 30 mL. Mepivacaine1.5% (AstraZeneca; Wayne, PA). As soon as the ISB provided sufficient analgesia to abduct the arm, the axilla was prepared and a "partial" axillary block was performed with a nerve stimulator. An ulnar nerve twitch was elicited (by design), followed by the injection of 15 mL Mepivacaine 1.5%. Sodium bicarbonate was added (both blocks) in the ratio of 1 mL to 10 mL mepivacaine to increase the speed of onset of blockade. The intercostobrachial and medial brachial cutaneous nerves were blocked by means of a subcutaneous band of local anesthetic (5 mL of mepivacaine 1.5%) high in the axilla.
The patient received 1.0 mg midazolam and 50 µg fentanyl before insertion of the blocks. An additional 1.5 mg midazolam (0.5 mg boluses) and 25 micrograms of fentanyl were administered IV for sedation during the procedure. The patient received no further IV medications with the exception of antibiotic prophylaxis. His vital signs were stable throughout and he tolerated the procedure well. On completion of the surgery he was transported to the postanesthesia care unit (PACU) pain-free 3 h after entering the operating room. Postoperative pain management was achieved by means of IV morphine patient-controlled analgesia after resolution of the block.
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Discussion
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A number of advantages have been attributed to regional anesthesia over general anesthesia for upper extremity surgery, including intraoperative anesthesia and muscle relaxation with less physiological trespass, the avoidance of general anesthesia and opioid-associated side effects, an awake patient, as well as postoperative analgesia (3,5). The specific approach to the brachial plexus is primarily determined by the surgical site (1,2), the experience of the anesthesiologist as well as the perceived risk of complications.
An ISB is the technique of choice for shoulder surgery but may be inadequate for elbow or hand surgery (3). The local anesthetic is deposited at the level of the cervical nerve roots resulting in blockade of C3 to C7, as well as C8 and T1 in 40%–75% of cases. The latter two nerve roots are therefore not blocked in 25%–60% of patients, resulting in inadequate anesthesia along the medial aspect of the arm (including the elbow) and ulnar side of the hand. A supraclavicular approach such as classic (6), subclavian perivascular (7,8), or plumb-bob technique1 as well as an infraclavicular approach (9) would be adequate for surgery below the shoulder, but this approach would have to be supplemented by a superficial cervical plexus block to guarantee complete anesthesia for shoulder surgery.
An axillary block is traditionally recommended for surgery below the elbow, although Schroeder et al. (4) demonstrated that this approach is as successful as the more proximal approaches for elbow surgery. This approach is obviously not indicated for shoulder surgery.
Our case presented an interesting challenge. The patient requested regional anesthesia, but we could not guarantee complete anesthesia for both surgical sites with a single approach to the brachial plexus. Urmey described a combined axillary-interscalene (axis) block to achieve complete anesthesia of the upper limb.2 In the aforementioned technique the axillary block preceded the ISB. We performed the ISB first, as the pain caused by the patient’s proximal humeral fracture prevented us from abducting his arm to perform the axillary block.
A recent study (10) examining the relationship between paresthesia and nerve stimulation for axillary brachial plexus block suggests that a motor response at 0.5 mA is a reasonable threshold to aim for when performing these blocks. An uninsulated needle was used in the aforementioned study, and the authors comment that an insulated needle (as used in our case report) requires slightly less current to stimulate because of a higher current density at the tip. Bernstein and Rosenberg (11) report success rates of 82% at 0.5 mA compared with 93% with a stimulating current 
0.3 mA for ISB performed with an insulated needle. On the basis of these findings, we have accepted an appropriate motor response at 0.3 mA as our end point.
Mepivacaine, rather than a longer-acting local anesthetic, was chosen at the surgeon’s request so that neurological function could be assessed in the early postoperative period. As the onset of mepivacaine (with added bicarbonate) varies between 10 and 20 min, and its average duration after brachial plexus blockade is 180–300 min (12) we considered it to be an appropriate choice of local anesthetic under the circumstances. The total dose of mepivacaine (750 mg) was on the large side; however, the safety of these doses (provided an intravascular injection is avoided) has been suggested and demonstrated for brachial plexus blockade (13,14).
Although we realize that the performance of regional anesthesia in an anesthetized (or partially anesthetized) patient (or limb) is controversial (15), if indicated and performed with due diligence, this practice is acceptable (16–18). It should be emphasized that the use of a nerve stimulator does not entirely eliminate the possibility of nerve damage occurring under these circumstances. In addition, blockade of nerve roots C8 and T1 (or the lower trunk) is usually delayed or frequently not achieved at all. It is therefore highly unlikely that the patient would not feel needle contact with the ulnar nerve. For these reasons we were comfortable performing the axillary block after the ISB. We decided against waiting to ascertain whether the C8 and T1 nerve roots would become blocked because in our experience these roots frequently remain unblocked. The risk associated with gentle abduction of the arm after the ISB was minimal, as the surgical neck fracture was nondisplaced and stable.
In summary, we present an interesting regional anesthetic technique (the axis block) that proved to be successful and acceptable to both patient and surgeon.
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Footnotes
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1Brown D, Bridenbaugh L. Physics applied to regional anesthesia results in an improved supraclavicular nerve block: The "plumb-bob" technique [abstract]. Anesthesiology 1988;69:A376. 
2Urmey W. Combined axillary-interscalene (axis) brachial plexus block for elbow surgery [abstract]. Reg Anesth 1993;18:88.
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References
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Accepted for publication August 17, 2001.
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Abstract
Introduction
