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LETTERS TO THE EDITOR

One View Is No View

Bezirkskrankenhaus Hall, Tyrol, Austria Institute of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria Department of Anaesthesia and Intensive Care, University of Vienna, Vienna, Austria

To the Editor:

Chan et al. (1) recently investigated the use of "state of the art" ultrasound equipment for ultrasound-guided supraclavicular brachial plexus block. They were able to demonstrate impressively the usefulness and benefits of ultrasound guidance.

Nevertheless, the authors ignored one of the golden rules of sonographic imaging: never make an interpretation of anatomy in only one view (2). In their study the supraclavicular region was visualized in a transverse view, hence the three fascicles of the brachial plexus appeared as hypoechoic nodules (3). Although their topographical position suggests correspondence with neural structures (Figure 1 in their article), this may lead to a misinterpretation. For instance, lymph nodes also appear as hypoechoic nodules of the same size (if they are not enlarged) and are numerous in the mentioned region. In a longitudinal view the fascicles of the brachial plexus appear as hypoechoic bands bordered by hyperechoic striations (3). This "fascicular" pattern represents one of the typical sonographic features of peripheral nerves (3) and, in combination with the "honeycomb" pattern obtained in a transverse view (3), rules out any misinterpretations of anatomy.

This has to be emphasized, because paying attention to the basic principles of sonographic imaging is mandatory for safe and successful ultrasound-guided peripheral nerve blocks.

References

1. Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 97: 1514–7.[Abstract/Free Full Text]
2. Kossoff G. Basic physics and imaging characteristics of ultrasound. World J Surg 2000; 24: 134–42.[Medline]
3. Peer S, Bodner G. High Resolution sonography of the peripheral nervous system. 1st ed. Berlin-Heidelberg: Springer, 2003.

Response

Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada

In Response:

We thank Kirchmair et al. for their interest in our paper (1). They raise concerns that brachial plexus anatomy may be misinterpreted when ultrasound imaging only obtains a transverse view of the plexus in the supraclavicular location. Hypoechoic nodules seen in this location may be lymph nodes. To avoid misinterpretation, we have also applied electrical stimulation for nerve confirmation in the study (1), not relying on topographical cues alone. We believe that combining ultrasound imaging with nerve stimulation adds accuracy and safety during brachial plexus blocks.

Reference

1. Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 97: 1514–7.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kirchmair, L. Articles by Perlas, A. Search for Related Content PubMed PubMed Citation Articles by Kirchmair, L. Articles by Perlas, A.