Comparison of outside versus inside brachial plexus sheath injection for ultrasound-guided interscalene nerve blocks

Joni Maga, Andres Missair, Alex Visan, Lee Kaplan, Juan F. Gutierrez, Annika R. Jain, Ralf E. Gebhard

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Objectives-Ultrasound-guided interscalene brachial plexus blocks are commonly used to provide anesthesia for the shoulder and proximal upper extremity. Some reviews identify a sheath that envelops the brachial plexus as a potential tissue plane target, and current editorials in the literature highlight the need to establish precise and reproducible injection targets under ultrasound guidance. We hypothesize that an injection of a local anesthetic inside the brachial plexus sheath during ultrasound-guided interscalene nerve blocks will result in enhanced procedure success and provide a consistent tissue plane target for this approach with a reproducible and characteristic local anesthetic spread pattern. Methods-Sixty patients scheduled for shoulder surgery with a preoperative interscalene block for postoperative pain management were enrolled in this prospective randomized observer-blinded study. Each patient was randomly assigned to receive a single-shot interscalene block either inside or outside the brachial plexus sheath. Results-The rate of complete motor and sensory blocks of the axillary nerve territory 10 minutes after local anesthetic injection for the inside group was 70% versus 37% for the outside group (P< .05). At all measurement intervals beyond 10 minutes, however, neither group showed a statistically significant difference in complete sensory blockade. The incidence rates of transient paresthesia during needle passage were 6.7% for the outside group and 96.7% for the inside group (P < .05). Conclusions-Except for faster onset, this prospective randomized trial did not find any advantages to performing an interscalene block inside the brachial plexus sheath. There was a higher incidence of transient paresthesia when injections were performed inside compared to outside the sheath.

Original languageEnglish (US)
Pages (from-to)279-285
Number of pages7
JournalJournal of Ultrasound in Medicine
Issue number2
StatePublished - Feb 1 2016


  • Brachial plexus
  • Interscalene block
  • Neurosonology
  • Regional anesthesia

ASJC Scopus subject areas

  • Radiological and Ultrasound Technology
  • Radiology Nuclear Medicine and imaging


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