MRI of axillary brachial plexus blocks: a randomised controlled study

Abstract

Background: Axillary plexus blocks are usually guided by ultrasound, but alternative methods may be used when ultrasound equipment is lacking. For a nonultrasound-guided axillary block, the need for three injections has been questioned.

Objectives: Could differences in block success between single, double and triple deposits methods be explained by differences in local anaesthetic distribution as observed by MRI?

Design: A blinded and randomised controlled study.

Setting: Conducted at Oslo University Hospital, Rikshospitalet, Norway from 2009 to 2011.

Patients: Forty-five ASA 1 to 2 patients scheduled for surgery were randomised to three equally sized groups. All patients completed the study.

Interventions: Patients in the single-deposit group had an injection through a catheter parallel to the median nerve. In the double-deposit group the patients received a transarterial block. In the triple-deposit group the injections of the two other groups were combined. Upon completion of local anaesthetic injection the patients were scanned by MRI, before clinical block assessment. The distribution of local anaesthetic was scored by its closeness to terminal nerves and cords of the brachial plexus, as seen by MRI. The clinical effect was scored by the degree of sensory block in terminal nerve innervation areas.

Main outcome measures: Sensory block effect and MRI distribution pattern.

Results: The triple-deposit method had a higher success rate (100%) than the single-deposit method (67%) and the double-deposit method (67%) in blocking all cutaneous nerves distal to the elbow (P = 0.04). The patients in the triple-deposit group most often had the best MRI scores. For any nerve or cord, at least one of the single-deposit or double-deposit groups had a similarly high MRI score as the triple-deposit group.

Conclusion: Distal to the elbow, the triple-deposit method had the highest sensory block success rate. This could be explained to some extent by analysis of the magnetic resonance images.

Trial registration: ClinicalTrials.gov identifier: NCT01033006.

Fig. 1

Flow diagram of the study.

Fig. 2

Single-deposit group, catheter injection; double-deposit group, transarterial injections; triple-deposit group, transarterial and catheter injections. MRI of local anaesthetic (LA) in the right axilla, cross-sectional view. Typical LA distribution for three axillary block methods, from patients with successful sensory block. T2-weighted MRI images with fat suppression. The LA appears white. In the triple-deposit group, the artery (black circular area) is more centrally located in the LA area. In the double-deposit case, two LA compartments are recognised.

Fig. 3

MRI of the right axilla, cross-sectional view. T2-weighted MRI image with fat suppression from a patient with a successful sensory block after a single local anaesthetic (LA) injection, through a short catheter positioned parallel to the median nerve. The local anaesthetic appears white. The musculocutaneous nerve (Mcn) is clearly seen before entering the coracobrachial muscle and is surrounded by LA.

Fig. 4

Single-deposit group, catheter injection; double-deposit group, transarterial injections; triple-deposit group, transarterial and catheter injections. MRI of right shoulder and axilla with local anaesthetic (LA), coronal (frontal) view. Typical LA distribution for three axillary block methods with successful sensory block. Maximum intensity projections of coronal T2-weighted MR images with fat suppression. The LA appears white. It extends more proximally in the single- and triple-deposit groups than in the double-deposit group (P = 0.001), although the distal distribution is almost equal in all groups. The catheter with an extension tube is seen as a white string.