An interventional study of axillary brachial plexus block in Pain, sponsored by Olfa kaabachi, MD. Completed at 1 site in Tunisia. Open to participants aged 18 Years to 85 Years. Per ClinicalTrials.gov, last updated 2025-12-24.
Sponsored by Olfa kaabachi, MD · Not applicable, Interventional, and Treatment
Brachial plexus block (BPB) alone, whether performed at the axilla or more proximally, does not provide sufficient anesthesia for the skin of the medial upper arm and elbow, because thoracic roots contribute to the innervation of these areas.
For surgery of the upper arm, the brachial plexus block needs to be completed by the Medial Brachial Cutaneous nerve (MBCN) and the Intercostobrachial nerve (ICBN) nerve blocks.
The ICBN is not part of the brachial plexus; it usually originates from the lateral branch of the second intercostals nerve (T2). The MBCN and the ICBN are often interconnected. In the axilla, they are separated from the brachial plexus by the brachial fascia. Therefore, when an axillary brachial plexus block (ABPB) is performed, the local anesthetic solution may be prevented from spreading toward the MBCN and ICBN.
These nerves are classically anesthetized by raising a subcutaneous wheel of local anesthetic spanning the entire width of the medial aspect of the arm at the level of the axilla, usually from anteriorly to posteriorly. The failure rate of this blind infiltration procedure has never been quantified in the literature. Traditional teaching suggests that the ICBN should be blocked to prevent tourniquet pain. Lanz et al (1) showed that BPB, whether performed to the axilla or more proximally, rarely extend to the ICBN (10% of cases). However, recent literature shows differences in opinion on the role of an ICBN/MBCN blocks in preventing tourniquet pain. Ultrasound guided ABPB is sufficient to provide anaesthesia for tourniquet even during prolonged ischemia. However, to ensure prevention of tourniquet discomfort a multiple injection technique that include musculocutaneous blockade should be preferred (2). The overall incidence of tourniquet pain in the setting of an effectively dense supraclavicular brachial plexus block for surgical anesthesia was low, even without the addition of an ICBN block. This tourniquet pain can be easily managed with small increases in systemic analgesics (3). However, in Magazzeni Ph et al (4) study, ultrasound-Guided Block of ICBN and MBCN was associated to a better sensory block and a less painful tourniquet compared to conventional block.
The optimal access for an ultrasound guided block of the MBCN and the ICBN nerves is not yet known.
Patients are allocated to one of the two groups:
Group C In patients allocated to the conventional group, 3 to 6 mL of bupivacaine (at the discretion of the anesthesiologist) was infiltrated blindly subcutaneously at the same level of the axilla in the anteroposterior direction prior to complete needle withdrawal.
Group U In patients allocated to the USG group, the needle was redirected, and between 1 and 2 mL of bupivacaine was injected around each visible nerve branch (MBCN and ICBN); if the nerve branches were not visible, 5 mL of the local anesthetic was injected (or less volume if the nerves appeared during the injection), in the subcutaneous area located above the brachial fascia, with a posterior direction, toward the latissimus dorsi muscle.
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Exclusion Criteria:
after blockage of the principal four nerves of the brachial plexus, the needle was redirected, and between 1 and 2 mL of bupivacaine was injected around each visible nerve branch (Intercostobrachial and Medial Brachial Cutaneous ); if the nerve branches were not visible, 5 mL of the local anesthetic was injected (or less volume if the nerves appeared during the injection), in the subcutaneous area located above the brachial fascia, with a posterior direction, toward the latissimus dorsi muscle.
Procedure: axillary brachial plexus block
after blockage of the principal four nerves of the brachial plexus, 3 to 6 mL of bupivacaine (at the discretion of the anesthesiologist) was infiltrated blindly subcutaneously at the same level of the axilla in the anteroposterior direction prior to complete needle withdrawal
Procedure: axillary brachial plexus block
conventional group, 3 to 6 mL of bupivacaine was infiltrated blindly subcutaneously at the same level of the axilla in the anteroposterior direction prior ultrasound group:1 and 2 mL of bupivacaine was injected around each visible nerve branch (Intercostobrachial and Medial Brachial Cutaneous ); if the nerve branches were not visible, 5 mL of the local anesthetic was injected in the subcutaneous area located above the brachial fascia, with a posterior direction, toward the latissimus dorsi muscle.
Also known as: conventional group, ultrasound group
tourniquet pain
The proportion of patients pain free when inflating tourniquet.
Time frame: during surgery
sensitive block
The proportion of patients who had no sensation in all 4 regions innervated by both Intercostobrachial and Medial Brachial Cutaneous Nerves
Time frame: 5, 10, 15 and 20 minutes after performing the block
rescue sedetion
Proportion of patient with rescue sedation/analgesia because of uncomfortable tourniquet
Time frame: during surgery
durationof ultrasound image
time to ultrasound visualisation of both Intercostobrachial and Medial Brachial Cutaneous Nerves
Time frame: during ultrasound procedure
Quality of ultrasound images
visualization of the 2 nerves
Time frame: during ultrasound procedure
Plan to share: No
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Olfa kaabachi, MD