Acta Anaesthesiol Scand 2011; 55: 565570

Printed in Singapore. All rights reserved

r 2011 The Authors

Acta Anaesthesiologica Scandinavica
r 2011 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2011.02420.x

Ultrasound-guided block of the axillary nerve:

a volunteer study of a new method
C. ROTHE1, S. ASGHAR1, H. L. ANDERSEN2, J. K. CHRISTENSEN3 and K. H. W. LANGE1

Department of Anesthesia and Intensive Care, Hillerd Hospital, Hillerd, Denmark, 2Department of Anesthesia, Frederiksberg Hospital,
Frederiksberg, Denmark and 3Department of Radiology, Hillerd Hospital, Hillerd, Denmark

Background: Interscalene brachial plexus block (IBPB) is

the gold standard for perioperative pain management
in shoulder surgery. However, a more distal technique
would be desirable to avoid the side effects and potential
serious complications of IBPB. Therefore, the aim of the
present study was to develop and describe a new
method to perform an ultrasound-guided specific axillary
nerve block.
Methods:
After initial investigations, 12 healthy
volunteers were included. We performed an in-line ultrasound-guided specific axillary nerve block by injecting
8 ml local anesthetic (lidocaine 20 mg/ml) after placing
the tip of a nerve stimulation needle cranial to the posterior circumflex humeral artery in the neurovascular space
bordered by the teres minor muscle, the deltoid muscle,
the triceps muscle and the shaft of the humerus. Needle
placement was aided by simultaneous nerve stimulation.
We assessed sensory (pinprick and cold stimulation) and

pain following shoulder surgery

is severe in many patients.1,2 For many years,
interscalene brachial plexus block (IBPB) has been
the gold standard to control this pain.25 However,
IBPB is a proximal brachial plexus block and therefore associated with extensive nerve blocking,
which results in significant side effects and possible
complications.2,6 Attempts to minimize the volume
of injected local anesthetic by the use of ultrasound
guidance may decrease but not eliminate the incidence of side effects.7,8 It would therefore be
desirable to have a more specific regional anesthetic technique than IBPB for treating post-operative pain after shoulder surgery. Suprascapular
nerve block has been used,9 but often does not
provide adequate post-operative analgesia because
the axillary nerve also contributes substantially to
the complex innervation of the shoulder joint.10
Recently, an anatomical landmark technique using
nerve stimulation was described to specifically
block the axillary nerve.1114 However, no studies
OST-OPERATIVE

motor (active resistive force) block of the axillary nerve

before, 15, 30, 60, 90 and 120 min after performing the block
and every 30 min until termination of the block.
Results: All 12 volunteers demonstrated sensory block of
the axillary nerve and 10 volunteers demonstrated complete motor block. Even though it was difficult to directly
visualize the axillary nerve, the block was easy to perform
with easily recognizable ultrasonographic landmarks.
Block duration was approximately 120 min.
Conclusions: We describe a new ultrasound-guided technique to specifically block the axillary nerve. The potential
clinical role of this new block remains to be determined.
Accepted for publication 10 February 2011
r 2011 The Authors
Acta Anaesthesiologica Scandinavica
r 2011 The Acta Anaesthesiologica Scandinavica Foundation

using ultrasound guidance to block the axillary

have been published so far. The aim of the present
study was therefore to develop and describe a new
ultrasound-guided technique to specifically block
the axillary nerve and we report the results from 12
healthy volunteers undergoing the procedure.

Anatomy
The sensory innervation of the shoulder joint is
complex and involves contributions from the axillary, suprascapular, subscapular, musculocutaneous
and lateral pectoral nerves. Of these, the axillary
and suprascapular nerves are considered the most
important. However, variations and communications among the nerves are probably common.

The axillary nerve

The axillary nerve is one of the terminal branches of
the posterior cord of the brachial plexus and con-

565

C. Rothe et al.

tains fibers from the ventral rami of C5 and C6. It

typically innervates three muscles: the deltoid (posterior, middle and anterior parts), the teres minor
and the long head of the triceps brachii. In addition,
it provides sensory innervation to the shoulder joint
as well as the skin covering the inferior region of the
deltoid muscle on the arm. The axillary nerve is
formed at the lateral border of the subscapularis
muscle as the nerve runs posteriorly, beneath the
shoulder joint towards the surgical neck of the
humerus.11,1517 It passes through the quadrangular
space in close relation with the posterior circumflex
humeral artery (PCHA) and splits into an anterior
and a posterior branch either within the quadrangular space or later within the deltoid muscle18 (Fig.
1). The posterior branch innervates the teres minor
muscle, the posterior part of the deltoid muscle and
terminates as the superior lateral brachial cutaneous
nerve, which courses around the medial border of
the deltoid muscle and provides sensory innervation to the skin over the inferior deltoid muscle.19
The anterior branch innervates the middle and
anterior parts of the deltoid muscle and gives off
branches to the anterior part of the joint capsule.

Methods
The Committees on Biomedical Research Ethics of
the Capital Region of Denmark approved the study
protocol (protocol no. H-I-2009-100) in accordance

Fig. 1. Anatomy of the axillary nerve. Anatomical relations of the

axillary nerve as it travels through the quadrangular space
(bordered medially by the long head of the triceps muscle, superiorly by the teres minor and subscapularis muscles, laterally by the
surgical neck of the humerus and inferiorly by the teres major
muscle) and divides into its anterior and posterior branches.

566

with the declaration of Helsinki. Twelve healthy

volunteers were included: females/males 6/6; age
32, 3267 year (median, minimummaximum);
height 175, 165195 cm; weight 69, 5390 kg; body
mass index 22.5, 19.426.8 kg/m2. Before inclusion,
all volunteers gave written informed consent. Exclusion criteria were: age o18 years, prescription
medicine (except for oral contraception) or any
shoulder complaint.
We inserted a secure intravenous catheter into a
superficial vein of the hand and performed routine
monitoring of the volunteers (NIBP, continuous
ECG and pulse oximetry) while performing the
block and during the first 15 min after performing
the block.

Ultrasound imaging
Before the study, we identified the axillary nerve in
a healthy volunteer (K. L.) in the following way: the
volunteer was in the sitting position, the shoulder
in the neutral position but rotated 451 inward and
the elbow flexed at 901 while the hand rested on the
knees. After disinfection with ethanolchlorhexidine (83% and 0.5%, respectively), we placed a
sterile transparent drape over the shoulder.
Using a high-frequency linear ultrasound transducer (HFL, 38 /136 MHz, S-ICUt Ultrasound System, SonoSite Inc., Bothell, WA) parallel to the
longitudinal axis of the shaft of the humerus and
approximately 2 cm below the postero-lateral part
of the acromion on the dorsal side of the arm
(Fig. 2), we identified the surgical neck and the
shaft of the humerus and the cross section of the
PCHA, using ultrasound Doppler (Fig. 3). Additional important ultrasonographic landmarks were
also identified: in the transverse section, the teres
minor muscle, which lies cranial to the PCHA, the
posterior part of the deltoid muscle closest to the
probe and as the probe was moved medially the
lateral and long head of the brachial triceps muscle
in longitudinal section just below the deltoid muscle (Fig. 3). The axillary nerve is located cranially in
close relation to the PCHA in the neurovascular
space between the teres minor muscle cranially, the
deltoid muscle posteriorly, the triceps muscle caudally and the shaft of the humerus anteriorly (Fig. 3).
The ultrasound probe was moved medially until
the shaft of the humerus disappeared posteriorly
and then slightly laterally until the shaft of
the humerus just reappeared. In this position, the
important landmarks are the transverse section of
the teres minor muscle, the cross section of the

Ultrasound-guided axillary nerve block

PCHA, the deltoid muscle, the triceps muscle and

the shaft of the humerus (Fig. 3). Using the in-line
technique, we inserted an 80 mm insulated nerve
s
stimulation needle (Stimuplex D 22G 80 mm, 151;
B. Braun Melsungen AG, Melsungen, Germany)
from the cranial end of the probe and placed the
needle tip just cranial to the PCHA but under the
muscle fascia (Fig. 4). This placement elicited contractions of the anterior, medial and posterior parts
of the deltoid muscle at a current of 0.5 mA
s
(Stimuplex HNS 12 Peripheral Nerve Stimulator,
B. Braun Melsungen AG) and we slowly injected
8 ml lidocaine 20 mg/ml (Lidokain, 20 mg/ml,
SAD, Amgros I/S, Copenhagen, Denmark), while
aspirating for every 2 ml injected.

Assessment of axillary nerve block

Fig. 2. Volunteer and transducer position. Lateral view of the
shoulder region demonstrating in-line needle insertion approximately 2 cm below the acromion and with the transducer parallel
to the longitudinal axis of the humerus. The shoulder joint is in the
neutral position and rotated 451 inward with the elbow flexed at
901, allowing the hand to rest on the knees. The black line marks
the lateral border of the acromion continuing medially in the
scapular spine.

Fig. 3. Ultrasonographic image of the shoulder region. The transducer is positioned as in Fig. 2 and the left side of the image is
oriented cranially. Important landmarks are the deltoid muscle
(DM) in longitudinal section, the head of the humerus (HH), the
humeral shaft (SH), the teres minor muscle (TM) in transverse
section and the triceps muscle (TrM) in longitudinal section. The
three arrowheads mark the axillary nerve cranially to the posterior
circumflex humeral artery (A) in the neurovascular space between
the TM, DM and TrM.

We assessed the motor and sensory function of the

axillary nerve before, at 15, 30, 60, 90, 120 min after
performing the block and every 30 min until termination of the block. Cold sensation was assessed by
applying a cooled object (5 1C) over the skin of the
distal part of the deltoid muscle, with the opposite
arm serving as a control. The sensation was
recorded as cold/not cold. Pinprick sensation was
assessed using a 22 G needle and compared with
the same dermatome on the opposite arm and
recorded as sensation or no sensation/numb. We

Fig. 4. Ultrasonographic image of the shoulder region with needle.

The transducer is positioned as in Fig. 3 and the left side of the
image is oriented cranially. The nerve stimulation needle is seen
(thin arrows) with the needle tip below the fascia caudal to the teres
minor muscle (TM) and just cranial to the posterior circumflex
humeral artery (A).

567

C. Rothe et al.

evaluated deltoid muscle function bilaterally in the

following way:20 (1) anterior part of the deltoid
muscle: active resistance against posterior and
downward movement of the arm with the shoulder
fixed in 701 abduction, 301 flexion, 301 lateral
rotation and the elbow in 901 flexion; (2) Middle
part of the deltoid muscle: active resistance against
adduction of the shoulder with the shoulder fixed
in 901 abduction and the elbow in 901 flexion; and
(3) Posterior part of the deltoid muscle: active
resistance against flexion of the arm with the
shoulder extended 301 and the elbow in 901 flexion.
Active resistive force was graded as 1 5 normal,
2 5 moderately decreased, 3 5 severely decreased
and 4 5 no force.

Volunteer study
In the 12 healthy volunteers, we performed and
evaluated the axillary block as described above. C.
R. performed all the blocks and K. L. evaluated all
the blocks.

Table 1
Motor and sensory function of the axillary nerve.

Motor function (deltoid

Anterior
Middle
Posterior
Sensory function
Pinprick
Cold stimulation

Baseline

15 min

30 min

muscle)
1
1
1

2.5 (14)
3.5 (14)
4 (14)

3 (14)
4 (14)
4 (14)

1
1

n 5 12. See text for further details.

Motor and sensory function at baseline and at 15 and 30 min
after performing a specific ultrasound-guided axillary nerve
block. Values are medians (minimummaximum).
1, sensation to pinprick or cold; , no sensation/numbness to
pinprick or no cold sensation.

on the forearm but not the hand. Sensory

block duration was 120 min (90150) and motor
block duration was 90 min (6050). All volunteers
found the pain associated with block performance
acceptable.

Results

Discussion

In 11 of the 12 volunteers, it was possible to obtain

satisfactory visualization of the PCHA in relation to
the surgical neck of the humerus. The shortest
distance from the skin to the wall of the artery
was 2.5 cm (2.24.0) [median (minimummaximum)]. The axillary nerve could not always be
clearly identified in the ultrasound image before
injection of the local anesthetic, but was identified
as a hyperechoic structure located cranial to the
PCHA embedded in the local anesthetic after
injection in six volunteers. Nerve stimulation elicited contractions of the posterior, middle and
anterior parts of the deltoid muscle in 10 volunteers. In one volunteer, no contractions were observed and in another volunteer, only contractions
of the posterior part of the deltoid muscle were
elicited. In both these volunteers, sensory block of
the axillary nerve could be demonstrated after
injection of the local anesthetic but no motor block.
Therefore, specific blocking of the axillary nerve
resulted in the absence of pinprick and cold sensation in the cutaneous area over the distal part of the
deltoid muscle in all 12 volunteers (Table 1) and 10
volunteers demonstrated motor block of the anterior, middle and posterior parts of the deltoid
muscle (Table 1). One volunteer demonstrated
sensory block to pinprick and cold stimulation in
the cutaneous innervation area of the radial nerve

To our knowledge, this is the first study to describe

an ultrasound-guided method to perform a specific
axillary nerve block. In 10 out of 12 healthy volunteers, the block was successful as evaluated by
sensory and motor function testing. The block
was easy to perform once the investigators became
acquainted with the ultrasonographic appearance
of the important landmarks. We speculate that the
reason for motor block failure in one volunteer is
due to the injection of the local anesthetic above the
fascia.
Only two previous studies have described a
technique to specifically block the axillary nerve
and both used a blind nerve stimulation technique.11,14 We appreciate the pioneering work carried
out by these authors. However, in our opinion, a
blind nerve stimulation technique in this region is
technically too difficult to become widely used.
Moreover, as the axillary nerve is located very close
to the humerus in this region, a blind technique
with multiple attempts to locate the nerve is not
comfortable in an awake patient. In our view, the
main advantage of an ultrasound-guided technique is the real-time visualization of the needle tip
and the spread of the local anesthetic, which make
the specific axillary nerve block easy to perform
with ultrasound. As direct visualization of the
axillary nerve is difficult, nerve stimulation may

568

Ultrasound-guided axillary nerve block

be needed to help locate the nerve once the needle

tip is below the fascia (Fig. 4). However, axillary
nerve block can probably be achieved successfully
just by injecting the local anesthetic cranial to the
PCHA in the neurovascular space without prior
nerve stimulation. We need further studies of local
anesthetic spread in and around the quadrangular
space to clarify this. This is important because the
axillary nerve divides into its major branches
(anterior and posterior branch) either within the
quadrangular space or later within the deltoid
muscle18 and complete axillary nerve block requires that both branches are blocked.
Sensory testing of specific axillary block is easy.
However, motor function testing is complicated,
because it involves the specific testing of the posterior, middle and anterior parts of the deltoid muscle
and because other shoulder muscles are able to
compensate for the lack of deltoid muscle force. In
our experience, an easy test is to ask the patient to
abduct both shoulders to 901 and palpate all three
parts of the deltoid muscle bilaterally. A flaccid
muscle in all three parts reveals a complete axillary
nerve block.
With our new technique, the patient is in the
sitting position, the shoulder in the neutral position
and rotated 451 inward with the elbow flexed at
901. This position is possible in almost every
patient with shoulder pathology. Other positions
may prove suitable as well.
We used 8 ml local anesthetic to perform the
block while previous studies used 15 ml. Clearly,
the optimal volume/concentration remains to be
determined. Does 15 ml provide a more reliable
block (i.e. proximal spread of LA) or is 5 ml
adequate? Previous studies have shown that the
minimal local anesthetic volume required for successful peripheral nerve block is related to the
cross-sectional area of the nerve.21
It seems reasonable to perform nerve blocks as
distally as possible for many reasons. The potential
advantages of a specific axillary nerve block either
alone or combined with a suprascapular nerve
block would include the ability to move the
shoulder, forearm and hand while avoiding the
side effects and potential serious complications
associated with IBPB. However, the clinical role
of a specific axillary nerve block remains undetermined. As described previously, only a few studies
have used the axillary nerve block.11,14 Price was
the first to describe the combination of the axillary
nerve block with a suprascapular nerve block, but
only used the techniques for post-operative analge-

sia after minor arthroscopic shoulder surgery. Recently, Price also mentioned an ultrasound-guided
approach to axillary nerve blocking in the NYSORA journal and reproduced similar ultrasound
images as in the present manuscript.22 Interestingly, Checcucci et al.14 used the combined blocks
for both intraoperative anesthesia and post-operative analgesia after arthroscopic shoulder surgery,
i.e. general anesthesia was not performed. Future
clinical studies should therefore investigate the
potential role for the specific axillary nerve block
for intraoperative anesthesia and/or post-operative analgesia either alone or in combination with
a suprascapular nerve block. Another very interesting question is whether a catheter placement is
possible in relation to the axillary nerve for prolonged post-operative analgesia.
In summary, we report a new technique to perform ultrasound-guided specific axillary nerve
blocking. The block is easy to perform and the
ultrasonographic landmarks are easily recognized.
The potential clinical role of this block remains to
be determined.

Acknowledgements
Kristian Antonsen, MD, Head of the Department of Anesthesia
and Intensive Care, Hillerd Hospital, is thanked for providing
excellent working conditions for all authors from the Department of Anesthesia and Intensive Care, Hillerd Hospital.
Funding: Kai Lange received a research grant from Hillerd
Hospital.
Conflicts of interest: The authors have no conflicts of interest.

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Address:
Kai H. W. Lange
Department of Anesthesia and Intensive Care
Hillerd Hospital
Dyrehavevej 29
DK-3400 Hillerd
Denmark
e-mail: klang@hih.regionh.dk