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The Internet Journal of Anesthesiology

Volume 11 Number 2

Sonoanatomy Of The Brachial Plexus With Single Broad

Band-High Frequency (L17-5 Mhz) Linear Transducer
A Thallaj
Citation

A Thallaj. Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear Transducer.
The Internet Journal of Anesthesiology. 2006 Volume 11 Number 2.
Abstract
Background: Sonographic mapping of the brachial plexus has been reported and may have clear clinical applications. The aim
of this study is to evaluate the quality of images of the brachial plexus with single high frequency broad band (L17-5MHZ)
ultrasound transducer for different regions.
Methods: 25 patients (5 femal, 20 male) age range (35-70yr), underwent sonographic examination for assessment of the
brachial plexus and its spatial relationship with other adjacent structures.
Results: Excellent quality of images was obtained in all patients except for infraclavicular region (19 images were rated as
excellent and 6 were rated as good).
Conclusion: Using single (L17-5 MHZ) ultrasound transducer can reliably illustrate the brachial plexus and the adjacent
structures of interest for different scanning depth.

BACKGROUND AND PURPOSE

METHODS

Mapping of the brachial plexus with broad band highfrequency linear transducers such as (5-10 MHz),
(10-13MHZ) and (8-14MHz) has been reported (1, 2, 3). The
purpose of this study is to demonstrate that mapping of the
brachial plexus with a wider band range; higher frequency
(L17-5MHz) ultrasound transducer may give more clear
images to superficial and deep adjacent structures. Also, we
are aiming to evaluate the efficiency of a single transducer
for different imaging depth.

In this prospective observational study, conducted on 25

adult patients (5 female) age range 35-70yr, scheduled for
upper limb and carotid artery sonographic assessment in the
vascular laboratory .Consent was obtained for the brachial
plexus ultrasonography.
Sonographic images were obtained with Philips IU22
ultrasound system using (L17 -5 MHz, USA) linear
transducer (Fig1).

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Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear
Transducer
Figure 1

Figure 1: Philips (IU22, USA) ultrasound system.

coronal oblique plane (Fig2-B).

Figure 3

Figure 2b: Coronal oblique plane

The infraclavicular region was imaged in a parasagital plane

(Fig2-C), and the axillary region was scanned in a
transversal view (Fig2-D).
Figure 4

Figure 2c: Coronal transverse view.

The examinations were performed while patients lying

supine and the head turned 45 degrees to the controlateral
side. Photographs were taken to identify the probe position
at each different site.
Started from the interscalene region, the probe positioned in
an axial oblique plane (Fig2-A).
Figure 2

Figure 2a: Axial oblique plane

In the supraclavicular fossa, the probe was placed in a

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Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear
Transducer
Figure 5

SUPRACLAVICULAR FOSSA

Figure 2d: Transverse view.

Excellent images were obtained in all patients. The brachial

plexus, appeared as a cluster of hypoechoic nodules lateral to
the subclavian artery, deeper structures (lung, first rib) were
illustrated clearly (Fig 4, 5).
Figure 7

Figure 4: Transverse sonogram in the supraclavicular region

showing the brachial plexus as a cluster of hypoechoic
nodules (N); 1RIB = first rib seen as hyperechoic band; SCA
= subclavian artery

Images were stored digitally and interpreted in agreement

between one anesthetist and two sonographers. The quality
of images was rated as excellent, good and poor.

RESULTS
INTERSCALENE REGION
Excellent images were obtained in all patients, the brachial
plexus was illustrated as hypoechoic nodules surrounded by
hyperechoic rims between the anterior and middle scalene
muscles and the posterior margin of the sternocleidomastoid
muscle. Adjacent and deeper structures of interest (carotid
artery, internal jugular vein, vertebral artery) all were
imaged clearly (Fig 3).

Figure 8

Figure 5: Color Doppler to identify the subclavian artery

Figure 6

Figure 3: SCM = sternocleidomastoid muscle; ASM =

anterior scalene; MSM =middle scalene; IJV =internal
jugular vein; CCA = common carotid artery; VA = vertebral
artery.

INFRACLAVICULAR REGION
The quality of images were rated as excellent in (19 patients)
and good in( 6 patient) ,the brachial plexus cords were
visualized deep to the pectoralis minor around the axillary
artery(Fig 6), no image was rated as poor .

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Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear
Transducer
Figure 9

Figure 11

Figure 6: Transverse sonogram in the infraclavicular region

showing the brachial plexus nodules (N).

Figure 8: Transverse sonogram in the axillary region shows

the musculocutaneus nerve as a round to oval hypoechoic
nodule. AA = axillary artery; BI = biceps muscle; CB =
coracobrachialis muscle; H = humerus.

AXA = axillary artery; AXV = axillary vein; PM =

pectoralis major muscle; Pm = pectoralis minor muscle

THE AXILLARY LEVEL

DISCUSSION

Excellent images were obtained in all patients (Fig7). The

terminal branches of brachial plexus appeared as hypoechoic
nodules around the axillary artery.

In 1978, la Grang (4) reported the use of Doppler ultrasound

blood flow detector to facilitate supraclavicular brachial
plexus block, although he was unable to visualize the
brachial plexus because of the limited ultrasound technology
at that time.

Figure 10

Figure 7: Transverse sonogram in the axillary region

showing the terminal branches of the brachial plexus as
hypoechoic nodules (N) , AA = axillary artery; AV =
axillary vein (one or two can be seen).

In 1994, Kapral described the use of ultrasound to directly

visualize the brachial plexus (5). In 1998, Sheppard
recommended linear transducers of 7.5 MHZ or higher for
imaging the brachial plexus (6). During the last few years
ultrasound technology has evolved dramatically. This lead to
better understanding of sonoanatomy (7, 8, 9).
Visualizing the roots, cords and nerves of the brachial plexus
requires high frequency transducers. However, the higher the
frequency the smaller the penetration depth.
New development in ultrasound technology has allowed a
broader band and higher frequencies to be achieved by a
single transducer, and may eliminate the need to change the
transducer for different imaging depth.

The musculocutaneus nerve was also illustrated as a round to

oval hypoechoic nodule between the two heads of the
coracobrachialis muscle (Fig 8).

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In 2003, Perlas used (L12-5 MHZ) probe to map the brachial

plexus, he could visualize the brachial plexus in only 27% of
patients in the infraclavicular region (10).
In our study, we used more advanced ultrasound system with
broader band and higher frequency (L17-5MHZ) transducer
with 100% success rate in visualizing the brachial plexus

Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear
Transducer
and its spatial relationship to surrounding structures in all
patients and for different scanning depth. This has clear
implications not only to identify the target structure, but also
to visualize the structures to be avoided during the
procedure.
This study also has demonstrated that single broad band
transducer can reliably cover different imaging depth with at
least good quality of images.

ACKNOWLEDGEMENT
We would like to thank Dr.A.Kayali, Associate Professor
and head of vascular surgery division at King Khalid
University Hospital for his kind approval of the project. I
would like to extend my thanks to Mr. M.Murtada, US
technician at vascular laboratory for his kind assistance
during the study period.

References
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plexus revealed by Sonography and the role of sonographic

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guidance in anesthesia of the brachial plexus. AJR AmJ

Roentgenol 1998; 171:1631-6
2. Demondion X, Herbinet P, Boutry N, Fontaine C.
Sonographic mapping of the normal brachial plexus. AJNR
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M. Ultrasound -guided supraclavicular approach for regional
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6. Sheppard D, Lyer R. Brachial plexus Demonstration at
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Sonoanatomy Of The Brachial Plexus With Single Broad Band-High Frequency (L17-5 Mhz) Linear
Transducer

Author Information
Ahmad Thallaj, M.D., CABA
Consultant, Anesthesia & Intensive Care, King Khalid University Hospital

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