REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
Ultrasound-Guided Selective Versus Conventional Block of the
Medial Brachial Cutaneous and the Intercostobrachial Nerves
A Randomized Clinical Trial
Philippe Magazzeni, MD,* Denis Jochum, MD,† Gabriella Iohom, MD,‡ Gérard Mekler, MD,*
Eliane Albuisson, MD, PhD,§ and Hervé Bouaziz, MD, PhD*
Background and Objectives: For superficial surgery of anteromedial
and posteromedial surfaces of the upper arm, the medial brachial cutaneous
nerve (MBCN) and the intercostobrachial nerve (ICBN) must be selec-
tively blocked, in addition to an axillary brachial plexus block. We com-
pared efficacy of ultrasound-guided (USG) versus conventional block of
the MBCN and the ICBN.
Methods: Eighty-four patients, undergoing upper limb surgery, were ran-
domized to receive either USG (n = 42) or conventional (n = 42) block of
the MBCN and the ICBN with 1% mepivacaine. Sensory block was evalu-
ated using light-touch on the upper and lower half of the anteromedial and
posteromedial surfaces of the upper arm at 5, 10, 15, 20 minutes after nerve
blocks. The primary outcome was the proportion of patients who had no sen-
sation in all 4 regions innervated by the MBCN and the ICBN at 20 minutes.
Secondary outcomes were onset time of complete anesthesia, volume of
local anesthetic, tourniquet tolerance, and quality of ultrasound images.
Results: In the USG group, 37 patients (88%) had no sensation at
20 minutes in any of the 4 areas tested versus 8 patients (19%) in the
conventional group (P < 0.001). When complete anesthesia was obtained,
it occurred within 10 minutes in more than 90% of patients, in both groups.
Mean total volumes of local anesthetic used for blocking the MBCN and
the ICBN were similar in the 2 groups. Ultrasound images were of good
quality in only 20 (47.6%) of 42 patients. Forty-one patients (97.6%)
who received USG block were comfortable with the tourniquet versus
16 patients (38.1%) in the conventional group (P < 0.001).
Conclusions: Ultrasound guidance improved the efficacy of the MBCN
and ICBN blocks.
Clinical Trial Registration: This study was registered at ClinicalTrials.
gov, identifier NCT02940847.
(Reg Anesth Pain Med 2018;00: 00–00)
T he medial brachial cutaneous nerve (MBCN) and the
intercostobrachial nerve (ICBN) innervate the medial surface
of the upper arm1 (Fig. 1) with a variable cutaneous distribution,
related to their size and their interconnections. The MBCN is a
branch of the medial cord of the brachial plexus. In the axilla, it
passes through the subcutaneous tissue, superficial to the brachial
fascia.2–4 The ICBN is not part of the brachial plexus; it usually
From the *Department of Anesthesiology, Hôpital Central, CHRU Nancy; and
†Department of Anesthesiology, Hôpital Albert Schweitzer, Colmar, France;
‡Department of Anaesthesia, Intensive Care and Pain Medicine/University Col-
lege Cork, Cork University Hospital, Wilton, Cork, Ireland; and §Unit of Meth-
odology, Data Management, Statistic, CHRU Nancy, France.
Accepted for publication February 12, 2018.
Address correspondence to: Hervé Bouaziz, MD, PhD, Service d'Anesthésie-
Réanimation Chirurgicale, Hôpital Central, CHRU Nancy, 29 Avenue du
Maréchal De Lattre de Tassigny, 54000 Nancy, France (e‐mail:
h.bouaziz@chru-nancy.fr).
The authors declare no conflict of interest.
Copyright © 2018 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000823
Regional Anesthesia and Pain Medicine • Volume 00, Number 00, Month 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
originates from the lateral branch of the second intercostal
nerve (T2); its course can be described as entering the medial
wall of the axilla, crossing the anterior aspect of the latissimus
dorsi muscle, and continuing into the posteromedial subcutane-
ous tissue of the upper arm.2,4,5 The MBCN and the ICBN are
often interconnected.4 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.
A brachial plexus block alone, whether performed at the ax-
illa 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. Surgeries, such as
superficialization of basilic vein for brachiobasilic arteriovenous
fistula, require anesthesia of MBCN and ICBN in addition to an
ABPB. These nerves are classically anesthetized by raising a sub-
cutaneous 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.6 The failure rate of this blind infiltration
procedure is inherent to the technique used, although it has never
been quantified in the literature. The advent of high-performance
ultrasound systems has made ultrasound guidance during this pro-
cedure feasible. The nerves can often be identified on the ultra-
sound images (Figs. 2 and 3). Wijayasinghe et al7 described an
ultrasound-guided (USG) ICBN block in the thoracic region (sec-
ond intercostal space), whereas Wisotzky et al8 described it in the
axillary fossa. However, no study has ever compared the effective-
ness of the USG technique with the conventional blind technique
for MBCN and ICBN blocks. The primary objective of our study
was to compare the effectiveness of conventional and USG blocks
of the MBCN and the ICBN in the axillary fossa. Our hypothesis
was that the proportion of patients with complete anesthesia in the
entire posteromedial and anteromedial surface of the arm would
be greater if a USG technique were used, compared with a conven-
tional technique. The secondary objectives were onset time of
complete anesthesia, volume of local anesthetic used for the pro-
cedure, tourniquet tolerance during surgery, and ultrasound visi-
bility of MBCN and ICBN.
METHODS
We performed a single-blind randomized clinical trial in pa-
tients undergoing surgery of the upper limb (hand, forearm, elbow,
and anteromedial and posteromedial arm). Distal surgeries of the
upper limb were included because the tourniquet was placed in
the area of interest. Pregnant women, minor patients, and those
under guardianship were excluded. Anesthesia consisted of a
USG ABPB and a block of the MBCN and the ICBN in the axilla,
with either conventional (conventional group) or USG technique
(USG group). The local anesthetic used was 1% mepivacaine
(Carbocaine; AstraZeneca, London, United Kingdom). Approval
from the Regional Ethics Committee (Comité de Protection des
1
Magazzeni et al Regional Anesthesia and Pain Medicine • Volume 00, Number 00, Month 2018

FIGURE 1. Skin distribution (and variations) of the MBCN and the ICBN (original image).

Personnes Est III) and consent from each patient were obtained.
This study was registered at ClinicalTrials.gov (NCT02940847).
We allocated patients to 1 of 2 groups, each including
42 patients, by block randomization (6 patients per block). Rou-
tine monitoring was applied, and intravenous access secured for
each patient. Ultrasound images were acquired with an M-Turbo
SonoSite device (Bothell, Washington), and a linear ultrasound
probe (HFL38X; 6–13 MHz, 38 mm; SonoSite) was used. Nerve
blocks were performed with 80-mm 22-gauge Sonoplex needles
(Pajunk Medical Systems LP, Norcross, Georgia) in awake pa-
tients through a single skin puncture.
In both groups, the median, radial, ulnar, musculocutaneous,
and medial antebrachial cutaneous nerves were blocked with a to-
tal of 30 mL of the local anesthetic solution. In patients allocated
to the conventional group, 3 to 6 mL of 1% mepivacaine (at the
discretion of the anesthesiologist) was infiltrated blindly subcuta-
neously at the same level of the axilla in the anteroposterior
direction prior to complete needle withdrawal. In patients allo-
cated to the USG group, the needle was redirected, and between
1 and 2 mL of 1% mepivacaine 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 vol-
ume if the nerves appeared during the injection), in the subcutane-
ous area located above the brachial fascia, with a posterior
direction, toward the latissimus dorsi muscle.
Blockade of the MBCN and the ICBN was evaluated every
5 minutes in the first 20 minutes from the end of the injection in
4 areas: the upper half and the lower half of the anteromedial
and posteromedial surfaces of the upper arm. Cutaneous sensation
in each area was compared in the anesthetized and contralateral
arm using light-touch perception with cotton wool using an ordi-
nate scale: “no sensation,” “blunted sensation,” or “normal sen-
sation.” The primary outcome variable was the percentage of
patients experiencing “no sensation” at 20 minutes, in all 4 areas.

FIGURE 2. Transverse section of the axilla region, with the MBCN and the ICBN (original image). MABCN indicates medial antebrachial
cutaneous nerve; MCN, musculocutaneous nerve; MN, median nerve; RN, radial nerve; UN, ulnar nerve.

2 © 2018 American Society of Regional Anesthesia and Pain Medicine

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Regional Anesthesia and Pain Medicine • Volume 00, Number 00, Month 2018 USG Block of Cutaneous Nerves of the Arm

FIGURE 3. Ultrasound images of the MBCN and the ICBN, using a 6–15 MHz linear probe for didactic purposes. AA indicates axillary artery;
MABCN, medial antebrachial cutaneous nerve; MCN, musculocutaneous nerve; MN, median nerve; RN, radial nerve; UN, ulnar nerve.

Secondary Outcomes recorded at the end of the surgery (comfortable, unpleasant, or

painful) as another means of assessing MBCN and ICBN block-
The onset time of complete anesthesia was defined as the in- ade. The volume (in milliliters) of 1% mepivacaine used for
terval between the end of injection and complete loss of sensory MBCN and ICBN block and ultrasound visibility of theses nerves
function in a specific territory. The tourniquet tolerance was (categorized as good before and after injection, poor before and

FIGURE 4. Consolidated Standards of Reporting Trials flow diagram.

© 2018 American Society of Regional Anesthesia and Pain Medicine 3

Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Magazzeni et al Regional Anesthesia and Pain Medicine • Volume 00, Number 00, Month 2018

good after injection, and poor before and after injection) were
also collected. TABLE 2. Light Touch Perception at 20 Minutes in Different
Areas of the Surface of the Upper Arm by Patient Group*
Each procedure was performed by a single, experienced an-
esthesiologist. Ultrasound visibility was evaluated by the anesthe-
Area of Skin USG Conventional
siologist who performed the procedure. Sensory testing in each
Considered Sensation (n = 42) (n = 42) P
area, tourniquet tolerance, and volume of mepivacaine used (in-
ferred from the volume left in the syringe) were evaluated by an- Distal anteromedial arm
other anesthesiologist, unaware of group allocation (blinded). No sensation 42 (100%) 21 (50%) <0.001
No opioids, general anesthetics, or sedatives were used be- Blunted sensation 0 1 (2.4%)
fore evaluating blockade of the MBCN and the ICBN. Intraoper- Normal sensation 0 20 (47.6%)
atively, if the tourniquet was painful, sufentanil was administered. Proximal anteromedial arm
The success rate of the conventional technique is estimated
No sensation 38 (90.5%) 17 (40.5%) <0.001
between 20% and 30% in clinical practice. To detect a 30% effect
of an intervention with an α risk of 5% and a power of 80%, an Blunted sensation 3 (7.1%) 1 (2.4%)
adequate sample size of 42 patients per group was calculated. Sta- Normal sensation 1 (2.4%) 24 (57.1%)
tistical analysis was performed using IBM SPSS Statistics version Distal posteromedial arm
22 (IBM Corp, Armonk, New York). According to their nature No sensation 41 (97.6%) 14 (33.3%) <0.001
and distribution, variables were expressed with mean (SD), me- Blunted sensation 0 1 (2.4%)
dian (interquartile range), or frequencies and percentages. Analy- Normal sensation 1 (2.4%) 27 (64.3%)
sis used Pearson χ2 test or Fisher exact test or parametric (Student Proximal posteromedial arm
test) or nonparametric (Mann-Whitney U) test. The bilateral sig- No sensation 39 (92.9%) 12 (28.6%) <0.001
nificance level was set at 5%. Blunted sensation 2 (4.7%) 1 (2.4%)
Normal sensation 1 (2.4%) 29 (69.0%)
RESULTS *The procedure investigated was a block of the MBCN and of the ICBN
Eighty-four eligible patients were enrolled between in the axillary fossa.
November 2016 and February 2017: 42 patients in each group
(conventional group or USG group) (Fig. 4). Demographic data
and location of surgery, for each group, are shown in Table 1. tourniquet times (mean ± SD, 28 ± 23 and 29 ± 22 minutes, re-
Operative times (mean ± SD, 25 ± 22 and 28 ± 27 minutes in spectively, P = 0.63) were similar in the 2 groups. The tourni-
the USG and conventional groups, respectively, P = 0.59) and quet pressure was set by the surgeons at 250 mm Hg for
all 84 patients.

TABLE 1. Patient Characteristics by Study Group Primary Outcome

In the USG group, 37 (88%) of 42 patients had “no sensa-
USG Conventional tion” at 20 minutes in all 4 areas tested versus only 8 (19%) of
(n = 42) (n = 42) 42 patients in the conventional group (P < 0.001).
Age, y
Median (interquartile range), y 47 (33) 50 (29) Secondary Outcomes
Sex Thirty-eight (90.5%) of 42 patients in the USG group had “no
Male 32 (76.2%) 24 (57.1%) sensation” over the entire anteromedial surface at 20 minutes versus
Female 10 (23.8%) 18 (42.9%) 17 (40.5%) of 42 patients in the conventional group (P < 0.001).
Body mass index Thirty-nine (92.9%) of 42 patients in the USG group had “no
Median (interquartile range), 25.0 (6.7) 25.5 (5.6) sensation” over the entire posteromedial surface at 20 minutes ver-
kg/m2 sus 12 (28.6%) of 42 in the conventional group (P < 0.001).
Location of surgery Table 2 lists the light-touch perception at 20 minutes in each
Hand or wrist 35/42 (83.3%) 40/42 (95.2%)
area tested.
In all the regions considered, when complete anesthesia was
Forearm 5/42 (11.9%) 2/42 (4.8%)
obtained, it occurred within 10 minutes in more than 90% of pa-
Elbow and medial upper arm 2/42 (4.8%) 0/42 (0%) tients in both groups.
Type of surgery The total volumes of local anesthetic used for the MBCN and
Hand and wrist trauma 28 (67%) 22 (52%) the ICBN blocks were similar in the 2 groups (median [interquar-
(bites, sores, foreign tile range], 5.0 mL [2.0 mL] in the USG group versus 5.0 mL
body, fractures) [1 mL] in the conventional group, P = 0.33).
Hand and wrist infection 4 (10%) 7 (17%) In terms of the ultrasound visibility of the MBCN and the
(abscess, cellulitis) ICBN, both nerves were clearly identified both before and after in-
Carpal tunnel 4 (10%) 2 (5%) jection in 20 (47.6%) of 42 patients, poorly identified before and
Dupuytren contracture 1 (2%) 1 (2%) clearly identified after injection in 9 (21.4%), and poorly identi-
Hand and wrist arthrodesis 2 (5%) 4 (10%) fied both before and after injection in 13 patients (31%).
Wrist arthroscopy 1 (2%) 1 (2%) For patients who underwent the USG procedure, the image
Elbow hygroma 1 (2%) 0 (0%) quality of MBCN and ICBN had no influence on the primary
Ulnar neurolysis at the elbow 1 (2%) 0 (0%) outcome. The proportion of patients with “no sensation” in
Removal of implanted metal 0 (0%) 5 (12%) all 4 areas at 20 minutes was similar irrespective of the visibility:
18 of 20 patients with good ultrasound visibility before and after

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Regional Anesthesia and Pain Medicine • Volume 00, Number 00, Month 2018
injection, versus 7 of 9 patients with poor visibility before and
good visibility after injection, versus 12 of 13 patients with poor
visibility before and after injection (P = 0.69).
Forty-one (97.6%) of 42 patients in the USG group were
comfortable with the tourniquet versus 16 (38.1%) of 42 in the
conventional group (P < 0.001). The remaining patient in the
USG group rated the tourniquet as uncomfortable, whereas in
the conventional group 24 (57.1%) patients rated it as uncomfort-
able and 2 (4.8%) as painful.
Intraoperatively, 2 patients in the conventional group re-
ceived sufentanil because the tourniquet was painful versus
0 patient of the USG group.
DISCUSSION
Lanz et al9 showed that brachial plexus blocks, whether per-
formed at the axilla or more proximally, rarely extend to the ICBN
(10% of cases). The ICBN, a branch of the second intercostal
nerve (T2), communicates4 with the MBCN, a branch of the me-
dial cord of the brachial plexus, to supply the medial aspect of the
upper arm.1 Either of the 2 nerves (MBCN or ICBN) may be the
predominant cutaneous supplier to the medial upper arm.4 There-
fore, medial upper arm surgery may require a separate blockade of
the ICBN, in addition to a brachial plexus block.10 If the brachial
plexus block is performed at the axilla, a block of the MBCN is
also required, because the MBCN often separates from the bra-
chial plexus more proximally.
For surgery about the elbow, an ABPB alone runs the risk of
inadequate anesthesia. In our clinical experience, when surgical
incision for elbow surgery extends to the medial surface of the up-
per arm, ABPB alone is often inadequate. This is contrary to
existing data11 resulting from a retrospective study, where sensory
blockade of the individual nerves was not assessed and intrave-
nous sedation was liberally used. In addition, selective anesthesia
of the MBCN and ICBN seems to be helpful for upper limb fistula
surgery.12 As such, for upper arm fistula creation, failure to block
the medial aspect of the upper arm may result in pain causing sur-
gical procedure disruption and requiring supplementary anesthe-
sia. Indeed, Purcell and Wu13 have combined supraclavicular
brachial plexus block (where the MBCN does not need to be se-
lectively blocked) and pectoral nerves block (PECS II) for upper
arm fistula with apparent good results. This technique, however,
mandates a second skin puncture.
Our study is the first clinical trial comparing USG and con-
ventional block of the MBCN and ICBN in the axillary fossa. It
comes in the context of increased use of ultrasound guidance for
regional anesthesia, as per the most recent recommendations.14
The rate of successful outcome was significantly higher in
the USG versus the conventional group. These results are not sur-
prising, considering previous published data on ultrasound guid-
ance; among many other examples, USG bilateral superficial
cervical plexus blocks are more effective than landmark tech-
niques for reducing pain following thyroidectomy.15 The fact that
in our study complete anesthesia was not obtained in all patients in
the USG group can be explained by anatomical variations. The
skin areas innervated by these nerves can vary from one individual
to another1 (Fig. 1).
Although there was no significant difference between the to-
tal volumes of local anesthetic injected in the 2 groups, volumes
were not standardized and could have affected success rates.
Ultrasound images of the MBCN and ICBN were of good
quality in approximately half of the patients, probably because
of the small size of these nerves.4 Because more than 50% of
the blocks were performed as a field injection rather than specific
block of a visible structure, we have no proof that we blocked both
© 2018 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
USG Block of Cutaneous Nerves of the Arm
the MBCN and the ICBN. With higher-resolution transducers (GE
L8-18i), visualization of very small nerves, such as subcutaneous
nerves of the forearm, becomes possible.16 Similarly, Hanson and
Auyong17 showed in their study that, using a 6–15 MHz ultra-
sound probe, only 10% of the targeted small nerves (dorsal scap-
ular and long thoracic nerves) were not visible. Poor image
quality, however, did not affect the success rate of the procedure
in our study. This suggests that knowledge of usual anatomical sit-
uation of these nerves allows USG deposition of local anesthetic
solution precisely at the right place.
Onset time of complete anesthesia was short when it was
achieved, likely because of the small size of the nerves. There
was no difference in block onset time between the 2 groups.
Patients in the USG group tolerated the pneumatic tourniquet
much better than did those in the conventional group. As tourni-
quet time and pressure did not differ between groups, this im-
proved tolerance may be attributable to more effective anesthesia
in the innervation areas of the MBCN and ICBN. However, the
pathophysiology of tourniquet pain is complex and multifactorial,
involving not only compression of the skin but also ischemia and
compression of nerves and muscles.18 In the absence of anesthe-
sia, the pain increases gradually and becomes dramatically intoler-
able after 30 to 40 minutes.
Block randomization can be seen as strength because it al-
lows for random assignment of patients between the 2 groups
and thus limits imbalances. On the other hand, the main weakness
is the possible anticipation of the group assigned to the last patient
in each block, especially because the blocks were small (6 pa-
tients) and only 1 anesthesiologist performed all the procedures;
therefore, it can be considered a bias.
One limitation of our study is that it was single-blind; be-
cause of technical reasons, the patients may have noticed which
technique (USG or conventional) was being used toward the end
of the procedure. Also, we only tested the cutaneous sensory dis-
tribution of the MBCN and the ICBN. Our study did not compare
effectiveness of USG versus conventional technique for medial
upper arm surgery because only 2 patients underwent elbow sur-
gery. Instead, tourniquet tolerance was used as an additional surro-
gate parameter of anesthesia effectiveness in these territories.
Another limitation is that all blocks were performed by a single
anesthesiologist, which although improves reproducibility of the
block technique, it only truly assesses a single provider's skill.
In conclusion, our findings demonstrated that ultrasound
guidance improved efficacy of MBCN and ICBN blocks in the ax-
illa compared with a blind approach. The clinical implication of
this is better tourniquet tolerance. Ideally, further double-blind
studies in patients undergoing medial upper arm surgery are re-
quired to confirm these results.
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