Anterior Scalene Block Test for Thoracic Outlet Question

[Timeoutofmind]

I have a thoracic surgeon sending me these for diagnostic purposes prior to first rib resection.

Pts are very legit and have extensive imaging/workup with positive findings ahead of time.

My question is this.

On review of the literature, it seems there is some ambiguity.

At times both the middle and anterior scalene muscles are blocked, and at times only the anterior scalene muscle.

I am not sure which is more appropriate diagnostically?

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[drrosenrosen]

The one time I did anterior and middle, I got some brachial plexus blockade, which I of course warned the patient about in advance but they still didn't appreciate. I've done anterior only since then and had no problem

 

[Orin]

I would ask your surgeon about their surgical plans. They generally would remove both, portion of the first rib, and sometimes part of the pec. The injection of the anterior alone though is sufficient to diagnose and sometimes treat.

 

[buddababa]

I have a thoracic surgeon sending me these for diagnostic purposes prior to first rib resection.

Pts are very legit and have extensive imaging/workup with positive findings ahead of time.

My question is this.

On review of the literature, it seems there is some ambiguity.

At times both the middle and anterior scalene muscles are blocked, and at times only the anterior scalene muscle.

I am not sure which is more appropriate diagnostically?

Only block anterior scalene, never block middle. Sometimes pectoralis minor block is done depending on sx
Thanks to the world renown surgeon who is famous for thoracic outlet, I had 4 or 5 of these patients weekly in my past job.

 

[Ferrismonk]

I usually do anterior and middle, but never as a diagnostic for a surgeon. Maybe as conservative care before surgery is contemplated.

However, in my experience, botox to the scalenes works better than surgery. (Although they all seem to get surgery anyway due to promises this can be "fixed").

 

[RoloTomassi]

What kind of surgeons do these, cardiothoracic or NSG/ortho?

Off topic, but do surgeons actually operate on Bertolotti, piriformis, cluneal entrapment, etc, or are these unlisted code, non-reimbursable type surgeries?

 

[buddababa]

What kind of surgeons do these, cardiothoracic or NSG/ortho?

Off topic, but do surgeons actually operate on Bertolotti, piriformis, cluneal entrapment, etc, or are these unlisted code, non-reimbursable type surgeries?

Mainly vascular surgeon/general

 

[Ducttape]

What kind of surgeons do these, cardiothoracic or NSG/ortho?

Off topic, but do surgeons actually operate on Bertolotti, piriformis, cluneal entrapment, etc, or are these unlisted code, non-reimbursable type surgeries?

none in my area. from my perspective, that is due to lack of interest or reliable benefit more than the code.

 

[nighty23]

Any advice/ words of wisdom for a non anesthesiologist to go about blocking the anterior scalene?

 

[SSdoc33]

please dont overdiagnose thoracic outlet syndrome.

the literature numbers for incidence of true TOS is very small

 

[SSdoc33]

What kind of surgeons do these, cardiothoracic or NSG/ortho?

Off topic, but do surgeons actually operate on Bertolotti, piriformis, cluneal entrapment, etc, or are these unlisted code, non-reimbursable type surgeries?

ive seen surgeons operate on bertolatti. they just put a screw thru the pseudojoint to fuse it. the 2 patients ive seen with it both failed (still had pain). and neither had a per-surgical injection

piriformis surgery i have seen once, and that was with MRI evidence of the sciatic actually going thru the piriformis. she did well with it.

im not sure that the cluneal nerve actually exists

 

[Ferrismonk]

Any advice/ words of wisdom for a non anesthesiologist to go about blocking the anterior scalene?

Make sure your ultrasound skills are awesome and don't miss.

 

[bedrock]

Make sure your ultrasound skills are awesome and don't miss.

not particularly helpful

 

[Orin]

Any advice/ words of wisdom for a non anesthesiologist to go about blocking the anterior scalene?

Think of it as a trigger point with an ultrasound, except with really big vessels and the brachial plexus there. You actually can use palpation of the muscles to find symptomatic spots, but if you start like you're doing a stellate with ultrasound, you'll see the anterior scalene and can follow it down easily to the clavicle. I normally scan as low as I can by the clavicle/1st rib, get in the muscle belly, and inject 2 - 3 mL of local +/- steroid into the muscle with a tiny needle.

Be careful as the phrenic runs anterior to the anterior scalene, so stick to the lateral border of the muscle down low and the medial border up high. You can sometimes see it if you're magic.

A comparison of the effectiveness of complex decongestive physiotherapy and stellate ganglion block with triamcinolone administration in breast cancer-related lymphedema patients - PubMed

SGB is an effective treatment which can reduce the circumference of arm in breast cancer-related lymphedema patients and could be an alternative treatment for lymphedema.

pubmed.ncbi.nlm.nih.gov

A Randomized Comparison between 4, 6 and 8 mL of Local Anesthetic for Ultrasound-Guided Stellate Ganglion Block

Background: Because it affords greater accuracy than landmark-based techniques, ultrasound guidance may reduce the volume of local anesthetic required for sympathetic blockade of the upper extremity. We hypothesized that 4 mL would provide a similar clinical effect when compared to larger...

www.mdpi.com

 

[callmeanesthesia]

Practice scanning yourself. Ultrasound your own brachial plexus and follow it up and down your neck, while looking at example pics online. Identify the vessels, the muscles, and the brachial plexus.

 

[jwalker12]

For those of you doing both the ASM and MSM are you injecting the MSM then removing the needle and coming from the opposite side of the transducer toward the ASM or do you go through the BP avoiding the roots?

 

[cameroncarter]

What CPT code do we use for the ant.scalene block? Seems like it should be more than a TPI

Only block anterior scalene, never block middle. Sometimes pectoralis minor block is done depending on sx
Thanks to the world renown surgeon who is famous for thoracic outlet, I had 4 or 5 of these patients weekly in my past job.

 

[deleted875186]

What kind of surgeons do these, cardiothoracic or NSG/ortho?

Off topic, but do surgeons actually operate on Bertolotti, piriformis, cluneal entrapment, etc, or are these unlisted code, non-reimbursable type surgeries?

I had a patient get resection of TP and fusion at L5-S1 from some “bertolotti expert” in New York City. Patient tells me it cured their back, but still on opioids ……

 

[swamprat]

What CPT code do we use for the ant.scalene block? Seems like it should be more than a TPI

20552 + 76942 (u/s guidance) - it is just trigger point 🤷‍♂️

 

[deleted131481]

I had a patient get resection of TP and fusion at L5-S1 from some “bertolotti expert” in New York City. Patient tells me it cured their back, but still on opioids ……

Doctor: "So you said your pain is gone now. Why do you still take Norco?"
Patient: "I don't understand what you mean."

 

[Ligament]

Use ultrasound
1-2 cc local into Anterior scalene
1-2 cc local into Middle scalene
4 cc local into pectoralis minor
Pain log

Rarely get brachial plexus block but it can happen

The reason they don't do middle scalene blocks is lack of skill or lack of appropriate imaging equipment

Most folks dealing with this issue are not advanced injectionists.

 

[Asclepius186]

Visualize the stoplight like an interscalene block. Except don’t go inter, go to each scalene. Simple 1.5” 25g needle on 5cc syringe. 1.5 cc local plus steroid to each scalene out of plane. Easy as pie.

 

[Ligament]

Visualize the stoplight like an interscalene block. Except don’t go inter, go to each scalene. Simple 1.5” 25g needle on 5cc syringe. 1.5 cc local plus steroid to each scalene out of plane. Easy as pie.

I agree, go out of plane for the scalenes, very quick. Don't even need to numb skin, too superficial to be of any benefit.

 

[Baron Samedi]

Does out of plane risk bagging the phrenic? I've been doing in plane but sometimes pesky nerve roots get in the way.

 

[Ligament]

Does out of plane risk bagging the phrenic? I've been doing in plane but sometimes pesky nerve roots get in the way.

If you mean physically damaging the phrenic with the needle, possibly...but you should be able to visualize it and avoid it. Also, you can use a 27ga or 30 ga in most people do do this block. Since you are injecting inside the muscle sheath should have minimal leakage. Finally, unless your patient has severe lung disease a phrenic block should be ok, unilaterally.

 

[epidural man]

For those of you doing both the ASM and MSM are you injecting the MSM then removing the needle and coming from the opposite side of the transducer toward the ASM or do you go through the BP avoiding the roots?

I inject the anterior, middle, and pec minor.

For the scalenes, it is one of the few blocks with ultrasound I do out-of-plane.