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Posterior access (according to Pippa)

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A posterior access can be used as an alternative to the anterior access. The puncture site is located on the back of the neck, at the level of C6/C7 and is directed dorsad towards the scalenus gap. This technique was first described by Kappis in 1912. Then it was forgotten until Pippa started using the posterior interscalene block again in 1990, applying the loss-of-resistance technique for localising the target. Thanks to the use of electrical nerve stimulation, this approach has gained importance over the last few years.

 

Anatomical landmarks

Processus spinosus C7 (vertebra prominens), Hinterrand M. sternocleidomastoideus, Cricoid

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Block technique

The patient is placed in the lateral recumbent position, the head is placed axially on a pillow, the cervical spine is flexed backwards. The puncture can also be made with the patient in a sitting position. The spinous process of the 7th cervical vertebra is usually well palpable. A mark is made in the middle between the spinous process of the sixth and seventh cervical vertebra. The puncture site is 3 cm lateral to this. The puncture is made 5 -10° laterally, towards the direction of the easily felt posterior edge of the sternocleidomastoid muscle at the level of the cricoid. Once the transverse process of C7 is encountered, the direction of puncture is corrected just slightly to the cranial, until, after another 1 -2 cm, the upper trunk (C5/C6) is reached. This becomes visible by contractions of the biceps brachii muscle.

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