{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T15:00:32Z","timestamp":1786114832685,"version":"build-2736575974"},"reference-count":22,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2025,4,23]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:p>The interscalene brachial plexus block is a well-described and widely used peripheral nerve block effective for regional anesthesia and analgesia in orthopedic surgical procedures of the shoulder, upper arm, and clavicle. Conventionally, an in-plane ultrasound-guided approach has been the technique of choice, while the out-of-plane approach, though less described, has been gaining anecdotal momentum among a growing number of proceduralists. This pro-con discussion highlights the out-of-plane approach\u2019s goal of avoiding needle injuries to nerves that course through the middle scalene muscle and the in-plane approach\u2019s benefit of whole-shaft needle visualization and increased distance away from the plexus on entry. We aim to provide a comprehensive comparison to guide proceduralists in their clinical decision-making.<\/jats:p>","DOI":"10.1136\/rapm-2025-106624","type":"journal-article","created":{"date-parts":[[2025,6,24]],"date-time":"2025-06-24T14:30:28Z","timestamp":1750775428000},"page":"985-988","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Tale of two approaches to ultrasound-guided interscalene brachial plexus block: a pro-con"],"prefix":"10.1136","volume":"51","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3934-4033","authenticated-orcid":false,"given":"Robert Loren","family":"Owen","sequence":"first","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beth A","family":"VanderWielen","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam W","family":"Amundson","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1920-9774","authenticated-orcid":false,"given":"Rebecca L","family":"Johnson","sequence":"additional","affiliation":[{"name":"Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,6,24]]},"reference":[{"key":"2026080502150691000_51.8.985.1","doi-asserted-by":"publisher","DOI":"10.1016\/S1098-7339(03)00189-5"},{"key":"2026080502150691000_51.8.985.2","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0b013e31826f0a63"},{"key":"2026080502150691000_51.8.985.3","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2020-101435"},{"key":"2026080502150691000_51.8.985.4","doi-asserted-by":"crossref","unstructured":"Samir GM , Ghallab MAEA . Onset and recovery of ultrasound guided out-of-plane versus in-plane interscalene block in arthroscopic shoulder surgery. Ain-Shams J Anesthesiol 2020;12. doi:10.1186\/s42077-020-00062-1","DOI":"10.1186\/s42077-020-00062-1"},{"key":"2026080502150691000_51.8.985.5","doi-asserted-by":"crossref","first-page":"1295","DOI":"10.1007\/s12630-015-0468-y","article-title":"Histological confirmation of needle tip position during ultrasound-guided interscalene block: a randomized comparison between the intraplexus and the periplexus approach","volume":"62","author":"Szerb","year":"2015","journal-title":"Can J Anaesth"},{"key":"2026080502150691000_51.8.985.6","doi-asserted-by":"publisher","DOI":"10.1097\/01.anes.0000299433.25179.70"},{"key":"2026080502150691000_51.8.985.7","doi-asserted-by":"crossref","first-page":"1600","DOI":"10.1111\/pme.12160","article-title":"Improving needle visualization by novice residents during an in-plane ultrasound nerve block simulation using an in-plane multiangle needle guide","volume":"14","author":"Gupta","year":"2013","journal-title":"Pain Med"},{"key":"2026080502150691000_51.8.985.8","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0b013e3181e859f0"},{"key":"2026080502150691000_51.8.985.9","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0246792","article-title":"Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial","volume":"16","author":"Harbell","year":"2021","journal-title":"PLoS One"},{"key":"2026080502150691000_51.8.985.10","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2044.2011.06712.x"},{"key":"2026080502150691000_51.8.985.11","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0b013e31820d5ee6"},{"key":"2026080502150691000_51.8.985.12","doi-asserted-by":"crossref","DOI":"10.5812\/aapm.31111","article-title":"Ultrasound-Guided Out-of-Plane vs. In-Plane Interscalene Catheters: A Randomized, Prospective Study","volume":"5","author":"Schwenk","year":"2015","journal-title":"Anesth Pain Med"},{"key":"2026080502150691000_51.8.985.13","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1016\/j.jse.2006.10.007","article-title":"The types and severity of complications associated with interscalene brachial plexus block anesthesia: Local and national evidence","volume":"16","author":"Lenters","year":"2007","journal-title":"J Shoulder Elbow Surg"},{"key":"2026080502150691000_51.8.985.14","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-00115550-200809000-00004"},{"key":"2026080502150691000_51.8.985.15","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-00115550-200811000-00006"},{"key":"2026080502150691000_51.8.985.16","article-title":"Ultrasound-Guided Interscalene Catheter Complicated by Persistent Phrenic Nerve Palsy","volume":"2018","author":"Koogler","year":"2018","journal-title":"Case Rep Anesthesiol"},{"key":"2026080502150691000_51.8.985.17","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0b013e318289e922"},{"key":"2026080502150691000_51.8.985.18","doi-asserted-by":"publisher","DOI":"10.1016\/S1058-2746(96)80031-0"},{"key":"2026080502150691000_51.8.985.19","doi-asserted-by":"crossref","first-page":"2425","DOI":"10.1007\/s10072-020-04836-1","article-title":"Ultrasound reference values of C5, C6, and C7 brachial plexus roots at the interscalene groove","volume":"42","author":"Bedewi","year":"2021","journal-title":"Neurol Sci"},{"key":"2026080502150691000_51.8.985.20","doi-asserted-by":"crossref","first-page":"745e","DOI":"10.1097\/PRS.0000000000003085","article-title":"Transverse Cervical Artery: Consistent Anatomical Landmarks and Clinical Experience with Its Use as a Recipient Artery in Complex Head and Neck Reconstruction","volume":"139","author":"Tessler","year":"2017","journal-title":"Plast Reconstr Surg"},{"key":"2026080502150691000_51.8.985.21","unstructured":"Zisquit J , Block NNI . 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