{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,25]],"date-time":"2026-07-25T00:29:37Z","timestamp":1784939377834,"version":"3.55.0"},"reference-count":20,"publisher":"BMJ","funder":[{"DOI":"10.13039\/501100001161","name":"Australian Society of Anaesthetists","doi-asserted-by":"publisher","award":["ASA Small Grant"],"award-info":[{"award-number":["ASA Small Grant"]}],"id":[{"id":"10.13039\/501100001161","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2026,4,2]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Axillary nerve blockade contributes to selective shoulder analgesia while minimizing phrenic nerve involvement. However, reliable ultrasound-guided approaches remain undefined. We evaluated dye spread following a novel ultrasound-guided trans-quadrangular space approach targeting the axillary nerve in a cadaveric simulation study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>12 ultrasound-guided trans-quadrangular space injections using 7\u2009mL of methylene blue were performed in six fresh, unembalmed cadavers positioned laterally. The needles were inserted into the quadrangular space with a posterior approach. Dissections were conducted 15\u2009min after injection using a standardized protocol. The primary outcome was the frequency and degree of staining of the axillary nerve trunk and its anterior and posterior divisions. Secondary outcomes included staining of the radial nerve, musculocutaneous nerve, and posterior cord.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The main axillary nerve trunk demonstrated consistent staining in 100% (12\/12) of injections. At the branching point, the anterior and posterior divisions were stained in 83% (10\/12) and 90% (11\/12) of injections, respectively. The radial nerve was lightly stained in 25% (3\/12) of injections. No staining of the musculocutaneous nerve or posterior cord was observed. In all injections, dye tracking extended longitudinally within the quadrangular space and slightly beyond the nerve\u2019s entrance at anterior quadrangular space.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The ultrasound-guided trans-quadrangular space approach consistently stained the axillary nerve trunk and divisions with minimal unintended spread. This posterior technique, performed in the lateral position without shoulder abduction, demonstrates anatomical feasibility and may support further clinical investigation of selective axillary nerve blockade.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rapm-2026-107774","type":"journal-article","created":{"date-parts":[[2026,4,11]],"date-time":"2026-04-11T06:05:11Z","timestamp":1775887511000},"page":"rapm-2026-107774","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Ultrasound-guided trans-quadrangular space (TQS) approach to axillary nerve block: evaluation of dye spread after simulated cadaveric injections"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-5596-2871","authenticated-orcid":false,"given":"Michelle","family":"Chong","sequence":"first","affiliation":[{"name":"Anaesthesia, St Vincent\u2019s Hospital (Melbourne) Limited, Fitzroy, Victoria, Australia"},{"name":"Critical Care, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason","family":"Ivanusic","sequence":"additional","affiliation":[{"name":"Department of Anatomy and Neuroscience, University of Melbourne, Melbourne, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Burns","sequence":"additional","affiliation":[{"name":"St Vincent\u2019s Hospital (Melbourne) Limited, Fitzroy, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1704-7991","authenticated-orcid":false,"given":"Philip","family":"Peng","sequence":"additional","affiliation":[{"name":"Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,4,10]]},"reference":[{"key":"2026041023050656000_rapm-2026-107774v1.1","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1016\/j.jatmed.2025.12.004","article-title":"Considerations for regional anaesthesia for the shoulder joint - Beyond the C5-C6 nerve roots","volume":"4","author":"Chong","year":"2025","journal-title":"J Anesth Transl Med"},{"key":"2026041023050656000_rapm-2026-107774v1.2","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2024-106010"},{"key":"2026041023050656000_rapm-2026-107774v1.3","doi-asserted-by":"crossref","first-page":"e499","DOI":"10.1016\/j.jse.2020.07.017","article-title":"Sensory innervation of the human shoulder joint: the three bridges to break","volume":"29","author":"Laumonerie","year":"2020","journal-title":"J Shoulder Elbow Surg"},{"key":"2026041023050656000_rapm-2026-107774v1.4","doi-asserted-by":"crossref","unstructured":"Tran J , Peng PWH , Agur AMR . Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention. Reg Anesth Pain Med 2019. doi:10.1136\/rapm-2018-100152","DOI":"10.1136\/rapm-2018-100152"},{"key":"2026041023050656000_rapm-2026-107774v1.5","doi-asserted-by":"crossref","unstructured":"Tran J , Peng P . Chapter 22: shoulder denervation. In: Jankovic DD , Peng P , eds. Regional nerve blocks in anesthesia and pain therapy. 5th edn. New York (United States): Springer Science, 2022: 307\u201322.","DOI":"10.1007\/978-3-030-88727-8_22"},{"key":"2026041023050656000_rapm-2026-107774v1.6","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-00115550-200805000-00022"},{"key":"2026041023050656000_rapm-2026-107774v1.7","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1055\/s-0034-1366089","article-title":"Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment","volume":"35","author":"Gruber","year":"2014","journal-title":"Ultraschall Med"},{"key":"2026041023050656000_rapm-2026-107774v1.8","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1007\/s00276-023-03168-x","article-title":"The surgical anatomy of the axillary approach for nerve transfer procedures targeting the axillary nerve","volume":"45","author":"Beytell","year":"2023","journal-title":"Surg Radiol Anat"},{"key":"2026041023050656000_rapm-2026-107774v1.9","doi-asserted-by":"crossref","first-page":"912","DOI":"10.3171\/jns.2005.102.5.0912","article-title":"Surgical anatomy of the axillary nerve within the quadrangular space","volume":"102","author":"Tubbs","year":"2005","journal-title":"J Neurosurg"},{"key":"2026041023050656000_rapm-2026-107774v1.10","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1002\/ca.23394","article-title":"Ultrasonography-guided anterior approach for axillary nerve blockade: An anatomical study","volume":"33","author":"Gonz\u00e1lez-Arnay","year":"2020","journal-title":"Clin Anat"},{"key":"2026041023050656000_rapm-2026-107774v1.11","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1016\/j.bjae.2018.12.004","article-title":"Regional anaesthesia for shoulder surgery","volume":"19","author":"Hewson","year":"2019","journal-title":"BJA Educ"},{"key":"2026041023050656000_rapm-2026-107774v1.12","doi-asserted-by":"crossref","first-page":"1114","DOI":"10.1213\/ANE.0000000000000688","article-title":"Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis","volume":"120","author":"Abdallah","year":"2015","journal-title":"Anesth Analg"},{"key":"2026041023050656000_rapm-2026-107774v1.13","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1213\/00000539-199104000-00014","article-title":"One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography","volume":"72","author":"Urmey","year":"1991","journal-title":"Anesth Analg"},{"key":"2026041023050656000_rapm-2026-107774v1.14","doi-asserted-by":"publisher","DOI":"10.1097\/AAP.0000000000000436"},{"key":"2026041023050656000_rapm-2026-107774v1.15","doi-asserted-by":"publisher","DOI":"10.1111\/anae.14957"},{"key":"2026041023050656000_rapm-2026-107774v1.16","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1016\/j.bja.2018.06.006","article-title":"Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation","volume":"121","author":"Feigl","year":"2018","journal-title":"Br J Anaesth"},{"key":"2026041023050656000_rapm-2026-107774v1.17","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1002\/ca.23295","article-title":"The change in position of the axillary nerve with rotation of the arm","volume":"32","author":"Fox","year":"2019","journal-title":"Clin Anat"},{"key":"2026041023050656000_rapm-2026-107774v1.18","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1177\/1558944716668849","article-title":"Change in the Distance From the Axillary Nerve to the Glenohumeral Joint With Shoulder External Rotation or Abduction Position","volume":"12","author":"Simone","year":"2017","journal-title":"Hand (N Y)"},{"key":"2026041023050656000_rapm-2026-107774v1.19","doi-asserted-by":"crossref","unstructured":"Nanda M , Auyong D , Grant SA . Same plane, different target: aiming for proximal origins of the subscapular and axillary nerves. Reg Anesth Pain Med 2025. doi:10.1136\/rapm-2025-106442","DOI":"10.1136\/rapm-2025-106442"},{"key":"2026041023050656000_rapm-2026-107774v1.20","doi-asserted-by":"crossref","unstructured":"Isteni\u010d S , Pu\u0161nik L , Kenneth Ugwoke C , et al . Mechanistic insights into bupivacaine spread through anisotropic tissue planes and fascial barriers: experimental evidence for interfascial block dynamics. Reg Anesth Pain Med 2026. doi:10.1136\/rapm-2025-107469","DOI":"10.1136\/rapm-2025-107469"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2026-107774","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,11]],"date-time":"2026-04-11T06:05:14Z","timestamp":1775887514000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2026-107774"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,10]]},"references-count":20,"alternative-id":["10.1136\/rapm-2026-107774"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2026-107774","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,10]]}}}