Benefits Of The Costoclavicular Space For.15 3p5u60

LETTERS TO THE EDITOR

Benefits of the Costoclavicular Space for Ultrasound-Guided Infraclavicular Brachial Plexus Block Description of a Costoclavicular Approach Accepted for publication: February 4, 2015. To the Editor: nfraclavicular brachial plexus block (ICBPB) is traditionally performed at the lateral infraclavicular fossa (LIF) where the cords of the brachial plexus lie deep to the pectoral muscles and adjacent to the second part of the axillary artery. However, at the LIF, the cords are separated from one another,1 there is substantial variation in the position of the individual cords relative to the axillary artery,1,2 and all 3 cords are rarely visualized in a single ultrasound window.2 Furthermore, the tip of a catheter, placed at the LIF, is unlikely to lie close to all 3 cords. Therefore, relatively large volumes of local anesthetic3 and/or multiple injections are used to produce successful brachial plexus blockade,3 and secondary catheter failure is not uncommon,4 even with ultrasound guidance. We propose that the anatomy of the brachial plexus at the “costoclavicular space” is better suited for ICBPB, than that at the LIF, and describe (with patient’s approval) the successful use

I

of ultrasound to perform brachial plexus blockade at this location. The costoclavicular space5 lies deep and posterior to the midpoint of the clavicle (Fig. 1).5 It is bound anteriorly by the subclavius and clavicular head of the pectoralis major muscle (Fig. 1) and posteriorly by the anterior chest wall (Fig. 1).5 The space is continuous cranially with the supraclavicular fossa and caudally with the medial infraclavicular fossa above the superior border of the pectoralis minor muscle.5 The axillary vessels and cords of the brachial plexus traverse this space, with the vessels lying medial to the 3 cords (Fig. 2). The cephalic vein also es through the deltopectoral fascia at the deltopectoral groove to the axillary vein from a lateral to medial direction at the lower part of the costoclavicular space. At the costoclavicular space, and in contrast to that at the LIF, the cords are relatively superficial,5,6 clustered together,5,6 exhibit a triangular arrangement,5 and share a consistent relationship with one another.5,6 In the sagittal plane, the lateral cord is located anterior to the posterior and medial cords, the posterior cord is cranial to the medial cord, and all 3 cords are cranial to the axillary artery (Fig. 1).6 In the transverse plane, the cords of the brachial plexus are located lateral to the first part of the axillary artery (Fig. 2B).5 The anatomical arrangement of the cords at the costoclavicular space makes it an attractive site for ultrasound imaging

FIGURE 1. Sagittal anatomic section through the midpoint of the clavicle showing the costoclavicular space between the subclavius and upper slips of the serratus anterior muscle. Note how the cords of the brachial plexus are clustered together and lie cranial to the first part of the axillary artery. AA, axillary artery; AV, axillary vein. Regional Anesthesia and Pain Medicine • Volume 40, Number 3, May-June 2015

(Fig. 2A, B) and ICBPB (Fig. 2C–E). A typical case where an ICBPB was successfully performed at the costoclavicular space using ultrasound is illustrated in Figure 2. As shown, all 3 cords of the brachial plexus can be identified in a single transverse sonogram of the costoclavicular space (Fig. 2B).5 The block needle is inserted in-plane from a lateral to medial direction (Fig. 2C), aiming to position the tip between the 3 cords (Fig. 2D). The local anesthetic (ropivacaine or levobupivacaine 0.5%, 20 mL) is injected at a single site (Fig. 2D). This results in a very rapid onset of brachial plexus blockade similar to that seen with a supraclavicular approach but without the occasional sparing of the nerves of the lower trunk. The costoclavicular space (Fig. 2B) also acts as a useful site for brachial plexus catheter placement, with the catheter tip lying close to all the 3 cords (Fig. 2F). Moreover, because the distal end of the catheter is wedged in an “intermuscular tunnel,” between the subclavius and serratus anterior muscle (Fig. 2B, F), this may help secure the catheter in situ and reduce the risk of dislodgment that is common with supraclavicular catheters. A limitation of the costoclavicular approach is the potential for inadvertent vascular or pleural puncture because of the close proximity of these structures to the costoclavicular space. However, having performed more than 100 ICBPBs using the costoclavicular approach, we haven’t encountered any such problem to date. Also, the position of the cords relative to the axillary artery (Fig. 2B) combined with ultrasound guidance and a lateral to medial–directed needle may offer protection against vascular and pleural puncture because the needle tip is more likely to encounter the cords of the brachial plexus before the artery and/or pleura. Therefore, it may be prudent to use peripheral nerve stimulation in conjunction with ultrasound guidance until one is familiar with the sonoanatomy and technique. Based on our initial experience, we believe that the costoclavicular space deserves attention as a potential site for ultrasound-guided ICBPB and encourage future research to compare ICBPB at this site with that at the LIF. ACKNOWLEDGMENTS The anatomical section in Figure 1 is courtesy of the Visible Human Server at EPLF (Ecole Polytechnique Fédérale de Lausanne), Visible Human Visualization

287

Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

Letters to the Editor

Regional Anesthesia and Pain Medicine • Volume 40, Number 3, May-June 2015

FIGURE 2. Ultrasound-guided infraclavicular brachial plexus block: the costoclavicular approach. A, Position of the patient and orientation of the transducer (linear, 12-5 MHz). B, Transverse sonogram showing all 3 cords of the brachial plexus within the costoclavicular space. C, The block needle is inserted in-plane from a lateral to medial direction. D, The needle tip is positioned between the 3 cords after which the local anesthetic (LA) is injected at a single site. E, An indwelling catheter assembly (Pajunk E-Catheter Over Needle unit; Pajunk Medical System, Georgia) has been positioned in the costoclavicular space. F, Sonogram showing the indwelling catheter, with its tip close to all the 3 cords. SC, subclavius muscle; SA, serratus anterior muscle; LC, lateral cord; PC, posterior cord; MC, medial cord; AA, axillary artery; PM, pectoralis major muscle (clavicular head).

Software (http://visiblehuman.epfl.ch), and Gold Standard Multimedia www.gsm.org. All illustrations and sonograms are reproduced with kind permission from www.aic.cuhk.edu. hk/usgraweb. Dr Ban C.H. Tsui has been involved with modifying and redeg of the Pajunk MultiSet 211156-40 E-catheter over needle unit. Manoj Kumar Karmakar, MD Department of Anesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital Shatin, New Territories, Hong Kong SAR, China Xavier Sala-Blanch, MD Department of Anesthesiology Hospital Clinic Barcelona Barcelona, Spain Department of Human Anatomy and Embryology University of Barcelona Barcelona, Spain Banchobporn Songthamwat, MD Department of Anesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital Shatin, New Territories, Hong Kong SAR, China Ban C.H. Tsui, MD Department of Anesthesia and Pain Medicine University of Alberta

288

Edmonton, Alberta Canada

Ultrasound Evidence of Injection Within the Nerve Accepted for publication: January 20, 2015.

REFERENCES 1. Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad Ø. Use of magnetic resonance imaging to define the anatomical location closest to all 3 cords of the infraclavicular brachial plexus. Anesth Analg. 2006;103: 1574–1576. 2. Di Filippo A, Orando S, Luna A, et al. Ultrasound identification of nerve cords in the infraclavicular fossa: a clinical study. Minerva Anestesiol. 2012;78:450–455. 3. Rodríguez J, Bárcena M, Taboada-Muñiz M, Lagunilla J, Alvarez J. A comparison of single versus multiple injections on the extent of anesthesia with coracoid infraclavicular brachial plexus block. Anesth Analg. 2004;99: 1225–1230. 4. Ahsan ZS, Carvalho B, Yao J. Incidence of failure of continuous peripheral nerve catheters for postoperative analgesia in upper extremity surgery. J Hand Surg Am. 2014;39: 324–329. 5. Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A. Sonographic mapping of the normal brachial plexus. AJNR Am J Neuroradiol. 2003;24:1303–1309. 6. Moayeri N, Renes S, van Geffen GJ, Groen GJ. Vertical infraclavicular brachial plexus block: needle redirection after elicitation of elbow flexion. Reg Anesth Pain Med. 2009;34: 236–241.

To the Editor: he recent publication by Krediet et al,1 “Intraneural or Extraneural: Diagnostic Accuracy of Ultrasound Assessment for Localizing Low-Volume Injection,” provides practical insights and recommendations for the regional anesthesiologist. One question that arises is the nature of the 16% of images that were mistakenly interpreted by the expert subjects. In particular, was there a subset of videos that misled these experts repeatedly? The authors describe 3 facets of visualization of a block that give clues to an intranerve (IN) injection: “dimpling” of the nerve, actual visible needle tip entry, and expansion of the nerve as injection proceeds. Did, in fact, all 18 of the recorded images of deliberate IN injection meet these conditions (in the opinions of the authors), or did some of them show only 1 or 2 of the characteristics that were sought? This helps to discriminate whether it is the fallibility of the subjects, the unreliability of our imaging systems, or perhaps the actual sensitivity of the 3 characteristic of injection into the nerves, as to the cause of these fairly frequent failures by experienced observers. Certainly, we would expect more obvious and demonstrable evidence of the 3 conditions of IN injection during a research

T

© 2015 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.