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 passes
through the deltopectoral fascia at the
deltopectoral groove to join 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

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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 redesigning 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

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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:
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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

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© 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.