Introduction:

The costoclavicular brachial plexus block was explained as an alternative approach to the infraclavicular block. The compact organization of the plexus at this level, clustered lateral to the 1^st part of the axillary artery and more superficial than in sagittal approach allows blockade with less volume and a single needle. Hence, it is called spinal anaesthesia of upper limb.

Anatomy:

Costoclavicular space lies deep and posterior to the mid point of clavicle.

Boundaries:

Anteriorly – subclavius muscle and clavicular head of pectoralis major muscle
Posteriorly – anterior chest wall

It is continuous cranially with supraclavicular fossa and caudally with medial infraclavicular fossa. In contrast to lateral infraclavicular fossa, the cords are relatively superficial, clustered together, exhibit a triangular arrangement, and share a consistent relationship with one another.

Indications:

• Upper limb surgeries, distal to the elbow.
• Obese patients with short neck where ultrasound visualization is difficult.
• Patients with other limitations to traditional plexus blocking technique.

Technique:

Position: Position: Patient is placed supine and head turned to other side, with the limb to be anaesthetized positioned on a Mayo table at 90 degree abduction.

Transducer: High-frequency linear transducer (10-18MHZ)

Needle: A neurostimulator needle / a block needle / a 22 g or 23 g spinal needle

The probe is positioned just below the middle third of the clavicle. The axillary artery and vein are located, and lateral to them, the three components of brachial plexus (lateral, posterior and medial cords) are seen. The needle is inserted in-plane from lateral to medial direction, aiming to position the needle tip between 3 cords. 20 to 25 ml of local anaesthetic drug is injected in a single site. This results in rapid onset of brachial plexus block similar to that seen with supraclavicular approach but without that occasional sparing of nerves of lower trunk. 8 to 10 minutes later, the dermatome sensitivity test of the radial, ulnar, median and musculocutaneous nerves is performed, and effective blockade is detected in all dermatomes tested.

Advantages:

Brachial plexus can be blocked by costoclavicular block precisely by a single injection, provides excellent anaesthesia to operate, provides superior pain relief, and helps in early recovery, early mobilization and early discharge.

Costoclavicular space also acts as a useful site for brachial plexus catheter with  the tip lying close to all 3 cords. Because the distal end of catheter is wedged in an intermuscular tunnel between subclavian AND serrratus anterior muscle, this may help in securing the catheter in situ and decrease the risk of dislodgement that is common in supraclavicular catheters.

Limitations:

Only limitation is the potential inadvertent vascular or pleural puncture because of close proximity to these structures. Combined with ultrasound guidance and lateral to medial directed needle, may offer protection against vascular and pleural puncture because needle tip is more likely to encounter the cords of brachial plexus before the artery & pleura.

Dr. Hemalatha Iyanar
Anaesthesiologist
Kauvery Hospital