Retroclavicular approach of brachial plexus block: Here to stay!!!

Sir,

Several techniques of infraclavicular brachial plexus nerve block (ICB) have been described in literature: stressing on various surface landmarks, site of needle insertion, and needle direction.[1]

Classical infraclavicular approach was the first one to be described followed by the retroclavicular approach. The retroclavicular approach offers the advantage of better needle visibility, lesser chances of vascular puncture and more patient comfort.[2] In this approach the linear transducer is placed vertically below the clavicle, lateral to the midclavicular line. The needle is inserted above and posterior to the clavicle in a caudad direction.

Lately, a horizontal approach (Japanese) or the costoclavicular approach has been described.[345] The linear transducer is placed parallel and inferior to the clavicle and lateral to the midclavicular line. The transducer is moved from distal to proximal position, so as to visualize the cords clustered lateral and superficial to the first part of the axillary artery. An insulated needle is inserted lateral to medial in plane to the transducer. All three cords are blocked by a single local anesthetic injection. As the pleura is superficial in this location, the risk of pneumothorax is present. However, constant visualization of the needle trajectory obviates this risk.

Although this technique is simple and handy, in our experience, retroclavicular technique is still of benefit over the horizontal approach in the following cases:

Patients with deep deltopectoral groove wherein a prominent humerus hinders with the needling

Patients with altered anatomy where the brachial plexus is located more laterally than usual position

Also in patients with acute trauma where abduction of the upper limb will not be comfortable for the patient.

Hence, though newer approaches have been described, the retroclavicular approach still offers few advantages over horizontal approach. Furthermore, if we rotate the transducer slightly vertically in the horizontal approach and enter our needle cephalad to caudad above the clavicle (retroclavically), it can solve our problem. [Figure 1] Hence, we suggest that more randomized trials are required to establish the benefit of costoclavicular approach of ICB.

Figure 1

Retroclavicular block at the proximal level

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