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Benefits of the

Costoclavicular Space for Ultrasound-Guided

Infraclavicular BrachialPlexus Block 

Description of a Costoclavicular Approach

Accepted for publication: February 4, 2015.

To the Editor:

Infraclavicular brachial plexus block (IC-

BPB) is traditionally performed at the lat-eral infraclavicular fossa (LIF) where thecords of the brachial plexus lie deep to the pectoral muscles and adjacent to the second  part of the axillary artery. However, at theLIF, the cords are separated from one an-other,1 there is substantial variation in the position of the individual cords relative tothe axillary artery,1,2 and all 3 cords arerarely visualized in a single ultrasound win-dow.2 Furthermore, the tip of a catheter, placed at the LIF, is unlikely to lie close toall 3 cords. Therefore, relatively large vol-umes of local anesthetic3 and/or multiple

injections are used to produce successful brachial plexus blockade,3 and secondarycatheter failure is not uncommon,4 evenwith 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

of ultrasound to perform brachial plexus blockade at this location.

The costoclavicular space5 lies deepand posterior to the midpoint of the clavi-

cle (Fig. 1).5 It is bound anteriorly by the

subclavius and clavicular head of the pec-

toralis major muscle (Fig. 1) and posteri-

orly 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 passesthrough 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 con-

trast to that at the LIF, the cords are rela-

tively superficial,5,6 clustered together,5,6

exhibit a triangular arrangement,5 and 

share a consistent relationship with one an-

other.5,6 In the sagittal plane, the lateral

cord is located anterior to the posterior 

and medial cords, the posterior cord is cra-

nial to the medial cord, and all 3 cords arecranial to the axillary artery (Fig. 1).6 In

the transverse plane, the cords of the bra-

chial plexus are located lateral to the first 

 part of the axillary artery (Fig. 2B).5

The anatomical arrangement of thecords at the costoclavicular space makes it an attractive site for ultrasound imaging

(Fig. 2A, B) and ICBPB (Fig. 2C – E). Atypical case where an ICBPB was suc-

cessfully performed at the costoclavicular space using ultrasound is illustrated inFigure 2. As shown, all 3 cords of the bra-chial plexus can be identified in a singletransverse sonogram of the costoclavicular space (Fig. 2B).5 The block needle isinserted in-plane from a lateral to medialdirection (Fig. 2C), aiming to position thetip between the 3 cords (Fig. 2D). The localanesthetic (ropivacaine or levobupivacaine0.5%, 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 thenerves of the lower trunk. The costoclavic-ular space (Fig. 2B) also acts as a useful sitefor brachial plexus catheter placement,with the catheter tip lying close to all the3 cords (Fig. 2F). Moreover, because thedistal end of the catheter is wedged in an“intermuscular tunnel,”   between the sub-clavius andserratus anterior muscle (Fig. 2B,F), this may help secure the catheter in situand reduce the risk of dislodgment that iscommon with supraclavicular catheters.

A limitation of the costoclavicular ap- proach is the potential for inadvertent vas-

cular or pleural puncture because of theclose proximity of these structures to thecostoclavicular space. However, having performed more than 100 ICBPBs usingthe costoclavicular approach, we haven’t encountered any such problem to date.Also, the position of the cords relativeto the axillary artery (Fig. 2B) combined with ultrasound guidance and a lateral tomedial – directed needle may offer protec-tion against vascular and pleural puncture because the needle tip is more likely to en-counter the cords of the brachial plexus be-fore the artery and/or pleura. Therefore, it 

may be prudent to use peripheral nervestimulation in conjunction with ultrasound guidance until one is familiar with thesonoanatomy and technique. Based on our initial experience, we believe that thecostoclavicular space deserves attentionas a potential site for ultrasound-guided ICBPB and encourage future research tocompare 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

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 howthe cords of thebrachial plexus are clustered together and lie cranial to the

 first part of the axillary artery. AA, axillary artery; AV, axillary vein.

LETTERS TO THE EDITOR 

Regional Anesthesia and Pain Medicine    •   Volume 40, Number 3, May-June 2015   287

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

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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, MDDepartment of Anesthesia and Intensive Care

The Chinese University of Hong KongPrince of Wales Hospital

Shatin, New Territories, Hong KongSAR, China

Xavier Sala-Blanch, MDDepartment of Anesthesiology

Hospital Clinic BarcelonaBarcelona, Spain

Department of Human Anatomyand Embryology

University of BarcelonaBarcelona, Spain

Banchobporn Songthamwat, MDDepartment of Anesthesia and Intensive Care

The Chinese University of Hong KongPrince of Wales Hospital

Shatin, New Territories, Hong KongSAR, China

Ban C.H. Tsui, MDDepartment of Anesthesia and Pain Medicine

University of Alberta

Edmonton, AlbertaCanada

REFERENCES

1. SauterAR, SmithHJ, Stubhaug A, Dodgson MS,

Klaastad Ø. Use of magnetic resonance

imaging to define the anatomical location

closest to all 3 cords of the infraclavicular 

 brach ial 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, BoutryN, 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 elbowflexion.  Reg Anesth Pain Med . 2009;34:

236 – 241.

Ultrasound Evidence of Injection Within the Nerve

Accepted for publication: January 20, 2015.

To the Editor:

The recent publication by Krediet et al,1

“Intraneural or Extraneural: DiagnosticAccuracy of Ultrasound Assessment for Localizing Low-Volume Injection,”   pro-vides practical insights and recommenda-tions for the regional anesthesiologist.One question that arises is the nature of the 16% of images that were mistakenlyinterpreted by the expert subjects. In par-ticular, was there a subset of videos that misled these experts repeatedly? The au-thors describe 3 facets of visualization of a block that give clues to an intranerve

(IN) injection:  “dimpling” of the nerve, ac-tual visible needle tip entry, and expansionof the nerve as injection proceeds. Did, infact, all 18 of the recorded images of delib-erate IN injection meet these conditions(inthe opinions of the authors), or did someof them show only 1 or 2 of the characteris-tics that were sought? This helps to dis-criminate whether it is the fallibility of thesubjects, the unreliability of our imagingsystems, or perhaps the actual sensitivityof the 3 characteristic of injection intothe nerves, as to the cause of these fairlyfrequent failures by experienced observers.

Certainly, we would expect more obviousand demonstrable evidence of the 3 condi-tions of IN injection during a research

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 brachialplexus within the costoclavicular space. C, Theblock needle is inserted in-plane from a lateral to medial direction. D, The needle tip is positioned between the 3 cords after which the localanesthetic (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, withits tipclose to all the 3 cords. SC,subclavius muscle; SA, serratus anterior muscle;LC, lateralcord; PC,posterior cord; MC, medial cord; AA, axillary artery; PM, pectoralis major muscle (clavicular head).

 Letters to the Editor    Regional Anesthesia and Pain Medicine    •   Volume 40, Number 3, May-June 2015

288   © 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.