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REGIONAL ANESTHESIA

An Evaluation of the Supraclavicular Plumb-Bob Technique for Brachial Plexus Block by Magnetic Resonance Imaging

Øivind Klaastad, MD^*, Timothy R. VadeBoncouer, MD, Terje Tillung, RT, and Örjan Smedby, DrMedSci^,

*Department of Anesthesiology and The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway; Department of Anesthesiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois; and Department of Radiology, University Hospital Linköping, Linköping, Sweden

Address correspondence and reprint requests to Ø. Klaastad, MD, Rikshospitalet University Hospital, Department of Anesthesiology, Sognsvannsveien 20, 0027 Oslo, Norway. Address e-mail to oivind.klaastad{at}rikshospitalet.no

Partly based on magnetic resonance imaging studies, the "plumb-bob" approach for brachial plexus block was designed to minimize the risk of pneumothorax. Nevertheless, the risk of pneumothorax has remained a concern. We analyzed magnetic resonance images from 10 volunteers to determine whether the risk of pneumothorax was decreased with this method. The recommended initial needle direction is anteroposterior through the junction between the lateral-most part of the sternocleidomastoid muscle and the superior edge of the clavicle. If the initial placement is not successful, the brachial plexus may be sought in sectors 20°–30° cephalad or caudad to the anteroposterior line in a sagittal plane through the insertion point. We found that the anteroposterior line reached the pleura in 6 of 10 volunteers without prior contact with the subclavian artery or the brachial plexus, but always with contact with the subclavian vein. To reach the middle of the brachial plexus, a mean cephalad redirection of the simulated needle by 21° was required (range from 41° cephalad to 15° caudad in one case). We conclude that the risk of contacting the pleura and the subclavian vessels may be reduced by initially directing the needle 45° cephalad instead of anteroposterior. If the brachial plexus is not contacted, the angle should be gradually reduced.

IMPLICATIONS: In magnetic resonance images of volunteers, simulated needle passes with the "plumb-bob" approach to the supraclavicular brachial plexus block were analyzed for precision and risk profile. To avoid needle contact with the lung, the subclavian vein, and the subclavian artery, our results suggest a change in the method’s initial needle direction.

This article has been cited by other articles:

				O. Klaastad, O. Smedby, T. Kjelstrup, and H.-J. Smith The Vertical Infraclavicular Brachial Plexus Block: A Simulation Study Using Magnetic Resonance Imaging Anesth. Analg., July 1, 2005; 101(1): 273 - 278. [Abstract] [Full Text] [PDF]