This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Crews, J. C. Articles by Weller, R. S. Search for Related Content PubMed PubMed Citation Articles by Crews, J. C. Articles by Weller, R. S. Related Collections Complications Regional Anesthesia

---

ANALGESIA

Pneumothorax After Coracoid Infraclavicular Brachial Plexus Block

From the Department of Anesthesiology, Section on Regional Anesthesia and Acute Pain Management, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Address correspondence to James Crews, MD, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1009. Address e-mail to jcrews{at}wfubmc.edu.

Abstract

Several variations on the technique for infraclavicular brachial plexus block have been described. The coracoid infraclavicular technique has become popular because of easily identified landmarks, reliable distribution of blockade, and low risk of respiratory complications such as pneumothorax. We report a case of pneumothorax in a patient after a coracoid infraclavicular brachial plexus block. Subtleties in landmark identification and measurement may affect the risk of pneumothorax.

Several variations on the technique for infraclavicular brachial plexus block have been described (1–14). The coracoid infraclavicular technique, originally described by Whiffler in 1981 (8), has become popular because of relatively easily identified anatomic landmarks, reliable distribution of neural blockade, and low risk of respiratory complications, such as phrenic nerve blockade and pneumothorax (9). At our institution, the coracoid infraclavicular brachial plexus block, based on the description of Wilson et al. in 1998 (9), has become our most frequently used brachial plexus block technique for upper extremity surgical procedures at or below the elbow. We report a case of pneumothorax in a patient after a coracoid infraclavicular brachial plexus block. The case illustrates subtleties in landmark identification and measurement that are pertinent to the risk of pneumothorax.

CASE REPORT

A 53-yr-old, male (height = 188 cm; weight = 87 kg) presented for left ulnar nerve transposition as an outpatient. He had previously undergone right ulnar nerve transposition with an upper extremity block at another hospital. The block procedure was performed by a PGY-4 resident, supervised by an attending anesthesiologist, after informed consent and standard monitoring and sedation. The supine patient was instructed to "reach toward his left knee with his left arm" to relax his shoulder musculature. The clavicle and the coracoid process were easily identified and a mark was made on the skin approximately 2 cm medial and 2 cm inferior to the coracoid process in the deltopectoral groove.

The skin was prepared, and after intradermal anesthesia was obtained with 1 mL of 1% lidocaine, a 90-mm 21-G insulated nerve block needle with a 20° cutting bevel (Polymedic® UPC 92090-21, Avid Medical, Inc. Toano, VA) was directed posteriorly from the previously marked skin site. The needle was advanced to approximately 5 cm depth without brachial plexus motor response. The needle was subsequently redirected caudally in the parasagittal plane, and bone, presumed to be rib, was contacted at approximately 5 cm depth. From this location the needle was redirected about 10° in the lateral direction and a motor response was obtained at approximately 7 cm depth in the distribution of the posterior cord of the brachial plexus (extension of the wrist). Twenty milliliter of 0.5% ropivacaine with epinephrine 1:200,000 and clonidine 0.00015% was injected in 5 mL increments after negative aspiration. The needle was withdrawn and repositioned and a lateral cord response (pronation of the forearm) was immediately obtained, and 20 mL of 0.5% ropivacaine with epinephrine 1:200,000 and clonidine 0.00015% was injected in 5 mL increments after negative aspiration. The needle was then redirected in a more caudad direction in the lateral parasagittal plane and a medial brachial plexus cord response (ulnar flexion of the wrist) was obtained and an additional 10 mL of 0.5% ropivacaine with epinephrine 1:200,000 and clonidine 0.00015% was injected in 5 mL increments after negative aspiration. The patient tolerated the procedure well and demonstrated adequate surgical anesthesia of the operative extremity within 15 min. The maximum depth of needle insertion was 7 cm in accordance with current clinical practice (9,15).

Approximately 5 min after completion of the block, the patient reported "muscle soreness" in the region of the left chest wall. He stated that the discomfort began around the time of the nerve block procedure. The patient’s vital signs were stable and he reported the discomfort as mild. The patient remained stable and after minimal sedation with propofol in the operating room, he reported complete resolution of the discomfort. With the history of encountering bone with one of the needle passes and the mild but suspicious chest discomfort, a pneumothorax was considered and a chest radiograph (CXR) was obtained in the operating room before the beginning of the surgical procedure. The patient remained asymptomatic throughout the surgical procedure with minimal to moderate sedation. At no time did he report dyspnea or sharp pain, and arterial oxygen saturation was 100% on 2 L of oxygen by nasal cannulae. During the surgical procedure, the supine CXR obtained preoperatively was reported as demonstrating a "small" pneumothorax. After completion of the surgical procedure, upright inspiratory and expiratory CXRs were obtained to more clearly define the extent of pneumothorax, and a 30% left pneumothorax was demonstrated. A thoracostomy tube was placed by the surgical team and the patient was admitted for postoperative observation and care. The chest tube was discontinued approximately 36 h later, and the patient was discharged home.

DISCUSSION

The coracoid infraclavicular approach to neural blockade of the upper extremity provides several advantages as compared to axillary, interscalene, and supraclavicular brachial plexus block. The anatomic surface landmarks are generally easy to identify, the head and arm may be in any position for the block, the technique is relatively easy to perform using either a nerve stimulator or ultrasound guidance, and the risk of pneumothorax is very low, particularly compared to supraclavicular approaches, which have a reported risk from 0.3% to 6% (16). A single report of pneumothorax with the coracoid approach appears in an observational series by Desroches (17), but none of the details of that particular complication are included. Pneumothorax (and phrenic nerve block) has been reported with the more medial "vertical infraclavicular block" originally described by Kilka et al. (5). Several variations of the coracoid infraclavicular brachial plexus block have been described with various surface landmarks and recommendations for needle direction.

In the description and study of the parasagittal anatomy important to the coracoid infraclavicular block by Wilson et al. (9), the specific point of needle insertion was described as being 2 cm medial and 2 cm caudad specifically to the lateral tip of the coracoid process. In general, the lateral tip of the coracoid process is prominent and is usually easy to identify. However, in some patients, due to anatomic variation and body habitus, the lateral, anterior, and medial aspects of the coracoid process may be palpated initially. After contact with bone (rib) in this patient, all subsequent needle passes were made with the needle directed more laterally. After thorough reassessment of the landmarks following completion of the procedure, it was determined that in this individual, the initial needle insertion site was located 2 cm medial to the medial tip of the coracoid (approximately 4 cm medial to the lateral tip) resulting in needle insertion approximately 2 cm more medial than originally described by Wilson et al. (9) (Fig. 1). Insertion of a 90-mm needle at a site 2 cm medial and 2 cm caudad to the medial aspect of the coracoid process placed the needle path sufficiently medial to result in the pneumothorax in this patient.

Variability in determining the point of needle insertion in peripheral nerve blocks, even among experienced anesthesiologists, has been reported (18). MacLeod et al. suggested a method for identification of the coracoid process for infraclavicular blocks (19).

We believe that the choice of needle insertion site based on palpation of the coracoid process for the coracoid infraclavicular block should be very particular. Our current practice is to mark the site for needle insertion 2 cm medial and 2 cm caudad to the lateral tip of the coracoid process or, alternatively, 2 cm caudad to the medial aspect of the coracoid process as the most medial extent of needle placement. If only one prominent part is encountered, needle insertion can be made 2 cm caudad to the medial aspect of the coracoid process as described in the study by Koscielniak-Nielsen et al. (20).

In conclusion, we present a complication of pneumothorax after a coracoid infraclavicular brachial plexus block where the correct measurements were made from the incorrect aspect of the coracoid process, resulting in an excessively medial needle insertion path. Anesthesiologists should be alert to the possibility of pneumothorax, particularly if rib is contacted during the procedure, or if the patient complains of chest pain after its completion.

Footnotes

Accepted for publication March 15, 2007.

Reprints will not be available from the authors.

REFERENCES

1. Bazy L. L’Anesthesie du plexus brachial. In: PauchetV, Sourdat P, Labouré J, eds. L’Anesthesie regionale. Paris: Doin et Cie, 1917:222–5.
2. Balog A. Leitungsanästhesie an dem infraaclavicularen Teile des Plexus Brachialis. Zentralbl Chir 1924;51:1563–4.
3. Labat G. Regional anesthesia. Philadelphia: W.B. Saunders, 1930:67–89.
4. Muntenau P, Atug S, Nahr E, Roth H, Katzer G. Die transpectorale blockade des Plexus Brachialis. Reg Anesth 1982;5:34–8.
5. Kilka HG, Geiger P, Mehrkens HH. Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study. Anaesthesist 1995;44:339–44.[Web of Science][Medline]
6. Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular brachial plexus block—a new approach. Anesth Analg 1973; 52:897–904.[Free Full Text]
7. Sims JK. A modification of landmarks for infraclavicular approach to brachial plexus block. Anesth Analg 1977;56:554–5.[Abstract/Free Full Text]
8. Whiffler K. Coracoid block—a safe and easy technique. Br J Anaesth 1981;53:845–8.[Abstract/Free Full Text]
9. Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg 1998;87: 870–3.[Abstract/Free Full Text]
10. Salazar CH, Espinosa W. Infraclavicular brachial plexus block: variation in approach and results in 360 cases. Reg Anesth Pain Med 1999;24:411–16.[Web of Science][Medline]
11. Kapral S, Jandrasits O, Schabernig C, Likar R, Reddy B, Mayer N, Weinstabl C. Lateral infraclavicular plexus block vs. axillary block for hand and forearm surgery. Acta Anaesthesiol Scand 1999;43:1047–52.[Web of Science][Medline]
12. Borgeat A, Ekatodramis G, Dumont C. An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001;93:436–41.[Abstract/Free Full Text]
13. Klaastad O, Smith HJ, Smedby O, Winther-Larssen EH, Brodal P, Breivik H, Fosse ET. A novel infraclavicular brachial plexus block: the lateral and sagittal technique, developed by magnetic resonance imaging studies. Anesth Analg 2004;98:252–6.[Abstract/Free Full Text]
14. Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth 2006; 96:502–7.[Abstract/Free Full Text]
15. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular perineural infusion with clonidine and ropivacaine compared with ropivacaine alone: a randomized, double-blinded, controlled study. Anesth Analg 2003;97:706–12.[Abstract/Free Full Text]
16. Brown DL, Bridenbaugh LD The upper extremity: somatic block. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain. Philadelphia, PA: Lippincott-Raven, 1998:357.
17. Desroches J. The infraclavicular brachial plexus block by the coracoid approach is clinically effective: an observational study of 150 patients. Can J Anaesth 2003;50:253–7.[Web of Science][Medline]
18. Grant SA, Breslin DS, MacLeod DB, Demeyts D, Martin G, D’Ercole F, Hardman D. Variability in determination of point of needle insertion in peripheral nerve blocks: a comparison of experienced and inexperienced anaesthetists. Anaesthesia 2003; 58:688–92.[Web of Science][Medline]
19. MacLeod DB, Grant SA, Martin G, Breslin DS. Identification of coracoid process for infraclavicular blocks. Reg Anesth Pain Med 2003;28:485.[Web of Science][Medline]
20. Koscielniak-Nielsen ZJ, Rotboll Nielsen P, Risby Mortensen C. A comparison of coracoid and axillary approaches to the brachial plexus. Acta Anaesthesiol Scand 2000;44:274–9.[Web of Science][Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Crews, J. C. Articles by Weller, R. S. Search for Related Content PubMed PubMed Citation Articles by Crews, J. C. Articles by Weller, R. S. Related Collections Complications Regional Anesthesia