Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block †

Abstract

The infraclavicular vertical brachial plexus block, first described by Kilka and coworkers, offers a more proximal spread of anaesthesia for the upper extremity than the classic axillary approach. In this technique, the puncture site is defined as lying at the exact centre of an infraclavicular line (k) between the jugular fossa and the ventral process of the acromion. Our study was designed to determine whether the point so defined (P) corresponds with the optimal puncture site determined sonographically (S) and to develop an improved prediction model. High-resolution ultrasonography was carried out in 59 volunteers to visualize the plexus. Sonography-derived distances and morphometric measurements were used to test accuracy and calculate multiple regressions. We found a clear trend towards a more lateral puncture site. In women, S was significantly (P<0.001) lateral (8 mm) to P. The overall accuracy of the infraclavicular vertical brachial plexus block technique was not sufficient to predict the optimal puncture site reliably. Our resulting improved prediction model is valid for both sexes and is based not just on the centre point but on the absolute length of k (22-22.5 cm). We found that for every 1 cm decrease in k the optimal puncture site moved 2 mm laterally from the exact centre of k, and for every 1 cm increase in k it moved 2 mm medially. The suggested modification should help to increase the success rate of the infraclavicular vertical brachial plexus block while decreasing the rate of potentially severe complications, although individual ultrasonographic guidance is to be recommended whenever possible.