Chapter 80C: Supraclavicular Brachial Plexus Block

INTRODUCTION

The supraclavicular block is one of several techniques used to anesthetize the brachial plexus. The block is performed at the level of the brachial plexus trunks where almost the entire sensory, motor, and sympathetic innervation of the upper extremity is carried in just three nerve structures confined to a very small surface area. Consequently, this technique typically provides a predictable, dense block with rapid onset.^1,2,3 In 1911, Georg Hirschel described a surgical approach to the brachial plexus in the axilla. A few months later, Diedrich Kulenkampff, in Germany, performed the first percutaneous supraclavicular approach, reportedly on himself. The technique was published in 1928 by Kulenkampff and Persky.⁴ As they described it, the technique was performed with the patient in the sitting position (“a regular chair will suffice”) or in the supine position with a pillow between the shoulders. The operator sat on a stool at the side of the patient. The needle was inserted above the midpoint of the clavicle where the pulse of the subclavian artery could be felt and was directed medially toward the spinous process of T2 or T3. Kulenkampff ‘s familiarity with brachial plexus anatomy allowed him to recognize that “the best way to reach the trunks was in the neighborhood of the subclavian artery over the first rib.” His technique was also simple: “all the branches of the plexus could be anesthetized through one injection.” These two assertions are still valid today. Unfortunately. his advice on needle direction carried an inherently high risk of pneumothorax. The popularity of the supraclavicular block remained unrivaled during the entire first half of the 20th century until well after World War II. During this time the technique underwent several modifications, most of them intended to reduce the risk of pneumothorax.^1,5,6,7,8

The introduction of axillary techniques by Accardo and Adriani⁹ in 1949 and by Burnham¹⁰ in 1958 marked the beginning of the decline in enthusiasm for the supraclavicular block. The axillary block was particularly popularized after a publication in the journal Anesthesiology by Rudolph De Jong in 1961¹¹ The paper was based on cadaver dissections and included the now well-known calculation of 42 mL as the volume needed to fill a cylinder 6 cm long (axillary sheath); according to De Jong, this dose “should be sufficient to completely bathe all branches of the brachial plexus.” The article was also critical of the supraclavicular approach. Coincidentally, the same journal published a paper by Brand and Papper,¹² who compared axillary and supraclavicular techniques and warned of the 6.1% rate of pneumothorax frequently quoted for supraclavicular block.

More modern modifications of supraclavicular block include Alon Winnie and Vincent Collins’s subclavian perivascular technique¹³ and the “plumb-bob” technique of Brown and collaborators.¹⁴ The former is more a concept than a radically different technique, stating that plexus anesthesia is performed ...