The technique described in this chapter is a modification of the
single-injection block, originally described by Kappis in the
1920s3 and modified by Pippa in 1990.4
The original technique never gained popularity, probably because it was
uncomfortable to patients due to penetration of the paraspinal extensor
muscles of the neck. A modified technique, which does not penetrate these
muscles, was described recently.5,6 The modification is
insertion of the needle in the V-shaped space between
the levator scapulae and trapezius muscles at the level of the sixth
cervical vertebra. By this method, penetration of the posterior paraspinal
muscles is avoided, which minimizes the associated pain of this approach.
Because all of the structures (eg, vertebral artery and vein, phrenic nerve,
carotid and other major arteries, internal jugular vein, etc.) associated
with complications from brachial plexus blockade are anterior to the nerve
roots in the neck, where they exit the neuroforamina, Kappis' original
argument that it is best to approach the roots from the posterior, where there
are only muscles, remains valid. Furthermore, at the root level of the
brachial plexus, which is the level at which this block is
done,5,6 the nerve fibers are arranged with sensory
fibers posterior and motor fibers anterior. This probably explains the
predominantly sensory block when approached from the posterior aspect of the
neck.