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The supraclavicular block is one of several techniques used to
anesthetize the 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,
typical features of this block include rapid onset, predictability, and
dense anesthesia.1–3 In 1911 Kulenkampff in Germany
performed the first percutaneous supraclavicular approach, reportedly on
himself, a few months after Hirschel described a surgical approach to the
brachial plexus in the axilla. The technique was later published in the United States 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 if the patient could not adopt the sitting position.
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 it 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 high during the entire first half of the twentieth century
until well after World War II. During this time the technique underwent
several modifications, most of them intended to deal with the risk of
pneumothorax.1,5–8
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The introduction of axillary techniques by Accardo and
Adriani9 in 1949 and especially by
Burnham10 in 1958 marked the beginning of the decline in
interest for supraclavicular block. The axillary block was particularly
popularized after a publication in the journal
Anesthesiology by De Jong in 1961.11 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
Papper12 who compared axillary and supraclavicular
techniques and
managed to produce a 6.1% rate of pneumothorax. This uniquely high rate is frequently cited in the literature in reference to supraclavicular block.
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More modern modifications of supraclavicular block include Winnie and
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, ...