Johnny K. Lee M.D.
Luminita M. Tureanu M.D., F.R.C.P.C
Department of Anesthesiology
Feinberg School of Medicine
Originally, surgical procedures performed on the elbow and distal upper extremity utilizing regional anesthesia were done under axillary block. The axillary block however was not without its limitations. Given the proximal take off of the musculocutaneous nerve, the lateral proximal arm would often be spared. Additionally, the axillary block is difficult to place in patients who are unable to abduct the arm.
The infraclavicular block (ICB) was developed to overcome the limitations of the axillary block. Bazy in 1917, followed by Labat in 1922 are credited with the infraclavicular approach to brachial plexus. In this technique, the needle is directed medially from the midpoint of the clavicle to the anterior tubercle of the transverse process of the sixth cervical vertebra, also known as Chassaignac’s tubercle. This approach however was also not without its own limitations, namely a higher likelihood of pneumothorax as the needle is directed superiorly and medially, near the apex of the lung.
In 1973, Raj reintroduced this approach with some modifications.1 The aim of his approach was to avoid the positioning limitations and sparing of the musculocutaneous nerve associated with the axillary block, while decreasing the chance of pneumothorax inherent with the Labat approach, by aiming the needle laterally. Since then, several more approaches have been described, each with their own advantages and disadvantages, some of which will be described here.
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