Journal of Research and Innovation in Anesthesia
Volume 7 | Issue 1 | Year 2022

Proximal Out-plane Retroclavicular Brachial Plexus Nerve Block as an Alternative to Costoclavicular Approach: A Case Report

Amarjeet Kumar1, Chandni Sinha2, Ajeet Kumar3, Kunal Singh4

1Department of Trauma and Emergency, AIIMS, Patna, Bihar, India

2-4Department of Anaesthesiology, AIIMS, Patna, Bihar, India

Corresponding Author: Chandni Sinha, Department of Anaesthesiology, AIIMS, Patna, Bihar, India, Phone: +91 7250333148, e-mail:


Several techniques of infraclavicular brachial plexus nerve block (ICB) have been described in literature: stressing on various surface landmarks, site of needle insertion, and needle direction. Classical infraclavicular approach was the first one to be described followed by the retroclavicular and costoclavicular approach. Here we describe a novel technique of ICB is proximal out-plane retroclavicular approach. Proximal out-plane retroclavicular is simple and handy, in our experience. It also offer advantages over distal in-plane retroclavicular approach as it targets proximally clustered cords rather than individual cord.

How to cite this article: Kumar A, Sinha C, Kumar A, et al. Proximal Out-plane Retroclavicular Brachial Plexus Nerve Block as an Alternative to Costoclavicular Approach: A Case Report. J Res and Innov Anesth 2022;7(1):27-28.

Source of support: Nil

Conflict of interest: None

Keywords: Infraclavicular brachial plexus block, Retroclavicular, Ultrasonography


Infraclavicular brachial block has come a long way with various techniques being described based on various surface landmarks, site of needle insertion, and needle direction.1 Lately retroclavicular and costoclavicular approach which have been described offer the advantages over classical approach in terms of technical ease, lesser needle passes, better needle tip and shaft visibility, visibility of injected drug spread, fewer chances of vascular puncture, greater patient satisfaction, comfort, and lesser performance time.2-4 Here we describe a novel technique of ultrasound (US) - guided ICB is proximal out-plane retroclavicular approach. The patient was informed about the publication and written consent taken.


A 25 years old male patient with BMI= 26 Kg/m2 was scheduled for open reduction and internal fixation of both bone right forearm. After connecting to the American Society of Anesthesiologists standard monitors, an infusion of balanced salt solution was started as maintenance fluid. Anesthesia was induced in a standardized manner: injection fentanyl 2 μg/kg, propofol 2 mg/kg, and vecuronium 0.08 mg/kg was given. The airway was secured with Igel sized 4. Anesthesia was maintained with oxygen, isoflurane in air. Patient was kept in supine position with arm adducted. High frequency US linear probe (US machine M-Turbo, Fujifilm Sonosite Edge II, Inc, Bothell, WA, United States) of frequency 6-12 MHz was placed parallel to the inferior border of clavicle in the lateral part. The transducer was so moved as to to visualize the cords clustered lateral and superficial to the first part of the axillary artery (AA). An insulated echogenic needle (21-gauge, 8 cm: Sonoplex, Pajunk, Germany) was inserted out of plane, above and posterior to the clavicle in such a way that the tip was positioned lateral to the clustered cord (Fig. 1). Following negative needle aspiration injection levobupivacaine 0.25% of volume 15 mL was given. Any increase in 20% heart rate/mean arterial pressure intraoperatively, was treated with 1 ug/kg fentanyl. Surgery lasted for 2 hours and was uneventful. As per the institutional protocol, 1 gm paracetamol (PCM) was given 8th hourly. The patient had mild pain with numerical rating score ≤4 in first postoperative day (24 hours).

Figs 1A and B: Sonoanatomy of proximal out-plane retroclavicular block. [Axillary artery (AA), axillary vein (AV), local anesthetic (LA), brachial plexus (BP)]


Proximal out-plane retroclavicular technique is similar to the costoclavicular approach because all the three cords can be blocked by a single pass of needle. We need not redirect the needle as the cords are clustered together. However, this technique could be beneficial in the following scenarios:

Infraclavicular brachial plexus block can be approached distally wherein the probe is placed near the coracoid process in the sagittal plane. The lateral, posterior, and medial brachial plexus cords can be seen surrounding the axillary artery (AA).5 But these might not always be visible in this approach due to their deeper position and variable anatomy. The retroclavicular brachial plexus block has been described using an in-plane approach where the needle is visualized in its entirety as it is directed toward the cords of the brachial plexus as they travel deep to the lateral half of the clavicle.2 Proximal out-plane retroclavicular is simple and targets the proximally clustered cords rather than the individual cord.

Limitation: In this proximal out-plane retroclavicular brachial plexus nerve block, the acoustic shadowing produced by the clavicle creates a safety concern as the needle has to be advanced blindly behind the clavicle. Beyond the clavicle, the needle tip visualization should obviate the risk.

Also the needle tip would encounter the cords of brachial plexus before encountering the pleura increasing the safety margin. Randomized trials would be required to establish the feasibility of this proximal out-plane retroclavicular approach.


Amarjeet Kumar

Chandni Sinha

Ajeet Kumar

Kunal Singh


1. Kilka HG, Geiger Mehrkens P, Mehrkens HH. Anaesthesist 1995;44(05):339-344. DOI: 10.1007/s001010050162

2. Sinha C, Kumar N, Kumar A, et al. Comparative evaluation of two approaches of infraclavicular brachial plexus block for upper-limb surgeries. Saudi J Anaesth 2019;13(01):35-39. DOI: 10.4103/sja.SJA_737_17

3. Yoshida T, Watanabe Y, Furutani K. Proximal approach for ultrasound-guided infraclavicular brachial plexus block. Acta Anaesthesiol Taiwan 2016;54(01):31-32. DOI: 10.1016/j.aat.2015.11.003

4. Li JW, Songthamwat B, Samy W, et al. Ultrasound-guided costoclavicular brachial plexus block: sonoanatomy, technique, and block dynamics. Reg Anesth Pain Med 2017;42(02):233-240. DOI: 10.1097/AAP.0000000000000566

5. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J Anaesth 2002;89(02):254-259. DOI: 10.1093/bja/aef186

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