REGIONAL ANESTHESIA AND ACUTE PAIN

BRIEF TECHNICAL REPORT

Anatomic Basis for Brachial Plexus Block

2 at the Costoclavicular Space
A Cadaver Anatomic Study
Xavier Sala-Blanch, MD,*† Miguel Angel Reina, MD, PhD,‡§
Pawinee Pangthipampai, MD,|| and Manoj Kumar Karmakar, MD, FRCA, FHKCA, FHKAM||
the “costoclavicular space” (CCS),8 which is located deep and
Background and Objectives: The costoclavicular space (CCS), posterior to the midpoint of the clavicle6 and where the cords of
which is located deep and posterior to the midpoint of the clavicle, may the brachial plexus are relatively superficial in location,8,9 clus-
be a better site for infraclavicular brachial plexus block than the traditional tered together,8,9 and share a consistent relation with each other8,9
lateral paracoracoid site. However, currently, there is paucity of data on the may be a more suitable site for USG ICBPB.7 However, currently,
anatomy of the brachial plexus at the CCS. We undertook this cadaver an- there is paucity of data on the anatomy of the brachial plexus at
atomic study to define the anatomy of the cords of the brachial plexus at the CCS.7–9 Published data describe the topography of the cords
the CCS and thereby establish the anatomic basis for ultrasound-guided below the midpoint of the clavicle,8,9 in the sagittal plane,8,9 and
infraclavicular brachial plexus block at this proximal site. in connection with the vertical infraclavicular block technique.9
Methods: The anatomy and topography of the cords of the brachial There are also no data describing the safety and efficacy of a
plexus at the CCS was evaluated in 8 unembalmed (cryopreserved), thawed, USG ICBPB at the CCS. We undertook this cadaver anatomic
fresh adult human cadavers using anatomic dissection, and transverse ana- study to define the anatomy and arrangement of the cords of
tomic and histological sections, of the CCS. the brachial plexus at the CCS and thereby establish the anatomic
Results: The cords of the brachial plexus were located lateral and parallel to basis for USG ICBPB at this proximal site.
the axillary artery at the CCS. The topography of the cords, relative to the ax-
illary artery and to one another, in the transverse (axial) plane was also con-
METHODS
sistent at the CCS. The lateral cord was the most superficial of the 3 cords
and it was always anterior to both the medial and posterior cords. The medial This study was approved by the Research Ethics Committee
cord was directly posterior to the lateral cord but medial to the posterior cord. of the University of Barcelona and performed in the dissection
The posterior cord was the lateral most of the 3 cords at the CCS and it was room of the Department of Human Anatomy and Embryology
immediately lateral to the medial cord but posterolateral to the lateral cord. at the Medical School of the University of Barcelona. Eight un-
Conclusions: The cords of the brachial plexus are clustered together lat- embalmed (cryopreserved), thawed, fresh adult human cadavers
eral to the axillary artery, and share a consistent relation relative to one an- were studied. None of the cadavers studied had any obvious pa-
other and to the axillary artery, at the CCS. thology or had undergone any intervention or surgery over the
infraclavicular fossa.
(Reg Anesth Pain Med 2016;41: 387–391)
Anatomic Dissection
The cadavers were positioned in the supine position, with
U ltrasound-guided (USG) infraclavicular brachial plexus block
(ICBPB) is commonly performed at the lateral infraclavicular
fossa (LICF) where the cords of the brachial plexus are located
the arm abducted to 90 degrees on the side to be dissected. The
medial infraclavicular fossa (MICF), immediately caudal to the
deep to the pectoral muscles and surrounding the second part of middle-third of the clavicle and above the medial border of the
the axillary artery.1–3 However, at the LICF, the cords are located pectoralis minor muscle, was carefully dissected in layers in 3 ca-
at a depth (3–6 cm),4 separated from one another,5,6 there is sub- davers on both sides (total 6 dissections). The identities of the
stantial variation in the position of the individual cords relative cords were confirmed independently by the 2 dissectors (X.S.B.
to the axillary artery (second part),5,6 and all 3 cords are rarely and M.K.K.). Thereafter, the pectoralis minor muscle was cut at
visualized in a single ultrasound image.5 This may explain why its lateral edge (ie, from its origin from the coracoid process)
relatively large volumes of local anesthetic2 and/or multiple injec- and reflected medially to expose the LICF and its contents
tions1,2 are used for ICBPB. We have recently proposed7 that (Fig. 1A). A single red silicone loop was applied around the axil-
lary artery, close to the origin of the thoracoacromial branch, and
2 yellow silicone loops were applied around the cords of the bra-
From the *Department of Anesthesiology, Hospital Clinic Barcelona; †Depart- chial plexus (Fig. 1B). The first yellow loop was applied to the
ment of Human Anatomy and Embryology, University of Barcelona, Barcelona; cord that was most superficial and adjacent to the axillary artery
‡Department of Anesthesiology, Madrid-Montepríncipe University Hospital; and the second yellow loop was applied to the other 2 cords that
§School of Medicine, CEU San Pablo University, Madrid, Spain; and ||Depart-
ment of Anesthesia and Intensive Care, The Chinese University of Hong Kong, were located slightly deeper and posterior to the above (Fig. 1B).
Shatin, Hong Kong, SAR, China. The loops allowed gentle traction to be applied on the cords so
Accepted for publication December 16, 2015. that their relationship could be accurately defined. Once the cords
Address correspondence to: Manoj Kumar Karmakar, MD, FRCA, FHKCA, were identified, the middle-third of the clavicle was cut and re-
FHKAM, Department of Anesthesia and Intensive Care, The Chinese
University of Hong Kong, Prince of Wales Hospital, Shatin, New moved without disturbing the underlying anatomy of the CCS
Territories, Hong Kong, SAR, China (e‐mail: [email protected]). (Fig. 1C). The arrangement of the cords in the CCS7 was then de-
The authors declare no conflict of interest. fined and their relationship to each other and the axillary artery
This work was locally funded by the Department of Anesthesiology, University was evaluated and documented photographically (Fig. 1).
of Barcelona, Barcelona, Spain.
Copyright © 2016 by American Society of Regional Anesthesia and Pain Anatomic Section
Medicine
ISSN: 1098-7339 Two cadavers with the arms abducted to 90 degrees were
DOI: 10.1097/AAP.0000000000000393 frozen at −20 °C for 24 hours. The frozen bodies were placed in

Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016 387

Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Sala-Blanch et al Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016

FIGURE 1. Cadaver anatomic dissection of the right MICF, below the middle-third of the clavicle and above the medial border of the pectoralis
minor muscle, showing the anterior view of the relations of the cords of the brachial plexus to the first part of the axillary artery (AA). Note
the legend for orientation of the images is presented in (D). The pectoralis minor muscle (PMn) has been cut at its origin from the coracoid
process (CP) and reflected medially. A, Figure showing the lateral (LC) and posterior (PC) cords lying lateral and parallel to the axillary artery
and the PC lying posterolateral to the LC. The medial cord (MC) is not visible in this image. Also note the origin of the thoracoacromial artery
(TAA) from the axillary artery. B, Figure showing the MC lying posterior to the LC and medial to the PC. The connective tissue binding the PC
and MC has been cut to separate the 2 cords. C, The middle-third of the clavicle has been removed to expose the subclavius muscle which with
the pectoralis major muscle (clavicular head) forms the anterior boundary of the CCS. D, The subclavius muscle has been removed to expose
the CCS and its contents. The LC is being retracted medially to expose the MC, which lies directly posterior to the MC and medial to the PC.

the supine position and serially sectioned in the transverse plane of the brachial plexus, were cut from the block of tissue obtained.
(1.5-cm-thick sections) and from a cranial to caudal direction These tissue slices were processed using paraffin wax and serially
(ie, from the base of the neck to the level of the nipple) using a sectioned (5 μm in thickness) using a microtome. The sections
band saw. Three anatomic sections (2 right and 1 left) from the were stained using hematoxylin and eosin under standard condi-
level of the CCS were then identified and the anatomic arrange- tions and examined under a light microscope to define the ar-
ment of the cords within the CCS was defined in these sections rangement of the cords relative to one another and to the axillary
and documented photographically (Fig. 2). artery in the CCS (Figs. 3–4).

Light Microscopy
Histological sections for light microscopic examination RESULTS
were prepared as follows from 3 cadavers. The cadavers were Eight cadavers (5 women and 3 men) aged between 68 and
placed supine with the arm in 90 degrees abduction as in the 82 years at death were examined. Dissections showing the gross
dissected cadavers. The MICF was dissected in layers until the anatomic relationship of the cords of the brachial plexus at the
neurovascular complex was identified. This involved reflecting CCS and upper part of the MICF are presented in Figure 1. A
the pectoralis major and minor muscles and excising the midsec- transverse anatomic section showing the relations of the cords to
tion of the clavicle using an osteotome. Then a complete block the undisturbed anatomy of the CCS is presented in Figure 2. His-
of tissue that included the brachial plexus and neighboring blood tological sections showing the anatomic arrangement and rela-
vessels and extending from the lateral aspect of the first rib to tions of the cords at the CCS and upper part of the MICF are
the medial edge of the pectoralis minor muscle was excised and shown in Figures 3 and 4, respectively.
fixed in 10% buffered formaldehyde for 3 days. Thereafter, tissue The CCS was located between the posterior surface of the
slices (5–6 mm thick), which were perpendicular to the long axis middle-third of the clavicle and the anterior chest wall. The cords

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Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016 Brachial Plexus Anatomy at the CCS

FIGURE 2. Transverse anatomic section through the right CCS showing the anatomic arrangement and relations of the cords of the
brachial plexus. The anatomy is presented as though one were looking at it from caudal to cranial (caudocranial view).

of the brachial plexus with the axillary vessels were seen to tra- it was immediately lateral to the medial cord but posterolateral
verse this space lying between the pectoralis major (clavicular to the lateral cord (Figs. 1–3). Furthermore, at the CCS, it was
head) and subclavius muscle anteriorly, and the upper slips of fairly easy to separate the lateral cord from the medial and poste-
the serratus anterior muscle overlying the anterior chest wall pos- rior cords but the medial and posterior cords were very closely ap-
teriorly (Figs. 1, 2). The cords were located lateral and parallel to posed to each other, and required dissection of the connective
the axillary artery (Figs. 1, 2), and the gross relations of the cords tissue between them to separate them (Fig. 1B). This close rela-
to the axillary artery was consistent in all the cadavers studied tionship of the medial and posterior cords at the CCS was also
(Figs. 1–3). The anatomic arrangement of the cords, relative to seen in the histological section from the same region (Fig. 4).
one another in the transverse (axial) plane, was also consistent at
the CCS (Figs. 1–3). The lateral cord was the most superficial of
the 3 cords and it was always anterior to both the medial and pos- DISCUSSION
terior cords (Figs. 1–3). The medial cord was directly posterior to This study aimed to define the anatomy and arrangement of
the lateral cord but medial to the posterior cord (Figs. 1–3). The the cords of the brachial plexus at the CCS and thereby establish
posterior cord was the lateral most of the 3 cords at the CCS and the anatomic basis for USG brachial plexus block (BPB) at this

FIGURE 3. Histological section from the right CCS, stained with hematoxylin and eosin, showing the anatomic arrangement and relations
of the cords of the brachial plexus (caudocranial view).

© 2016 American Society of Regional Anesthesia and Pain Medicine 389

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Sala-Blanch et al Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016

FIGURE 4. Histological section from immediately distal to the right CCS (same cadaver as in Fig. 3), stained with hematoxylin and
eosin, showing the anatomic arrangement and relations of the cords of the brachial plexus (caudocranial view).

proximal infraclavicular site. We chose to study the anatomy in cranial to the axillary artery; the posterior cord was cranial to the
the transverse plane to mimic the plane of ultrasound imaging medial cord, and all 3 cords were posterior to the axillary artery.
used during a USG ICBPB at the CCS, which we have recently Therefore, our findings on the topography of the cords at the
described.7 We have demonstrated that the cords of the brachial CCS in the transverse plane are consistent with what has previ-
plexus are clustered together lateral to the axillary artery, and lying ously been reported in the sagittal plane.
between the pectoralis major (clavicular head) and subclavius The medial and posterior cords were very closely apposed to
muscle anteriorly and the upper slips of the serratus anterior mus- each other at the CCS, and the intervening connective tissue had
cle overlying the anterior chest wall posteriorly, at the CCS. The to be dissected in all the cadavers studied to separate them. We are
arrangement of the cords, relative to one another, was also consis- not aware of any previous report describing this close anatomic re-
tent with the lateral cord being most superficial, the medial cord lationship of the medial and posterior cords at the CCS, although
lying deep and posterior to the lateral cord, and the posterior cord this is also evident at the mid-infraclavicular point in the report by
lying immediately lateral to the medial cord but posterolateral to Moayeri and colleagues.9 Future research should evaluate this rela-
the lateral cord. We are not aware of any published data describing tionship in greater detail because it may partly explain why the
the topography of the cords of the brachial plexus at the CCS in success of a vertical infraclavicular block is enhanced when a me-
the transverse plane. dial or posterior cord motor response is elicited than after a lateral
At the CCS, the cords of the brachial plexus were located lat- cord motor response.9,10 The same may apply for BPB at the CCS.
eral to the axillary artery and in between the pectoralis major (cla- Infraclavicular BPB is most frequently performed at the
vicular head) and subclavius muscle anteriorly and the upper slips LICF,1–4 and the coracoid approach has an excellent track record
of the serratus anterior muscle overlying the anterior chest wall of safety.11 However, although the coracoid approach is effective1–4
posteriorly. Our observations are in agreement with Demondion and frequently avoids the chest wall4 and pleura, the LICF may not
and colleagues8 who have demonstrated in sagittal sonograms of be the optimal site for brachial plexus blockade because, at the
volunteers that the CCS is a triangular area wedged between the LICF, the cords of the brachial plexus are located at a depth (ap-
pectoralis major (clavicular head) and subclavius muscle anteriorly proximately 3–6 cm),4 separated from one another,5,6 there are sig-
and the anterior rib cage posteriorly. As in this study, Demondion nificant variations in the position of the individual cords relative to
and colleagues8 also found that the cords of the brachial plexus the axillary artery,5,6 and all 3 cords are rarely visualized in a single
traversed this space lying lateral to the axillary vessels. ultrasound window5 during a USG ICBPB. This probably explains
The anatomic arrangement of the cords, relative to one an- why relatively large volumes of local anesthetic2 and/or multiple
other, in the transverse (axial) plane was also consistent with the injections1,2 are used for ICBPB. In contrast, and as demonstrated
lateral cord being most superficial, the medial cord lying deep in this study, at the CCS, the cords of the brachial plexus are lo-
and posterior to the lateral cord, and the posterior cord lying im- cated in a well-defined intermuscular space, clustered together lat-
mediately lateral to the medial cord but posterolateral to the lateral eral to the axillary artery, and share a consistent relation relative to
cord. There are no comparable data evaluating the topography of one another and to the axillary artery. Therefore, the CCS may be a
the cords of the brachial plexus at the CCS in the transverse plane useful site for USG ICBPB. However, due to the close proximity
but there are data describing similar consistency in the position of the cords of the BP to the axillary vessels, pleura, and the lung
and topography of the cords at the MICF in the sagittal plane.8,9 at the CCS, there may be potential risk for accidental puncture of
Demondion and colleagues8 studied the anatomic relations of these structures. Currently, there are limited data describing USG
the cords in sagittal sonograms of the CCS and observed that BPB at the CCS (costoclavicular approach),7 and future research
the cords were located above and posterior to the axillary artery. to evaluate the safety and efficacy of this proximal infraclavicular
More recently, Moayeri and colleagues,9 while studying the to- approach is warranted.
pography of the cords at the mid-infraclavicular area in sagittal The anatomic relationship of the cords of the BP presented in
cryomicrotome sections from cadavers found that the lateral cord this report was determined with the arm of the cadaver in 90 degrees
was always anterior to either the medial or posterior cord and abduction. This was done to mimic the position of the arm during

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Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 41, Number 3, May-June 2016 Brachial Plexus Anatomy at the CCS

a costoclavicular BPB.7 Published data indicate that there are 5. Di Filippo A, Orando S, Luna A, et al. Ultrasound identification of nerve
changes in the configuration of the neurovascular bundle at the cords in the infraclavicular fossa: a clinical study. Minerva Anestesiol.
LICF with position (ie, abduction or adduction) of the arm.12 2012;78:450–455.
However, there are no data describing such variation at the CCS. 6. Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad O. Use of
It is our observation, during costoclavicular BPB, that the position magnetic resonance imaging to define the anatomical location closest to
of the cords remains relatively constant with change in the posi- all three cords of the infraclavicular brachial plexus. Anesth Analg.
tion of the arm. Future research to evaluate the topography of 2006;103:1574–1576.
the cords at the CCS with change in arm position is warranted. 7. Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC. Benefits of
In conclusion, this anatomic study shows that the cords of the the costoclavicular space for ultrasound-guided infraclavicular brachial
brachial plexus are clustered together lateral to the axillary artery, plexus block: description of a costoclavicular approach.
and share a consistent relation relative to one another and to the Reg Anesth Pain Med. 2015;40:287–288.
axillary artery, at the CCS. We believe our findings will simplify 8. Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A.
the task of identifying the individual cords of the brachial plexus Sonographic mapping of the normal brachial plexus. AJNR
using ultrasound, and form the anatomic basis for future research Am J Neuroradiol. 2003;24:1303–1309.
on USG BPB, at the CCS. 9. Moayeri N, Renes S, van Geffen GJ, Groen GJ. Vertical infraclavicular
brachial plexus block: needle redirection after elicitation of elbow flexion.
REFERENCES Reg Anesth Pain Med. 2009;34:236–241.
1. Gaertner E, Estebe JP, Zamfir A, Cuby C, Macaire P. Infraclavicular plexus 10. Neuburger M, Kaiser H, Rembold-Schuster I, Landes H. Vertical
block: multiple injection versus single injection. Reg Anesth Pain Med. infraclavicular brachial-plexus blockade. A clinical study of reliability of
2002;27:590–594. a new method for plexus anesthesia of the upper extremity [in German].
2. Rodríguez J, Bárcena M, Taboada-Muñiz M, Lagunilla J, Alvarez J. A Anaesthesist. 1998;47:595–599.
comparison of single versus multiple injections on the extent of anesthesia 11. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional
with coracoid infraclavicular brachial plexus block. Anesth Analg. anesthesia: essentials of our current understanding, 2008.
2004;99:1225–1230. Reg Anesth Pain Med. 2009;34:134–170.
3. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial 12. Ruiz A, Sala X, Bargallo X, Hurtado P, Arguis MJ, Carrera A.
plexus block. Br J Anaesth. 2002;89:254–259. The influence of arm abduction on the anatomic relations of
4. Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound infraclavicular brachial plexus: an ultrasound study. Anesth Analg.
guided infraclavicular block. Br J Anaesth. 2006;96:502–507. 2009;108:364–366.

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