The costoclavicular block is a specialized regional anesthesia technique used in pain management and surgical anesthesia, particularly for procedures involving the upper limb. It temporarily blocks nerve signals, providing numbness and pain relief in the arm, forearm, and hand. This method serves as an alternative to general anesthesia in certain situations or as a supplementary measure for controlling discomfort after surgery.
Understanding the Costoclavicular Block
The costoclavicular block is a type of regional nerve block that precisely targets the brachial plexus, a network of nerves originating from the spinal cord that controls sensation and movement in the upper limb. This block is administered at the costoclavicular space, an anatomical region situated deep to the midpoint of the clavicle and between the clavicle and the first rib. Within this space, the major nerves of the brachial plexus, specifically the lateral, medial, and posterior cords, are clustered together and positioned lateral to the axillary artery.
The cords of the brachial plexus are relatively superficial and arranged in a consistent, triangular pattern in this area, making them accessible for targeted anesthesia. By injecting local anesthetic into this compact region, the block effectively delivers anesthesia or analgesia to the entire upper limb, including the shoulder, arm, forearm, and hand.
Conditions Treated with Costoclavicular Block
The costoclavicular block is used for a range of medical indications, primarily involving surgical procedures and pain management for the upper extremity. It is suitable for various surgeries on the arm, forearm, and hand, such as repairs of humerus fractures, elbow procedures, and operations on the wrist and fingers. This block can also be used for shoulder surgeries, providing effective analgesia.
For instance, it has been successfully used to facilitate painless reduction of upper extremity fractures in emergency department settings. The costoclavicular block is also considered for patients who may have limitations with more traditional nerve block techniques, including individuals with obesity where other approaches might be challenging to visualize.
Procedure and Patient Experience
Before a costoclavicular block, patients undergo a thorough assessment, including a review of their medical history and a discussion of the procedure. Patient consent is obtained after explaining the benefits and potential considerations. The patient is positioned lying on their back, with the arm to be anesthetized abducted, often placed on a table.
The procedure heavily relies on ultrasound guidance for accuracy and safety. A high-frequency linear ultrasound transducer is placed just below the middle third of the clavicle to visualize the axillary artery and vein, and the three cords of the brachial plexus located lateral to these vessels. The block needle is then inserted in-plane from a lateral to medial direction, with the goal of positioning the needle tip between the three brachial plexus cords.
Once the needle is correctly positioned, a local anesthetic, such as ropivacaine or bupivacaine, is injected in a volume of 15 to 25 mL, to surround the nerve cluster. Patients may feel a brief sensation of pressure or tingling during the injection, but significant discomfort is avoided. The onset of numbness and weakness in the affected limb is rapid, often within 5 to 15 minutes for sensory and motor blockade, with complete sensory blockade achieved in 20 to 30 minutes. The duration of the block’s effects varies depending on the type and concentration of local anesthetic used, but it can provide prolonged pain relief.
Advantages and Important Considerations
The costoclavicular block offers several advantages over other regional anesthesia techniques for the upper limb. Its precise anatomical targeting leads to a more complete and reliable block of the entire upper extremity. This approach is associated with a significantly lower incidence of hemidiaphragmatic paralysis, a complication sometimes seen with other upper limb blocks that can affect breathing. Studies have shown a very low incidence, or even 0%, of phrenic nerve block with the costoclavicular approach, which controls diaphragm movement.
Patients should be aware of common temporary side effects, including numbness, weakness, and tingling in the treated limb, which are expected and resolve as the anesthetic wears off. Rare but potential complications exist, such as nerve injury, which is minimized by the use of ultrasound guidance and careful technique. There is also a small risk of local anesthetic systemic toxicity or vascular puncture, though these are avoided with precise ultrasound visualization and monitoring. Suitability for the block depends on individual patient health, the specific surgical needs, and the desired duration of pain control.