To the Editor:—

We read with interest the recent report by Martinez et al.  1regarding a combined infraclavicular plexus blockade with suprascapular nerve block for humeral head surgery in a patient with severe respiratory failure. However, we have some concerns with regard to the following points: First, it is not clearly stated whether the authors performed an infraclavicular plexus block using the coracoid technique (originally described by Whiffler 2) or the vertical infraclavicular technique (described by Kilka et al.  3). In the case report section the authors wrote, “brachial plexus was performed using “the coracoid and infraclavicular technique.” However, figure 1B in the case report of Martinez et al.  shows the territories usually blocked by the vertical infraclavicular brachial plexus block. One must be aware of the different extensions of sensory blockade produced by the coracoid technique, the vertical infraclavicular technique, and the modified approach of the Raj technique. 4Because the coracoid technique approaches the brachial plexus more distally than the vertical infraclavicular technique, the axillary and musculocutaneus nerves are often missed or are not adequately blocked with the former technique. Deleuze et al.  5described a successful sensory blockade of the axillary nerve by the coracoid technique in only about 22%. Gaertner et al.  6showed that a multiple injection technique, as compared to a single injection, improved the overall success rate of the coracoid technique from 40% up to more than 70%, without detailing the effect on the axillary nerve.

Martinez performed a suprascapular nerve block to avoid hemidiaphragmatic paresis secondary to interscalene brachial plexus block. In the current case, the possibility of an iatrogenic pneumothorax during this procedure must be mentioned. 7This theoretical disadvantage is also described for the vertical infraclavicular technique. 8In the current case, a pneumothorax could have been at least as deleterious as a phrenic nerve paresis. As shown by Borgeat et al.  9and Boezaart et al. , 10the decrease of hemidiaphragmatic excursion after interscalene brachial plexus block can be reduced when the block is performed through the interscalene catheter rather than with a single bolus. The catheter technique, either performed at the interscalene or at the infraclavicular level (where the modified approach of the Raj technique seems to be the optimal solution 11), would have also offered good surgical conditions and efficient postoperative analgesia without the danger of a pneumothorax or an insufficient block.

Martinez J, Sala-Blanch X, Ramos I, Gomar C: Combined infraclavicular plexus block with suprascapular nerve block for humeral head surgery in a patient with respiratory failure: An alternative approach. A nesthesiology 2003; 98: 784–5
Whiffler K: Coracoid block: A safe and easy technique. Br J Anaesth 1981; 53: 845–8
Kilka HG, Geiger P, Mehrkens HH: Die vertikale infraclaviculäre Blockade des plexus brachialis. Anaesthesist 1995; 44: 339–44
Raj PP, Montgomery SJ, Nettles D, Jenkins MT: Infraclavicular brachial plexus block: A new approach. Anesth Analg 1973; 52: 897–904
Deleuze A, Gentili ME, Marret E, Lamonerie L, Bonnet F: A comparison of a single-stimulation lateral infraclavicular plexus block with a triple-stimulation axillary block. Reg Anesth Pain Med 2003; 28: 89–94
Gaertner E, Estebe JP, Zamfir A, Cuby C, Macaire P: Infraclavicular plexus block: Multiple injection versus singe injection. Reg Anesth Pain Med 2002; 27: 59–4
Moore DC: Block of the suprascapular nerve, Regional nerve block, 4th edition. Springfield, Illinois, Charles C Thomas, 1979, pp 300–3
Neuburger M, Kaiser H, Uhl M: Biometrische Daten zum Pneumothoraxrisiko bei der vertikalen infraklavikulären Plexus-brachialis-Blockade. Anaesthesist 2001; 50: 511–6
Borgeat A, Perschak H, Bird P, Hodler J, Gerber C: Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery. A nesthesiology 2000; 92: 102–8
Boezaart AP, de Beer JF, du Toit C, van Rooyen K: A new technique of continuous interscalene nerve block. Can J Anesth 1999; 46: 275–81
Borgeat A, Ekatodramis G, Dumont Ch: An evaluation of the infraclavicular block via a modified approach of the Raj technique. Anesth Analg 2001; 93: 436–41