title: An evaluation of the supraclavicular plumb-bob technique for brachial plexus block by magnetic resonance imaging.
abstract: Partly based on magnetic resonance imaging studies, the "plumb-bob" approach for brachial plexus block was designed to minimize the risk of pneumothorax. Nevertheless, the risk of pneumothorax has remained a concern. We analyzed magnetic resonance images from 10 volunteers to determine whether the risk of pneumothorax was decreased with this method. The recommended initial needle direction is anteroposterior through the junction between the lateral-most part of the sternocleidomastoid muscle and the superior edge of the clavicle. If the initial placement is not successful, the brachial plexus may be sought in sectors 20 degrees -30 degrees cephalad or caudad to the anteroposterior line in a sagittal plane through the insertion point. We found that the anteroposterior line reached the pleura in 6 of 10 volunteers without prior contact with the subclavian artery or the brachial plexus, but always with contact with the subclavian vein. To reach the middle of the brachial plexus, a mean cephalad redirection of the simulated needle by 21 degrees was required (range from 41 degrees cephalad to 15 degrees caudad in one case). We conclude that the risk of contacting the pleura and the subclavian vessels may be reduced by initially directing the needle 45 degrees cephalad instead of anteroposterior. If the brachial plexus is not contacted, the angle should be gradually reduced.
  
  
  CONCLUSIONS
  In magnetic resonance images of volunteers, simulated needle passes with the "plumb-bob" approach to the supraclavicular brachial plexus block were analyzed for precision and risk profile. To avoid needle contact with the lung, the subclavian vein, and the subclavian artery, our results suggest a change in the method's initial needle direction.
authors.affiliation: *Department of Anesthesiology and ‡The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway; †Department of Anesthesiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois; and §Department of Radiology, University Hospital Linköping, Linköping, Sweden.
authors.forename: Denise J
authors.initials: DJ
authors.lastname: Wedel
authors.forename: Øivind
authors.initials: Ø
authors.lastname: Klaastad
authors.forename: Timothy R
authors.initials: TR
authors.lastname: VadeBoncouer
authors.forename: Terje
authors.initials: T
authors.lastname: Tillung
authors.forename: Örjan
authors.initials: Ö
authors.lastname: Smedby
mesh_terms: D000328:Adult; D001917:Brachial Plexus; D005069:Evaluation Studies as Topic; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D011030:Pneumothorax / Q000517:prevention & control; D013348:Subclavian Artery / Q000033:anatomy & histology*; D013350:Subclavian Vein / Q000033:anatomy & histology*