Letters to the Editor
any of the relevant references. In their cor-
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Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018
2. Cornish PB. Ultrasound-guided axillary tunnel
we elevate the shoulder with a wedge or
respondence,1 they have acknowledged
that the costoclavicular space is part of the
axillary tunnel.
They have given several reasons whereby
they believe costoclavicular block is different
from axillary tunnel block. In so doing,
they have misrepresented and incorrectly
described my work. The significance of
the axillary tunnel is in the effect of the
closely surrounding rigid anatomy on
spread of solution. The dye study in my
correspondence showed the needle tip in
axillary tunnel block well outside the first
rib, with dye spread laterally beyond the
second rib as well as medially over the first
rib. The dye study of axillary tunnel block
also showed spread quite different from
that which occurs with a supraclavicular
block. In terms of block profile, inferior
trunk sparing was not an observed pattern.
Philip Cornish, BHB, MBChB,
FANZCA, FFPMANZCA, MD
Specialised Pain Medicine Pty Ltd
Adelaide, Australia
The author declares no conflict
of interest.
REFERENCES
1. Karmakar MK, Sala-Blanch X. Reply to Dr
Cornish. Reg Anesth Pain Med. 2018;43:
337–338.
FIGURE 1. Combined 3-in-1 retroclavicular approach; needle position and orientation in anatomical 3D model in sagittal (A), coronal
(B), and transverse (C) modified planes. Some anatomical structures are removed for better visualization. AA indicates axillary artery; AS,
anterior scalene muscle; AV, axillary vein; CL, clavicle; ICBP, brachial plexus at infraclavicular region; OH, inferior belly of omohyoid muscle;
MS, medium scalene muscle; PS, posterior scalene muscle; SC, scapula. White arrows point to needle position and orientation; white dot,
puncture point.
806
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
block revisited. Reg Anesth Pain Med. 2018;43:
336–337.
3. Li JW, Songthamwat B, Samy W, Sala-Blanch X,
Karmakar MK. Ultrasound-guided costoclavicular
brachial plexus block: sonoanatomy, technique,
and block dynamics. Reg Anesth Pain Med. 2017;
42:233–240.
Combined Retroclavicular
Approach for
Shoulder Surgery
A New Description Technique
of 3-in-1 Combined Block
Accepted for publication: April 25, 2018.
To the Editor:
R elated to diaphragm-sparing nerve
blocks, it has been demonstrated that
nerve blocks for shoulder surgery need
not be unique.1 We propose a new com-
bined retroclavicular approach to the
infraclavicular brachial plexus block (ICB),
suprascapular nerve (SSN), and sup-
raclavicular nerve (SCN). We proceed
with single midretroclavicular puncture
performing 3 consecutive blocks from
the same point (Fig. 1). We use 21-gauge
100-mm Stimuplex A needle, 30 mL of
levobupivacaine 0.5%, and an ultrasound
machine with multifrequency (8–14 MHz)
linear transducer. With the patient supine,
© 2018 American Society of Regional Anesthesia and Pain Medicine
pillow.
First, we place the probe under the
clavicle, and we perform ultrasound-guided
posterior approach to the infraclavicular
brachial plexus previously reported by
Hebbard and Royse.2 We can either selec-
tively block the 3 cords with 5 mL each or
inject 15 mL periarterially in case of difficult
cord visualization. Retroclavicular approach
lets the needle pass perpendicular to
the ultrasound beam, making needle tip
visualization simple and more accurate
(Fig. 2A). This is also a very useful approach
for catheter placement for postoperative
pain control if needed.
Second, we move the transducer above
the clavicle, partially withdrawing the nee-
dle and redirecting it; SSN block is done
using the proximal approach described pre-
viously by Rothe et al,3 blocking the SSN
located in the fascial layer between the
omohyoid muscle and the serratus anterior
muscle. Frequently, we modify this original
block performing a fascial block rather than
locating SSN; after traversing the inferior
belly of the omohyoid muscle with the nee-
dle, we inject 8 to 10 mL of local anes-
thetic, observing hydrodissection of this
fascial layer, blocking the SSN (Fig. 2B).
Finally, we locate the SCN using
Valdés-Vilches and Sánchez-del Águila's4
echographic approach. We perform this
block in a similar echographic plane.
There, the SCN divides itself into terminal
branches that cover cutaneous innervation
of the shoulder joint. After we partially
Regional Anesthesia and Pain Medicine • Volume 43, Number 7, October 2018 Letters to the Editor

FIGURE 2. Needle orientation and echographic view of ICB (A), the SSN block (B), and the SCN block (C). White arrows point to the
needle. AA indicates axillary artery; AS, anterior scalene muscle; AV, axillary vein; BP, brachial plexus nerves; MS, medium scalene muscle;
OH, inferior belly of omohyoid muscle; Pm, pectoralis minor muscle; PM, pectoralis major muscle; PS, posterior scalene muscle;
SCM, sternocleidomastoid muscle; TRZ, trapezius muscle.

withdraw the needle and redirect it more su-
perficially in this plane, we block the SCN with
a subcutaneous injection of 5 mL (Fig. 2C).
Some authors have combined 2 blocks
for shoulder surgery, namely, the SSN
and axillary nerve blocks, but combining
these blocks ignores contributions of
the supraclavicular, lateral pectoral, and
subscapular nerves.1 Other authors such
as Bansal et al5 reported combining 4 single-
shot nerve blocks (cervical plexus, SSN
axillary nerve, and Pecs blocks), but again
this strategy ignores the contribution of
the subscapular nerve to the innervation
of the rotator cuff, and it is difficult to place
a catheter that does not interfere with the
surgical field for postoperative analgesia.
Although a large volume of local an-
esthetic (30 mL) at the ICB could produce
diaphragm palsy,6 it is not the first time that
the combined use of SSN and ICB for
shoulder surgery is described even in a
patient with respiratory compromise. Com-
bined ICB and SSN blocks are an effective
combination for shoulder surgery; only cu-
taneous innervation of the shoulder joint is
not covered with this block because it is
mediated by the SCN; therefore, we need
3 single-shot nerve blocks.
We have developed this new tech-
nique that lets us combine with a single
puncture 3 nerve blocks (ICB, SSN, SCN).
We use this new combined retroclavicular
approach for all kinds of shoulder surgeries,
including complex ones (humeral prosthesis
and multifragment fractures). Usually, gen-
eral anesthesia is not needed, and great pa-
tient satisfaction with only 1 puncture was
obtained (more prolonged if a catheter is
placed during infraclavicular block). We have
not studied whether this approach produces
hemidiaphragm palsy. However, we used half
of the volume described by Petrar et al6 that
produces a 3% incidence of hemidiaphragm
palsy, and we have not had complications
(using 15 mL) in this sense. The combined
retroclavicular approach is our technique of
choice for shoulder surgery even in patients
with respiratory compromise.
ACKNOWLEDGMENTS
The anatomical 3D model in Figure 1
is courtesy of Biodigital 3D Human Visual-
ization Platform for Anatomy and Disease
(https://human.biodigital.com/).
Lucas Rovira, MD, PhD, EDAIC
Jorge Úbeda, MD
Department of Anesthesiology
Critical Care and Pain Medicine
Hospital General Universitario de Valencia
Valencia, Spain
José de Andrés, MD, PhD,
EDRA, EDPM
Surgical Specialties Department
Valencia University School of Medicine
and Department of Anesthesiology
Critical Care and Pain Medicine
Hospital General Universitario de Valencia
Valencia, Spain
The authors declare no conflict
of interest.
REFERENCES
1. Tran DQ, Elgueta MF, Aliste J, Finlayson RJ.
Diaphragm-sparing nerve blocks for shoulder
surgery. Reg Anesth Pain Med. 2017;42:
32–38.
2. Hebbard P, Royse C. Ultrasound guided posterior
approach to the infraclavicular brachial plexus.
Anaesthesia. 2007;62:539–539.
3. Rothe C, Steen-Hansen C, Lund J, Jenstrup MT,
Lange KH. Ultrasound-guided block of the
suprascapular nerve—a volunteer study of a new
proximal approach. Acta Anaesthesiol Scand.
2014;58:1228–1232.
4. Valdés-Vilches LF, Sánchez-del Águila MJ.
Anesthesia for clavicular fracture: selective
supraclavicular nerve block is the key.
Reg Anesth Pain Med. 2014;39:258.
5. Bansal V, Shastri U, Canlas C, Gadsden JC.
Diaphragm-sparing nerve blocks for shoulder
surgery: an alternative approach. Reg Anesth
Pain Med. 2017;42:544–545.
6. Petrar SD, Seltenrich ME, Head SJ, Schwarz SK.
Hemidiaphragmatic paralysis following
ultrasound-guided supraclavicular versus
infraclavicular brachial plexus blockade: a
randomized clinical trial. Reg Anesth Pain Med.
2015;40:133–138.
Understanding ESP
and Fascial Plane Blocks
A Challenge to Omniscience
Accepted for publication: May 23, 2018.
To the Editor:
e congratulate Ivanusic et al1 on their
W rigorous attempt to elucidate the
mechanism of action of the erector spinae
plane (ESP) block. There is no disputing

© 2018 American Society of Regional Anesthesia and Pain Medicine 807

Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.