A comparison of coracoid and axillary approaches to the brachial plexus

Background: Brachial plexus block by the coracoid approach does not require arm abduction and may be more effective than the axillary approach because of a more proximal injection of local anaesthetic. However, the clinical usefulness of the coracoid approach has not been tested in prospective controlled trials. The present randomized, observer-blinded study compared success rates, time to obtain a complete block, frequency of adverse effects and block discomfort in two groups of 30 patients, anaesthetized for hand surgery using either the coracoid or the axillary approach to the brachial plexus. Methods: After subcutaneous infiltration with 5 mi of 1% mepivacaine/adrenaline the brachial plexus was located using a nerve stimulator and an insulated pencil-point needle. Ropivacaine 0.75%,, 20-40 mi, depending on body weight, was used for the initial block. In the coracoid (C) group two plexus cords, and in the axillary (A) group four terminal nerves were electrolocated and the volume of ropivacaine was divided equally between them. Spread of analgesia to the arm was assessed every 5 min, by an anaesthetist unaware of the block technique. The block was defined as effective (complete) when analgesia was present in all five sensory nerve areas distal to the elbow. Incomplete blocks were supplemented 30 min after the initial block. Results: In the C group a median 11 min was required for block performance as compared to 12 min in the A group (NS). Onset of block was shorter and the frequency of incomplete blocks lower in the A group (median 17 min and 17%) than in the C group (30 min and 47%, respectively). Lack of analgesia of the ulnar nerve was the main cause of incomplete initial blocks in the C group. All incomplete blocks were successfully supplemented. However, total time to obtain complete block was shorter in the A group than in the C group (29 min vs. 41 min, P<0.05). Accidental arterial puncture occurred in seven patients (five in C and two in A group), which resulted in two haematomas, both in the C group (NS). No permanent sequelae were observed. Conclusion: The axillary approach to the brachial plexus using four injections of ropivacaine results in a faster onset of block and a better spread of analgesia than the coracoid approach using two injections.