Korean J Pain.  2020 Apr;33(2):144-152. 10.3344/kjp.2020.33.2.144.

Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study

  • 1Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
  • 2Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
  • 3College of Nursing, Chungnam National University, Daejeon, Korea


Hemidiaphragmatic paralysis, a frequent complication of the brachial plexus block performed above the clavicle, is rarely associated with an infraclavicular approach. The costoclavicular brachial plexus block is emerging as a promising infraclavicular approach. However, it may increase the risk of hemidiaphragmatic paralysis because the proximity to the phrenic nerve is greater than in the classical infraclavicular approach.
This retrospective analysis compared the incidence of hemidiaphragmatic paralysis in patients undergoing costoclavicular and supraclavicular brachial plexus blocks. Of 315 patients who underwent brachial plexus block performed by a single anesthesiologist, 118 underwent costoclavicular, and 197 underwent supraclavicular brachial plexus block. Propensity score matching selected 118 pairs of patients. The primary outcome was the incidence of hemidiaphragmatic paralysis, defined as a postoperative elevation of the hemidiaphragm > 20 mm. Factors affecting the incidence of hemidiaphragmatic paralysis were also evaluated.
Hemidiaphragmatic paralysis was observed in three patients (2.5%) who underwent costoclavicular and 47 (39.8%) who underwent supraclavicular brachial plexus blocks (P < 0.001; odds ratio, 0.04; 95% confidence interval, 0.01-0.13). Both the brachial plexus block approach and the injected volume of local anesthetic were significantly associated with hemidiaphragmatic paralysis.
The incidence of hemidiaphragmatic paralysis is significantly lower with costoclavicular than with supraclavicular brachial plexus block.


Anesthesia; Brachial Plexus Block; Diaphragm; Incidence; Nerve Block; Paralysis; Phrenic Nerve; Propensity Score; Retrospective Studies; Ultrasonography


  • Fig. 1 Sonographic view of a brachial plexus in the costoclavicular space (A, B) and the supraclavicular region (C). (A) A block needle was inserted in-plane in a lateral to medial direction, followed by initial injection of local anesthetic between the medial and posterior cords. (B) The needle was relocated adjacent to the lateral cord, followed by injection of additional anesthetic. (C) Initial injection of local anesthetic into the corner pocket, defined as the intersection between the first rib and the subclavian artery. Subsequent injection after relocation of the needle toward the neural cluster is not shown. AA: axillary artery, LC: lateral cord, MC: medial cord, PC: posterior cord, SA: subclavian artery, LA: local anesthetic, NC: neural cluster.

  • Fig. 2 Height measurement in a patient with right-sided hemidiaphragmatic paralysis on pre-operative (left) and postoperative (right) images. The vertical distance between the two lines (parallel to the vertebral body and passing through the highest points of each hemidiaphragm) was measured. The height of the right hemidiaphragm was determined relative to the height of the left hemidiaphragm, set at 0 mm. The difference between pre- and post-operative heights was calculated as postoperative height (D2) – preoperative height (D1).

  • Fig. 3 Flow diagram of patient selection and propensity score matching.

  • Fig. 4 Histogram showing changes in height of the hemidiaphragm. The dashed line indicates the cut off value for hemidiaphragmatic paralysis. CCB: costoclavicular brachial plexus block, SCB: supraclavicular brachial plexus block.


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