Original research
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101783 on 14 September 2020. Downloaded from http://rapm.bmj.com/ on September 19, 2020 at University of Rochester
1
Anesthesiology, Faculty
of Medicine, Chiang Mai
University, Chiang Mai, Thailand
2
Anatomy, Faculty of Medicine,
Chiang Mai University, Chiang
Mai, Thailand
3
Excellence in Osteology
Research and Training Center
(ORTC), Faculty of Medicine,
Chiang Mai University, Chiang
Mai, Thailand
Correspondence to
Dr Prangmalee Leurcharusmee,
Anesthesiology, Chiang Mai
University Faculty of Medicine,
Chiang Mai 50200, Thailand;
​prangmalee.​l@​cmu.​ac.​th
Received 6 June 2020
Revised 2 August 2020
Accepted 6 August 2020
© American Society of Regional
Anesthesia & Pain Medicine
2020. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Samerchua A,
Leurcharusmee P,
Panjasawatwong K, et al.
Reg Anesth Pain Med Epub
ahead of print: [please
include Day Month Year].
doi:10.1136/rapm-2020-
101783
Cadaveric study identifying clinical sonoanatomy for
proximal and distal approaches of ultrasound-­guided
intercostobrachial nerve block
Artid Samerchua,1 Prangmalee Leurcharusmee,1 Krit Panjasawatwong,1
Kittitorn Pansuan,1 Pasuk Mahakkanukrauh2,3
ABSTRACT
Background and objectives  The intercostobrachial
nerve (ICBN) has significant anatomical variation.
Localization of the ICBN requires an operator’s skill. This
cadaveric study aims to describe two simple ultrasound-­
guided plane blocks of the ICBN when it emerges at the
chest wall (proximal approach) and passes through the
axillary fossa (distal approach).
Methods  The anatomical relation of the ICBN and
adjacent structures was investigated in six fresh cadavers.
Thereafter, we described two potential techniques of
the ICBN block. The proximal approach was an injection
medial to the medial border of the serratus anterior
muscle at the inferior border of the second rib. The
distal approach was an injection on the surface of the
latissimus dorsi muscle at 3–4 cm caudal to the axillary
artery. The ultrasound-­guided proximal and distal ICBN
blocks were performed in seven hemithoraxes and
axillary fossae. We recorded dye staining on the ICBN, its
branches and clinically correlated structures.
Results  All ICBNs originated from the second
intercostal nerve and 34.6% received a contribution
from the first or third intercostal nerve. All ICBNs gave off
axillary branches in the axillary fossa and ran towards the
posteromedial aspect of the arm. Following the proximal
ICBN block, dye stained on 90% of all ICBN’s origins.
After the distal ICBN block, all terminal branches and
43% of the axillary branches of the ICBN were stained.
Conclusions  The proximal and distal ICBN blocks,
using easily recognized sonoanatomical landmarks,
provided consistent dye spread to the ICBN. We
encourage further validation of these two techniques in
clinical studies.
INTRODUCTION
The intercostobrachial nerve (ICBN) originates
mainly from the lateral cutaneous branch of the
second intercostal nerve.1–3 It travels along the axil-
lary fossa and gives off the posterior axillary branch
before passing through the subcutaneous tissue of
the posteromedial aspect of upper arm.1–3 Along
with the medial brachial cutaneous nerve (MBCN)
and the posterior cutaneous branch of the radial
nerve, the ICBN supplies the skin of the medial
and posterior portions of the arm, the axilla and
the upper lateral chest wall.1 4 5 As it is not part of
the brachial plexus, the ICBN block is required as
an adjunct to the brachial plexus block to achieve
complete anesthesia of the entire upper extremity
Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
and axilla.6 7 The ICBN block in combination with
the brachial plexus block is indicated for surgery
involving medial/posterior upper arm, such as arte-
riovenous fistula creation in the upper arm, or for
anterior arthroscopic port placement of shoulder
surgery.7 Moreover, the ICBN block, as a sole anal-
gesic technique, is effective to treat postmastectomy
pain.8 9 The ICBN is conventionally anesthetized by
a blind or landmark-­based approach; however, the
ultrasound-­guided technique improves the success
rate and speeds the onset of the ICBN block.10
A variety of techniques for ultrasound-­ guided
ICBN blocks have been described and can be
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simply categorized based on the location of local
anesthetic injection into two groups, the proximal
and distal ICBN blocks. The proximal approach of
the ICBN block is defined as an injection of local
anesthetic over the anterolateral chest wall where
the ICBN emerges from the external intercostal or
serratus anterior muscles. The previously described
regional anesthesia that involve the ICBN block
at the proximal approach includes the proximal
ICBN block,7 8 11 PECS II block,12 13 subpectoral
intercostal plane block,14 serratus plane block15
and serratus-­ intercostal fascial plane block.5 The
distal approach of the ICBN block is described as
a deposition of a local anesthetic around the ICBN
or in the subcutaneous plane at the axillary crease.
In a clinical study, the success rate of the proximal
and distal ICBN blocks with ultrasound guidance
varied from 67% to 94% and 51% to 100%, respec-
tively.4 5 7 10 13
Because of (1) a significant variation of the origin
and branching of the ICBN,1–3 (2) an unfeasibility
of the ICBN visualization at the chest wall8 and (3)
difficulty in the ICBN identification in the axillary
fossa,10 16 17 the sonoanatomy related to the course
of the ICBN is needed for describing the technique
for ultrasound-­guided ‘plane’ block of the proximal
and distal portions of the ICBN. Accordingly, this
two-­phase cadaveric study aims to elucidate the
anatomical relationship between the ICBN and the
adjacent structures easily identified under ultra-
sound (phase I) and to examine the effectiveness
of two redescribed techniques of the ultrasound-­
guided ICBN block (phase II).
MATERIALS AND METHODS
Phase I of the study involved dissection of 12 hemi-
thorax and axillary fossae of six cadavers to deter-
mine the relationship between the extrathoracic
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Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101783 on 14 September 2020. Downloaded from http://rapm.bmj.com/ on September 19, 2020 at University of Rochester
course of the ICBN and its relevant echogenic structures. Then,
Table 1  Demographic of cadavers and characteristics of the ICBN
the ultrasound-­guided proximal ICBN blocks were performed in
seven hemithorax, and the distal ICBN block was done in seven Phase I Phase II Overall
n=6 specimens n=7 specimens n=13 specimens
axillary fossae during phase II of the study.
(12 sides) (14 sides) (26 sides)
Gender (male); N (%) 4 (66.7%) 4 (57.1%) 8 (61.5%)
Cadaveric dissection
Age (years); mean±SD 69.2±7.2 67.8±2.5 68.4±5.1
The dissection in phase I and II was uniformly performed on
Height (cm); mean±SD 164.9±8.1 162.6±8.5 163.9±8.0
the bilateral anterolateral chest wall and upper arm in all
BMI (kg/m2); mean±SD 23.0±1.6 22.8±1.6 22.9±1.5
cadavers. The cadavers were placed in a supine position with
Pattern of the ICBN’s origin; N (%)
90° arm abduction. The first incision was made over the clav-
icle, extending medially to the sternal notch, then downward  From the 1st, 2nd 2 (16.7%) 1 (7.1%) 3 (11.5%)
intercostal nerves
to the xiphoid process, and laterally along the costal margin.
 From the 2nd 8 (66.7%) 9 (64.3%) 17 (65.4%)
The second incision was made longitudinally along the lateral
intercostal nerve
aspect of the arm, extending into the cubital fossa. Then, the
 From the 2nd, 3rd 2 (16.7%) 4 (28.8%) 6 (23.1%)
skin flap was inferolaterally retracted to expose the thoracic cage intercostal nerves
and axillary fossa. The clavicular head and sternocostal heads
Diameter of the ICBN at the EP (mm); median(min-­max)
of the pectoralis major muscle (PMM), along with the origin of
 T1-­ICBN 2.0 (1.1–2.9) 1.2 (1.2–1.2) 1.2 (1.1–2.9)
the pectoralis minor muscle (PmM) were resected and retracted
 T2-­ICBN 2.2 (0.7–4.5) 2.1 (0.8–2.8) 2.2 (0.7–4.5)
laterally to reveal the deep structures. The origins and branches
 T3-­ICBN 2.0 (1.8–2.2) 2.1 (1.9–2.3) 2.1 (1.8–2.3)
of the ICBN, the infraclavicular part of the brachial plexus (ie,
medial, lateral and posterior cords), the subclavian artery and Presence of the posterior 12 (100%) 14 (100%) 26 (100%)
axillary branch; N (%)
vein, the terminal branches of the brachial plexus (ie, MBCN,
medial antebrachial cutaneous nerve, ulnar nerve, radial nerve, BMI, body mass index; EP, point of emergence; ICBN, intercostobrachial nerve.
median nerve and musculocutaneous nerve) and the axillary
artery and veins were carefully identified and preserved.

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Origin and branching of the ICBN
We dissected cadavers from the thorax to the cubital fossa to
identify the ICBN at the level of its origin, where it emerges at
the chest wall, and its branches. The ICBNs that arose from the
first, second, third and fourth intercostal spaces were assumed
to be originated from the first, second, third and fourth inter-
costal nerves and labeled as T1-­ICBN, T2-­ICBN, T3-­ICBN and
T4-­ICBN, respectively. We recorded the diameter of the ICBN
at the site where it emerged from the serratus anterior muscle
(SAM) and the presence of the posterior axillary branches.
al17 and Feigl et al19 have systematically investigated the sono-
anatomy relevant to the ultrasound-­guided distal ICBN block.
Our anatomical exploration at the axilla intended to support and
simplify their findings. In our opinion, the easily detected land-
marks in the axillary fossa are the PMM, the axillary artery, and
the conjoint tendon of the latissimus dorsi muscle (LDM) and
the teres major muscle; whereas, the brachial and axillary fascia
layers, subscapularis muscle and the muscle-­tendon junction of
the LDM are sometimes difficult in visualizing. Therefore, the
distances between the ICBN and the axillary artery at the level
of the LDM’s distal attachment along with the proximity of the
ICBN to the conjoint tendon were recorded in this study.

Phase I: relationship of the ICBN and the adjacent structures

To specify the target for needle placement during ultrasound-­
guided proximal ICBN block, the proximity of the ICBN’s origin
to adjacent structures has to be identified in two dimensions (ie,
cranial–caudal and medial–lateral). We speculated that the land-
mark of the proximal ICBN block in the craniocaudal direction
is the second rib or the second intercostal space as the ICBN
consistently originates from the lateral cutaneous branch of the
second intercostal nerve.3 However, the exact location of the
needle tip whether on the rib or in between the second and the
third ribs requires further clarification. To determine the land-
mark in the mediolateral dimension, we chose the SAM as a
reference because its attachment on the surface of the ribs can
be easily recognized by ultrasound. We expected to find that the
ICBN’s origin is lateral to the medial border of the SAM and the
potential target for needle placement during the proximal ICBN
block is underneath the SAM. Therefore, at the chest wall, the
point of emergence (EP) of all origins of the ICBN were marked
as a reference point.18 The distances from the EPs to the infe-
rior border of the upper rib, the medial border of the SAM, and
the midclavicular line were measured in millimeters by a digital
Vernier caliper.
To identify the point of injection for the ultrasound-­guided
distal ICBN block, the relationship between the branches of
the ICBN and the surrounding structures in the cranial-­caudal
and superficial-­deep dimensions has to be determined. Varela et
2 Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
Phase II: investigation of the techniques of ICBN block
Based on the results of phase I as shown in table 1 and figure 1,
two regional anesthesiologists (AS and PL) confirmed the possi-
bility to visualize the sonoanatomy related to the ICBN at the
chest wall and in the axillary fossa. The two anesthesiologists
then defined certain ultrasound images and specific needle
targets for the ultrasound-­guided ‘plane’ blocks at the proximal
and distal parts of the ICBN as following.
►► Ultrasound-­guided proximal ICBN block (figure 2A,C)
–– The ultrasound image includes the surface of the second
rib where the SAM disappears.
–– The needle target is on the inferior border of the second
rib and just medial to the medial border of the SAM.
►► Ultrasound-­guided distal ICBN block (figure 2B,D)
–– The ultrasound image includes the axillary artery and the
surface of the conjoint tendon.
–– The needle target is along the anterior surface of the
conjoint tendon at approximately 3–4 cm caudal to the
axillary artery.
Thereafter, the ultrasound-­guided proximal and distal ICBN
blocks were performed in seven hemithoraxes and seven axillary
fossae. In each cadaver, the proximal ICBN block was randomly
assigned to one side and the distal ICBN block was performed
on the other side. A high frequency (6–13 MHz) linear probe
(LOGIQ F8, GE Healthcare, Wisconsin, USA) and a 22-­gauge,

Figure 1  Schematic drawing of the extrathoracic course of the intercostobrachial nerve (ICBN) and the relationship between the ICBN and the
adjacent structures of all six cadavers in phase I. LDM, latissimus dorsi muscle; SAM, serratus anterior muscle.
50 mm block needle (B Braun Medical AG, Melsungen, Germany)
were used in all blocks.
Ultrasound-guided proximal ICBN block
Each cadaver was placed in a supine position with shoulder
adduction. The ultrasound probe was initially placed over
the upper chest wall in the sagittal plane on the midclavicular
line. After the second rib was identified, the caudal end of the
probe was rotated laterally towards the axilla. The probe was
then moved in a medial–lateral direction to identify the PMM,
PmM, and the attachment of the SAM overlying the second rib.
Using the in-­plane technique from cranial to caudal direction,
the block needle was advanced until its tip contacted the inferior
border of the second rib at the point where the medial border of
the SAM disappeared. While injecting 10 mL of 0.1% methylene
blue, lifting of the PmM and the craniocaudal movement of the
dye towards the axilla in the subpectoral plane were confirmed
(figure 2A,C).
Ultrasound-guided distal ICBN block
Each cadaver was positioned in supine with 90° shoulder abduc-
tion. The ultrasound probe was initially placed transversely over
the midpoint of the upper arm and then slid toward the axilla to
identify the distal end of the PMM on the humerus. At this level,
the probe was slid caudally (perpendicular to the skin) to iden-
tify the humeral insertion of the LDM and its conjoint tendon.
The axillary artery and the terminal branches of the brachial
plexus were visualized at the cranial part of this ultrasound
image. Avoiding piercing through the neurovascular structures,
the block needle was in-­plane inserted from cranial to caudal
direction and advanced until its tip was 3–4 cm caudal to the
axillary artery and lied on the surface of the conjoint tendon.
While injecting 10 mL of 0.1% methylene blue, the dye spread
in the subcutaneous tissue superficial to the conjoint tendon was
visualized (figure 2B,D).
In phase II, the dissection started 2 hours after the dye injec-
tion. For the proximal ICBN block, we recorded the spread of
Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
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dye on the first, second, third, and fourth intercostal spaces and
staining of dye on the origins of the ICBN, the three cords of the
brachial plexus and the long thoracic nerve. For the distal ICBN
block, dye stained on branches of the ICBN and the brachial
plexus were recorded. The staining intensity was categorized as
a no, faint or deep stain.
Statistics
The data are presented as number (%), mean±SD or median
(min-­max), where appropriate.
RESULTS
The characteristics of cadavers are shown in table 1. All cadavers
were within the age range between 61 and 83 years and the BMI
range from 22.7 to 25.2 kg/m2.
Anatomical variation of the ICBN
The ICBN was observed bilaterally in all dissected cadavers.
One hundred per cent of the ICBN originated from the second
intercostal nerve and 34.6% of the ICBN received a contribution
from either the second or third intercostal nerves. The contribu-
tion patterns observed in this study were a single origin from the
second intercostal nerve alone (65.4%), a combined origin from
the first and second intercostal nerves (11.5%), and a combined
origin from the second and third intercostal nerves (23.1%). There
was no ICBN originating from the fourth intercostal nerve. The
mean diameters of the T1-­ICBNs, T2-­ICBNs and T3-­ICBNs were
1.7±1.0, 2.1±0.9 and 2.1±0.2 mm, respectively. All ICBNs gave
off at least one axillary branch to the posterior axillary fold (table 1
and figure 1).
Relationship of the ICBN and the adjacent structures at the
chest wall
All ICBNs origins emerged from the chest wall close to the inferior
border of the corresponding rib and lateral to the midclavicular
line. The mean distances from the EP of T1-­ICBNs, T2-­ICBNs
and T3-­ICBNs to the midclavicular line were 0.4±0.6, 3.6±1.2
3
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Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101783 on 14 September 2020. Downloaded from http://rapm.bmj.com/ on September 19, 2020 at University of Rochester
Table 2  Dye staining following ultrasound-­guided proximal and
distal ICBN blocks
Deep Faint
staining, N staining, N No staining,
Structure (%) (%) N (%)
At the chest wall (after proximal ICBN block)
Intercostal space
 1st 7 (100) 0 (0) 0 (0)
 2nd 7 (100) 0 (0) 0 (0)
 3rd 1 (14.3) 2 (28.6) 4 (57.1)
 4th 0 (0) 0 (0) 7 (100)
Origin of the ICBN (at the EP)
 T1-I­ CBN 1 (100) 0 (0) 0 (0)
 T2-I­ CBN 6 (85.7) 1 (14.3) 0 (0)
 T3-I­ CBN 0 (0) 1 (50) 1 (50)
Brachial plexus, infraclavicular part
 Medial cord 0 (0) 2 (28.6) 5 (71.4)
 Posterior cord 0 (0) 2 (28.6) 5 (71.4)
 Lateral cord 1 (14.3) 1 (14.3) 5 (71.4)
Long thoracic nerve 7 (100) 0 (0) 0 (0)
In the axillary fossa (after distal ICBN block)
Branch of the ICBN
 Terminal branch 7 (100) 0 (0) 0 (0)

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 Axillary branch 0 (0) 3 (42.9) 4 (57.1)
Brachial plexus, axillary part
 Medial antebrachial cutaneous nerve 4 (57.1) 3 (42.9) 0 (0)
 Medial brachial cutaneous nerve 3 (42.9) 2 (28.6) 2 (28.6)
 Ulnar nerve 1 (14.3) 3 (42.9) 3 (42.9)
 Redial nerve 0 (0) 6 (85.7) 1 (14.3)
 Median nerve 0 (0) 1 (14.3) 6 (85.7)
 Musculocutaneous nerve 0 (0) 0 (0) 7 (100)
EP, point of emergence on the chest wall; ICBN, intercostobrachial nerve.

between the ICBN and the axillary artery was 3.7±0.8 cm (a

range from 2.7 to 4.5 cm) (figure 1).

Dye spread following the proximal ICBN block

Figure 2  Ultrasound probe’s position and ultrasound image for the
proximal (A, C) and distal (B,D) intercostobrachial nerve (ICBN) blocks.
In D, a horizontal 4.7 cm scale (black marks 1 cm apart) represents
the size of the ultrasound transducer footprint. The point of injection
of the distal ICBN block is 3 cm caudal to the axillary artery. * point
of injection; white arrow, needle position; Ax, axillary artery; CBM,
coracobrachialis muscle, ICM, intercostal muscle, LDM, latissimus dorsi
muscle; PMM; pectoralis major muscle; PmM, pectoralis minor muscle.
and 4.3±0.1 cm, respectively. We failed to measure the distance
between the EP and the medial border of the SAM because the
first and second serrations of the SAM were not always clearly
identified.20 Therefore, we instead recorded whether the loca-
tion of the EP was lateral or medial to the medial border of the
SAM. Interestingly, 50% of T1-­ICBNs and 25% of T2-­ICBNs
appeared medial to the SAM attachment (figure 1).
Relationship of the ICBN and the adjacent structures in the
axilla fossa
The terminal branch of the ICBN consistently lay superficial to
the conjoint tendon and caudal to the axillary artery. At the level
of the distal border of the LDM insertion, the mean distance
4 Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
The first and second intercostal spaces were accurately stained
from the point of injection towards the lateral chest wall. Dye
seldom spread to the third intercostal space and consequently, it
unpredictably reached the ICBN that originated from the third
intercostal nerve. Dye injection with this technique occasionally
involved the brachial plexus; however, it certainly approached
posteriorly to the long thoracic nerve (table 2 and figure 3A,C).
Dye spread following the distal ICBN block
The ICBN gave off the axillary branches proximal to the point
of injection. Dye deeply deposited in the subcutaneous fat
located superficial to the conjoint tendon and surrounded the
main branch of the ICBN for a 3.5–14.2 cm distance. It spread
1.0–12.7 cm proximal and 5.7–12.2 cm distal to the injection
point. Because of its inconsistent proximal distribution, the
dye reached the posterior axillary branches in only 57.1% of
the blocks. The communication of the ICBN and the MBCN
was not detected in this study. The course of the MBCN was
regularly along with the ICBN. Therefore, the MCBN was often
stained with dye when it passed through the medial aspect of the
arm. Regarding a visualization of the ICBN under ultrasound,
we unintentionally recognized the ICBN or the MCBN in two
specimens (28.6%) after the dye injection completed (table 2 and
figure 3B,D).

Figure 3  Distribution of dye following ultrasound-­guided proximal (A,C) and distal (B,D) ICBN blocks. ICBN, intercostobrachial nerve; MBCN, medial
brachial cutaneous nerve.
DISCUSSION
This cadaveric study demonstrated that all ICBNs entirely or
partly derived from the second intercostal nerve. The ICBN
mostly appeared on the chest wall close to the lower border of the
corresponding rib and lateral to the medial border of the corre-
sponding serration of the SAM; however, some of them arose
medial to the latter. Therefore, our proposed needle target for
the proximal ICBN block was just medial to the medial border of
the SAM at the inferior surface of the second rib. This technique
showed an 85.7% success rate as indicated by complete staining
on all origins of the ICBN. At the level of the distal border of
the LDM insertion on the humerus, the distance between the
ICBN and the axillary artery was approximately 3–4 cm. There-
fore, our proposed needle target for the distal ICBN block was
at 3–4 cm caudal to the axillary artery on the anterior surface
of the conjoint tendon. This technique demonstrated 100% and
42.9% dye staining on the main branch to the upper arm and the
axillary branches of the ICBN, respectively.
Various anatomical variants of the extrathoracic course of the
ICBN have been reported over the last two decades. Even though
we had a small number of cadavers, our results were consistent
with previous large anatomical studies. In general, the ICBNs
were present bilaterally in all specimens.2 All ICBNs received
a contribution from the second intercostal nerve and 24.5% of
these specimens had another contributing origin from either
the first or the third intercostal nerves.21 The ICBN emerged
from the second intercostal space at approximately 0.5 cm infe-
rior to the second rib and 3.3 cm lateral to the midclavicular
line.18 The posterior axillary branch of the ICBN existed in all
specimens and sometimes divided early before it entered the
axillary fossa.1 22 Along the posteromedial aspect of the upper
arm, the ICBN passed superficial to the LDM and the average
distances between the ICBNs and the axillary artery previously
reported by Varela et al17 were around 3.5 cm in men and 2.7 cm
Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
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Medical Center. Protected by copyright.
in women.1 19 Our result that was distinct from previous studies
was the relationship between the EP of the ICBN and the SAM.
From our knowledge, the ICBN pierced through the SAM at the
midaxillary line1 18; however, our study demonstrated that 25%
of the ICBN arose medial to the medial border of the SAM.
Ultrasound-guided proximal ICBN block
The ICBN pierces through multiple muscular layers of the chest
wall and heads laterally towards the axilla. Previous studies
have described dissimilar needle targets (eg, on different ribs
and muscular planes) and volumes of injection. The injection
on the second or the third ribs showed constant dye spread
over the second and third intercostal spaces in cadaveric
studies and provided the predictable sensory loss of the T2 and
T3 dermatomes in clinical studies.5 7 8 11 13–15 23 24 Concerning
the depth of the needle target, either an injection in the plane
between the PMM and PmM,24 the PmM and SAM,7 8 13 the SAM
and rib,5 11 or the PmM and rib14 resulted in effective blockade
of the ICBN. Therefore, the plane of the needle injection might
be a minor factor affecting the ICBN block’s outcomes. Another
factor that potentially influences the success of the proximal
ICBN block is the injectate volume since the proximal part of
the ICBN could not be visualized under ultrasound guidance.
The volume of local anesthetic used in clinical studies aiming
to selectively anesthetize the ICBN varied from 6 to 20 mL.5 7 8
With six mL of local anesthetic, complete sensory loss in the
medial side of the upper arm was achieved in 91% of patients.7
The proposed technique of the proximal ICBN block in the
present study derived from the location of all ICBNs observed
in the phase I. The target for dye injection was within close
range among all ICBN’s origins. We speculated that 10 mL of
dye could spread towards all ICBNs when they arose from the
external intercostal muscle. Our results demonstrated consistent
5
 Original research
staining on the T1-­ICBNs and T2-­ICBNs. However, one out of
the two T3-­ICBNs was spared. This incomplete stained ICBN
was eventually soaked with dye when the nerve traveled on the
lateral chest wall before entering the axilla. If we assumed that
this ICBN was successfully blocked, the success rate of this tech-
nique would be 100%.
Ultrasound-guided distal ICBN block
The target of the distal ICBN block was commonly in the subcu-
taneous plane superficial to the conjoint tendon.10 17 19 With a
nerve localization technique, the success of the block was achieved
with a 1–5 mL volume of injection.10 17 19 However, specific sono-
graphic landmarks described in these previous studies required
operator’s expertise and/or high-­resolution ultrasound.16 18 In
this study, we proposed a simplified ultrasound-­guided plane
block because the ICBN in this area sometimes branches off
small cutaneous nerves resulting in difficulty in visualizing.
After 10 mL of dye injection, we found consistent staining on
all terminal branches of the ICBN. However, dye occasionally
spared the axillary branches because they branched off proximal
to the injection point. None of the previous studies assessed the
area of sensory loss in the axillary region. Further well-­designed
clinical studies are suggested to verify the use of the distal ICBN
block for surgery involving the axilla. Another concern about
the technique of the distal ICBN block is a potential injury to
the brachial plexus and the axillary artery because these neuro-
vascular structures are usually on the needle trajectory when the
block needle approaches in cranial-­to-­caudal direction.
The ICBN block is indicated for controlling acute and chronic
pain involving the axilla and the posteromedial aspect of the
arm. As a sole anesthetic technique, the ICBN block is an effec-
tive alternative treatment for intercostobrachial neuralgia and
persistent pain after breast cancer surgery.8 9 As an adjunct to the
brachial plexus block, the ICBN block alleviates surgical pain of
the upper arm surgery, such as arteriovenous fistula formation,
and attenuates pain or discomfort from the pneumatic tourni-
quet.12 13 25 Also, it is known that the ICBN often contributes
to the brachial plexus by anastomosing to the medial cord or
the MBCN.3 26 Therefore, combined brachial plexus and ICBN
block is necessary for entire upper limb anesthesia.7 13 The choice
of approaches for the brachial plexus block depends on surgical
area, patient’s anatomy, and anesthesiologist’s preference.
Besides its benefits, the risks of the ICBN block have to be
taken into account. The ICBN block is not routinely performed
in clinical practice because there are alternative pain management
modalities such as administration of oral/intravenous sedative
and analgesic medications, and subcutaneous infiltration of local
anesthetics. If the risks of needle placement and local anesthetic
deposition following the ICBN block outweigh its benefits, the
block should be studied only for academic purposes. However,
no block-­related complications were observed in previous clin-
ical studies.5 8 13 Specifically, following the ultrasound-­guided
proximal ICBN block, no pneumothorax was reported even
though the injection was underneath the SAM, which was in
close proximity to the pleura.5
A selection of approaches of the ICBN block depends primarily
on types of operation. For the upper limb surgery involving the
skin at the posteromedial aspect of the arm, either the prox-
imal or distal approach could be performed in combination
with the brachial plexus block.10 13 The proximal approach is
more preferable when the surgery extends to the axillary area.7
However, difficulty in performing the proximal ICBN block
may be caused by instruments placed on the anterior chest wall
6 Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101783 on 14 September 2020. Downloaded from http://rapm.bmj.com/ on September 19, 2020 at University of Rochester
such as hemodialysis catheter or pacemaker. One previous study
mentioned that the distribution of injectate following the prox-
imal approach was promising even though a vascular port or a
pacemaker was situated on the chest wall.14
The limitations of this cadaveric study arose from a limited
number of samples which might not account for a high variation
of the ICBNs. Nonetheless, our findings were reliably consistent
with previous studies. In phase I, the true origin of the ICBN
at the nerve root was not dissected. We assumed that the ICBN
arising from the second intercostal space (close to the inferior
surface of the second rib) originated from the second intercostal
nerve which originated from the T2 nerve root. In phase II, the
spread pattern of dye after the ICBN block in fresh cadavers
might not mirror clinical practice. Moreover, regarding the
intensity of dye staining, we assumed that both faint and deep
stains on the nerves represented a successful nerve blockade. If
a manner of dye staining on the nerves was not similar to the
nerves bathed in local anesthetic, and faint staining was insuf-
ficient to suppress the nerve conduction, the rate of success
reported in this study would be lower. Besides, because the ICBN
has complex communication with the brachial plexus,3 26 bene-
fits of anatomical studies are limited and further clinical studies
are encouraged to elucidate functional outcomes (eg, the area of
a sensory block) following the ultrasound-­guided proximal and
distal ICBN blocks.
Medical Center. Protected by copyright.
CONCLUSIONS
Our findings suggested that ultrasound-­ guided proximal and
distal ICBN blocks, which were performed using simple sono-
anatomical landmarks, provided reliable dye spread to the ICBN.
Because of variations of the ICBN and its complex connections
to the brachial plexus, further clinical studies are encouraged
to validate these techniques of the ICBN block when combined
with the brachial plexus block for surgery at the upper arm and
the axillary regions.
Acknowledgements  The authors would like to thank Pagorn Navic, Naraporn
Maikong and Perada Kantakam for their assistance with cadaveric dissection.
Contributors  AS, PL, KrP, KiP and PM designed the trial and reviewed the
manuscript. AS, PL, KiP and PM conducted the study and collected the data. AS and
PL wrote the manuscript.
Funding  This work was supported by the Faculty of Medicine Research Fund,
Chiang Mai University, Chiang Mai, Thailand.
Competing interests  None declared.
Patient consent for publication  Not required.
Ethics approval  The Ethics Exemption was granted by the Ethics Committee of the
Faculty of Medicine, Chiang Mai University.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  All data relevant to the study are included in the
article. The authors confirm that the data supporting the findings of this study are
available within the article.
REFERENCES
1 O’Rourke MG, Tang TS, Allison SI, et al. The anatomy of the extrathoracic
intercostobrachial nerve. Aust N Z J Surg 1999;69:860–4.
2 Loukas M, Hullett J, Louis RG, et al. The gross anatomy of the extrathoracic course of
the intercostobrachial nerve. Clin Anat 2006;19:106–11.
3 Henry BM, Graves MJ, Pękala JR, et al. Origin, branching, and communications of
the intercostobrachial nerve: a meta-­analysis with implications for mastectomy and
axillary lymph node dissection in breast cancer. Cureus 2017;9:e1101.
4 Thallaj AK, Al Harbi MK, Alzahrani TA, et al. Ultrasound imaging accurately identifies
the intercostobrachial nerve. Saudi Med J 2015;36:1241–4.
5 Torre PAdela, Jones JW, Álvarez SL, et al. [Axillary local anesthetic spread after the
thoracic interfacial ultrasound block - a cadaveric and radiological evaluation]. Rev
Bras Anestesiol 2017;67:555–64.

6 Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia: essentials
of our current understanding, 2008. Reg Anesth Pain Med 2009;34:134–70.
7 Moustafa MA, Kandeel AA. Randomized comparative study between two different
techniques of intercostobrachial nerve block together with brachial plexus block
during superficialization of arteriovenous fistula. J Anesth 2018;32:725–30.
8 Wijayasinghe N, Duriaud HM, Kehlet H, et al. Ultrasound guided intercostobrachial
nerve blockade in patients with persistent pain after breast cancer surgery: a pilot
study. Pain Physician 2016;19:E309–18.
9 Wisotzky EM, Saini V, Kao C. Ultrasound-­Guided Intercostobrachial Nerve Block
for Intercostobrachial Neuralgia in Breast Cancer Patients: A Case Series. Pm R
2016;8:273–7.
10 Magazzeni P, Jochum D, Iohom G, et al. Ultrasound-­guided selective versus
conventional block of the medial brachial cutaneous and the intercostobrachial
nerves: a randomized clinical trial. Reg Anesth Pain Med 2018;43:1–837.
11 Yamak Altinpulluk E, Galluccio F, Salazar C, et al. New approach for blocking
intercostobrachial and medial brachial cutaneous nerve in the axillary area: response
to Varela. Reg Anesth Pain Med 2020. doi:10.1136/rapm-2020-101317. [Epub ahead
of print: 19 Feb 2020].
12 Purcell N, Wu D. Novel use of the PecS II block for upper limb fistula surgery.
Anaesthesia 2014;69:1294.
13 Quek KH, Low EY, Tan YR, et al. Adding a PECS II block for proximal arm
arteriovenous access - a randomised study. Acta Anaesthesiol Scand
2018;62:677–86.
14 Seidel R, Gray AT, Wree A, et al. Surgery of the axilla with combined brachial plexus
and intercostobrachial nerve block in the subpectoral intercostal plane. Br J Anaesth
2017;118:472–4.
15 Biswas A, Castanov V, Li Z, et al. Serratus plane block: a cadaveric study to evaluate
optimal injectate spread. Reg Anesth Pain Med 2018;43:854–8.
Samerchua A, et al. Reg Anesth Pain Med 2020;0:1–7. doi:10.1136/rapm-2020-101783
Original research
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101783 on 14 September 2020. Downloaded from http://rapm.bmj.com/ on September 19, 2020 at University of Rochester
16 Yu HC, Spencer AO, Endersby RVW. Plane but not so simple: ultrasound-­guided plane
block of the medial brachial cutaneous and intercostal brachial nerves. Reg Anesth
Pain Med 2019:rapm-2018-100054.
17 Varela V, Ruíz C, Pomés J, et al. Usefulness of high-­resolution ultrasound for small
nerve blocks: visualization of intercostobrachial and medial brachial cutaneous nerves
in the axillary area. Reg Anesth Pain Med 2019:929–33.
18 Hwang K, Huan F, Hwang SW, et al. The course of the intercostobrachial nerve in the
axillary region and as it is related to transaxillary breast augmentation. Ann Plast Surg
2014;72:337–9.
19 Feigl G, Aichner E, Mattersberger C, et al. Ultrasound-­guided anterior approach
to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical
investigation. Br J Anaesth 2018;121:883–9.
20 Smith R, Nyquist-­Battie C, Clark M, et al. Anatomical characteristics of the upper
serratus anterior: cadaver dissection. J Orthop Sports Phys Ther 2003;33:449–54.
21 Nayak SR, Banerjee SS. Anatomic variations of the extrathoracic course of the
intercostobrachial nerve and its clinical significance. Asian J Med Sci 2018;9:77–80.
22 Soares EWS. Anatomical variations of the axilla. Springerplus 2014;3:306.
23 Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of PecS II
(modified PecS I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim
2012;59:470–5.
24 Versyck B, Groen G, van Geffen G-­J, et al. The PecS anesthetic blockade: a correlation
between magnetic resonance imaging, ultrasound imaging, reconstructed cross-­
sectional anatomy and cross-­sectional histology. Clin Anat 2019;32:421–9.
25 Schoenherr J, Bortsov A, Rowan C, et al. Effectiveness of an “axillary ring block” in
reducing tourniquet pain in volunteers: Double blind, randomized crossover clinical
trial. Matters 2016.
26 Loukas M, El-­Zammar D, Tubbs RS, et al. A review of the t2 segment of the brachial
plexus. Singapore Med J 2010;51:464–7.
Medical Center. Protected by copyright.
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