Paravertebral approach to the brachial plexus: An anatomic improvement in technique

In the early 1920s, Kappis developed blocks of the spinal nerves at all levels of the vertebral column, including blocks of the the cervical and brachial plexis.1 Because the vertebral artery and vein are anterior to these nerves, he advocated a posterior rather than lateral approach. Probably due to penetration of the paraspinal extensor muscles of the neck, these blocks were painful and remained little used until Pippa’s 1990 report of a modified approach to the brachial plexus.2 We describe a modification of the techniques introduced by Kappis and Pippa, which minimizes the pain associated with this approach to the brachial plexus by inserting the needle between the levator scapulae and trapezius muscles.3 Secondarily we describe catheter insertion for continuous brachial plexus nerve block using a “stimulating catheter.”