Lateral Cord Of Brachial Plexus Research Articles

Variations of musculocutaneous nerve – A cadaveric study

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm.

Rare Branching Pattern of Brachial Plexus- A Case Series

Introduction: The musculocutaneous nerve is one of the branches from the lateral cord of brachial plexus. This nerve is solely devoted to the flexor compartment of arm hence it is called as nerve of arm. Numerous studies have been reported about the variations of this nerve but the real prevalence is still unknown, whereas, it may be hypothetical. Case report: This study shows a rare branching pattern where a thin nerve takes origin from the medial fasciculus of brachial plexus which then pierces the coracobrachialis and lies between the biceps brachii and brachialis. The nerve then pierces the biceps to supply the skin over the lateral surface of forearm. The median nerve took over the muscular branches of musculocutaneous nerve by giving off the branches to both biceps and brachialis.

Anatomical variation of median nerve: cadaveric study in brachial plexus.

Median nerve is formed by lateral root from lateral cord and medial root from medial cord of brachial plexus. Formation of median nerve occur in front or lateral to axillary artery in axilla. In the present study we observed anatomical variations of median nerve formation in the brachial plexus. We examined formalin fixed 60 upper limbs from 30 adult cadavers (15 males and 15 females) which were above the age 40 years from the department of Anatomy. All the cadavers were dissected on both sides according to Cunningham’s Manual of Practical Anatomy. Normal formation of median nerve by two roots noted in 42 (70.0%) of upper limb specimen. Variation of median nerve formation noted in 18 (30.0%) upper limb specimen. Three roots taking part in the formation of median nerve in 13 (21.7%) upper limb specimen where additional root coming from lateral cord of brachial plexus. Four roots taking part in formation of median nerve in 3 (5.0%) upper limb specimen, where additional roots coming from lateral cord and posterior cord of brachial plexus. Lateral root crossed the axillary artery anteriorly to join with medial root lying medial to axillary artery. The median nerve formed medial to third part of axillary artery. Additional communication with musculocutaneous nerve with median nerve seen in 2 (3.3%) upper limb specimen. Knowledge of such anatomical variations is of interest to the anatomist and clinician alike. Surgeons who perform procedures involving neoplasm or repairing trauma need to be aware of these variations. Median nerve variation may lead to confusions in surgical procedures and axillary brachial plexus nerve block anesthesia.

Absence of Musculocutaneous Nerve: A Rare Anatomical Variation

Neural variation of the brachium constitutes a significant anatomical and clinical entity. The absence of Musculocutaneous Nerve is occasional in humans and accordingly there may be unforeseen clinical implication regarding the atypical innervations of musculature otherwise supplied by the Musculocutaneous Nerve. The present study is an absence of Musculocutaneous nerve observed during our routine educational dissection, where the lateral cord of brachial plexus took over the area of supply of Musculocutaneous Nerve by giving both the muscular and sensory branches. Knowledge of these variations is important in surgeries and during the administration of regional anaesthesia near shoulder joint and upper arm.

Study of variations in the formation and branching pattern of lateral cord of brachial plexus- A detailed cadaveric study

As the formation of brachial plexus involves numerous nerve roots, it is more common than rare to find variations in the formation and its branching pattern. Innumerable variations in the formation of lateral cord of brachial plexus and the branches of the lateral cord of brachial plexus are reported. This study is done with an intension to specifically look into the possible variations in the formation and branches of the lateral cord of brachial plexus only. The present study was carried on cadavers during undergraduate dissection, in the Department of Anatomy, Velammal Medical College, Annupanadi, Madurai, Tamilnadu India. In the present study The cadavers were dissected out to find the branching pattern of the Lateral cord and the observations were analysed, many variations in the branching patterns were observed, significant one being the musculocutaneous nerve being absent, coracobrachialis being supplied by branch from lateral root of median nerve, in another musculocutaneous nerve ends by supplying only coracobrachialis and the rest are supplied by the branches from median nerve. The frequency of anomalies found in the arrangement and distribution of lateral cord and its branches makes this anatomic region complicated with regard to surgical approaches.

Bilateral variation in origin of thoracodorsal artery along with non-piercing variant of musculocutaneous nerve on left side

Subclavian artery continues as axillary artery in the axilla and is the principal source of blood supply of the lateral thoracic wall, axilla, scapular region, and upper limb. Thoracodorsal artery is one of the terminal branches of subscapular artery, which in turn is branch from the third part of axillary artery. Musculocutaneous nerve, a branch from lateral cord of brachial plexus, is the chief nerve supply of anterior compartment of arm, commonly seen piercing the coracobrachialis muscle before continuing as lateral cutaneous nerve of forearm. In the current case report, thoracodorsal arteries on both sides were arising from lateral thoracic artery, branch of second part of axillary artery and the left musculocutaneous nerve was not piercing the coracobrachialis muscles. Also, there was a communication between left musculocutaneous nerve and left median nerve. The knowledge about normal and variant pattern of origin and course of branches of axillary artery is very important as it may help the surgeons to identify the source of bleeding during surgeries in region of shoulder or axilla. Also, post-surgical complication or symptoms of nerve repair can be explained by the variation in course of musculocutaneous nerve and its communication with median nerve.

Erb’s Palsy in a Newborn Child and Clinicoanatomical Approach

Erb’s palsy is found in upper trunk of brachial plexus. C5, C6 roots join to from upper trunk. Each trunk again divides into anterior and posterior divisions. All trunks and divisions are found above the clavicle in the posterior triangle of neck. Branches from the upper trunk are suprascapular nerve and nerve to subclavius. Suprascapular nerve supplies supraspinatus and infraspinatus muscle along with it a articular trig to capsule of shoulder joint. Supraspinatus helps in initial 15 ºabduction at shoulder joint. Infraspinatus acts as lateral rotator of shoulder joint and assists subscapularis and teres minor muscles to abduct at this joint when there is contraction of middle fibers of deltoid and supraspinatus. Some fibers of C5 also give contribution to accessory phrenic nerve. Lateral cord of brachial plexus giving– musculocutaneous nerve, lateral pectoral nerve, lateral root of median nerve. Musculocutaneous nerve supplies all flexor muscles of arm like biceps brachii, brachialis, coracobrachialis. Brachialis muscle flexes the elbow joint, coracobrachialis is a weak flexor of shoulder joint and biceps brachii is a strong supinator of forearm, flexor of elbow joint only when forearm is supinated. Injury occurs in the Erb’s point found in the upper trunk of brachial plexus where there are emergence of six branches- C5 & C6 nerve roots, suprascapular nerve, nerve to subclavius, anterior and posterior division of upper trunk of the plexus. In this palsy, the arm remains medially rotated and adducted at the shoulder joint, the elbow is extended or semiflexed, forearm is pronated, and the wrist semiflexed. In this case a newborn child was found unable to flex his elbow, and abducted the arm on the right side. The limb is medially rotated, adducted in shoulder joint, semiflexion at the elbow joint and forearm pronated and wrist semiflexed. The child was kept on artificial respiratory ventilation. Plain Chest X-ray done to see if any musculoskeletal abnormality is there but no positive findings found so far. Both the clavicles and all ribs were found intact. Both domes of diaphragm were moving normally. On the other hand left sided upper limb found fully flexed at the elbow joint, supinated at forearm, abducted externally rotated at the shoulder joint and wrist extended. Moros reflex on the right side was absent but on left side it was clearly present. So, there is asymmetrical Moros reflex.

OBLIGATORY ALTERATIONS IN THE MORPHOLOGY OF MEDIAN NERVE: A SONOGRAPHIC STUDY IN ASYMPTOMATIC INDIVIDUALS

Introduction: Median nerve is formed in axilla by contributions from medial and lateral cords of brachial plexus. It descends in the arm, forearm and then through carpal tunnel in close conjunction with flexor tendons of forearm. Carpal tunnel syndrome (CTS) is a common entrapment neuropathy. Median nerve cross sectional area (CSA) and ratio of nerve major axis to minor axis (flattening ratio) serve as potential diagnostic criteria for carpal tunnel syndrome. Median nerve cross sectional area and flattening ratio (FR) can be assessed by ultrasonography (US). Aim of the study was to assess median nerve by US and tabulate mean values for CSA and FR in asymptomatic population. This would serve to limit the cut-off values that differentiate asymptomatic nerves from neuropathic nerves. Material & Methods: Study was conducted in the Department of Anatomy, KGMU, Lucknow. Fifty randomly selected asymptomatic volunteers (undergraduate students: 30 males, 20 females) participated in the study. Sonography was performed to evaluate certain morphological dimensions of median nerve. Height, weight and wrist circumference of participants were also noted. Ultrasonography was performed using high frequency linear probe and observations were made at two pre-determined sites. Observations were recorded, tabulated and analyzed. Results: Median nerve was easily observable at both sites. It was round in shape in forearm (Fo), and flattened as it reached the carpal tunnel (Ct). Among all 50 study subjects, at both sites, flattening was more on right side (FRFoRt-1.71; FRCtRt-3.08) than on left side (FRFoLt-1.66; FRCtLt-2.78). In right forearm, nerve was flatter in females (FRFoRt-1.77) as compared to males (FRFoRt-1.68). In left forearm, median nerve was slightly rounder in females (FRFoLt-1.65) as compared to males (FRFoLt-1.67). At the distal wrist crease on right side, increased flattening was observed in females (FRCtRt-3.30) as compared to males (FRCtRt-2.94), whereas on left side, at same site flattening was more in females (males FRCtLt-2.74; females FRCtLt-2.83). Conclusion: Altered FR has both diagnostic as well as prognostic values in carpal tunnel syndrome. The database generated from the study will help in facilitating comparisons between normal, asymptomatic and pathological, asymptomatic individuals.

A CADAVERIC STUDY ON THE ANATOMICAL VARIATIONS OF THE MUSCULOCUTANEOUS NERVE IN RELATION WITH MEDIAN NERVE AND CORACOBRACHIALIS MUSCLE

Introduction: Musculocutaneous nerve is derived from the lateral cord of brachial plexus and supplies the muscles of the arm. Initially the nerve accompanies the lateral side of third part of axillary artery and then pierces the coracobrachialis muscle after supplying it, passes downwards and laterally in between biceps brachii and brachialis sending branches to both and continues as lateral cutaneous nerve of the forearm. Variations of musculocutaneous nerve is important for surgeons, orthopedic surgeons and traumatologists, so a detailed cadaveric study of musculocutaneous nerve was done to observe the variations. Material & Methods: Musculocutaneous nerve was studied in 50 human cadavers (30 males and 20 females) of age group 40-60 years at Department of Anatomy, Subharti Medical College, Meerut, India. Results: Musculocutaneous nerve was present in all the cases and was piercing the coracobrachialis muscle. In 4% of the cases, the nerve was rejoining the median nerve after piercing the coracobrachialis.

S41. Study of electromyography, ultrasound and magnetic resonance imaging in idiopathic brachial plexus

Introduction The brachial plexus consist of the fifth to the eighth cervical nerves and the first anterior thoracic anterior branch. The terminal branches of the brachial plexus mainly include the axillary nerve, the radial nerve, the musculocutaneous nerve, the median nerve and the ulnar nerve, dominating the feeling and motor function of the upper limbs. Idiopathic brachial plexus neuritis is a more common brachial plexus neuropathy, but it is easy to misdiagnosis and missed diagnosis in clinic, resulting in irreversible damage to the upper limb function of patients and seriously affecting the life of the patient. Methods The clinical data of 19 patients diagnosed with idiopathic brachial plexus neuropathy in Beijing Tsinghua Changgung Memorial hospital from January 2015 to October 2017 were analyzed retrospectively. All patients underwent rigorous neurological examination. Nicolet EDX electromyography and evoked potentials were used to evaluate the limb nerve conduction of the patients. All patients were performed with brachial and/ or cervical MRI, and shoulder muscle examination by GE 3.0T MR scanner. Brachial plexus sonography was performed on patients with Philips iU22 Color Doppler Ultrasound. Some patients had a lumbar puncture cerebrospinal fluid examination. Most patients undergo standardized rehabilitation. Results Of the 19 patients, 14 were males and 5 were females, with duration of 2 weeks to 9 months, ranging in age from 25 years to 83 years. All patients have shoulder pain, and gradually muscle weakness, muscle atrophy. Eleven patients had uncomfortable symptom in the left upper extremity and 8 in the right.EMG results suggested that 17 patients had injury in the upper and middle stem of the brachial plexus, lower stem injury in 1 case. One patient had clinical symptoms with normal EMG analysis, but the lateral cord of brachial plexus was abnormal in the ultrasound examinations. Vulnerable nerves followed by axillary nerve in 14 cases, 13 cases of musculocutaneous nerve, suprascapular nerve in 13 cases, 3 cases of radial nerve, median nerve in 1 case, ulnar nerve in 1 case. High-frequency ultrasound results showed abnormality in 17 cases, with thickening of the edema of the nerves or significant edema with changes of the hourglass. A total of 18 cases were performed MRI examination, of which 12 cases were abnormal, no abnormalities in 6 cases (6/18). The direct signs of MRI examination included the performance of nerve thickening, increased signal. The indirect signs included visible atrophy and diffuse T2 high signal in supraspinatus, subocular muscles and deltoid muscle. Conclusion Electromyography combined with ultrasound and magnetic resonance imaging can evaluate the function and morphology of brachial plexus, and greatly improve the diagnosis rate of idiopathic brachial plexus neuritis.

An unusual case of accessory head of coracobrachialis muscle involving lateral cord of brachial plexus and its clinical significance.

Knowledge of anatomical variations in the peripheral nervous system is key in the interpretation of unusual clinical signs or during physical or diagnostic imaging. This case study is a description of an anatomical variation between the coracobrachialis muscle and brachial plexus. In a routine dissection in the human anatomy laboratory, we were faced with an anatomical variation in the coracobrachialis muscle, observed in the upper right limb of a male cadaver. The coracobrachialis muscle had a common origin at the apex of the coracoid process and then divided into two heads. The lateral head followed its normal course until insertion into the middle third of the humerus, while the medial head involved the lateral cord of the brachial plexus before insertion into the intermuscular septum in the proximal third of the humerus. Atypical anatomical variations have clinical and surgical implications in procedures such as brachial plexus block and lateral cord compression. In these cases the result could be paralysis of the flexor musculature of the forearm and hypoesthesia of the forearm.

Unusual and Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A Cadaveric Study.

Adequate knowledge on variant morphology of brachial plexus and its branches are important in clinical applications pertaining to trauma and surgical procedures of the upper extremity. Current study was aimed to report variations of the branches of the lateral cord of brachial plexus in the axilla and their possible clinical complications. Total number of 82 upper limbs from 41 formalin embalmed cadavers was dissected. Careful observation was made to note the formation and branching pattern of lateral cord. Meticulous inspection for absence of branches, presence of additional or variant branches and presence of abnormal communications between its branches or with branches of other cords was carried out. In the present study, we noted varied branching pattern of lateral cord in 6 out of 82 limbs (7%). In one of the limb, the median nerve was formed by three roots; two from lateral cord and one from medial cord. Two limbs had absence of lateral pectoral nerve supplemented by medial pectoral nerves. One of which had an atypical ansa pectoralis. In 2 upper limbs, musculocutaneous nerve was absent and in both cases it was supplemented by median nerve. In one of the limb, coracobrachialis had dual nerve supply by musculocutaneous nerve and by an additional branch from the lateral cord. Variations of brachial plexus and its branches could pose both intraoperative and postoperative complications which eventually affect the normal sensory and motor functions of the upper limb.

Third root of median nerve –a cadaveric study

The third root of median nerve though rare has definite embryological basis and clinical impact. The Present study was conducted in the postgraduate Department of Anatomy at Government Medical College Srinagar to study the variations in the number of roots of median nerve during routine dissection for academic purposes between 2001 -20014. Both upper limbs of 35 Indian cadavers were dissected out for routine anatomic teaching and simultaneously recording observations. It was observed that in one of the female cadavers the left median nerve had three roots (one medial and two lateral). The two lateral roots originated from the lateral cord and the medial root originated from medial cord of brachial plexus. The third root originated between the origins of the lateral root and the musculocutaneous nerve from lateral cord of brachial plexus. This anomalous root joined with the median nerve distal to the lateral root in the proximal third of arm. The third root of median nerve though rare is of great academic and clinical significance in Surgery, Neurophysiology, Orthopedics, Anaesthesiology, Sports medicine and Physiotherapy.

Unilateral variant motor innervations of flexor compartment of arm (915.10)

Variations in the nerves of the upper limb are very important in routine surgeries, where these nerves are more prone for injuries; these variations may also help in interpretation of a nervous compression having unexplained clinical symptoms. The musculocutaneous nerve usually branches out from the lateral cord of brachial plexus. It innervates the coracobrachialis, biceps brachii and brachialis muscles and continues as the lateral cutaneous nerve of forearm without exhibiting any communication with the median nerve or any other nerve. We report a unilateral variation in motor innervations of the right arm in a 72‐year‐old Female cadaver. The musculocutaneous nerve was found to be piercing coracobrachialis muscle, supplying it and later continue as lateral cutaneous nerve of forearm. A muscular branch of the median nerve was supplying the short and long head of biceps muscle. In the middle of arm, the median nerve was found to be giving a separate branch, which supplied the brachialis muscle and continued in the cubital fossa with normal relation to biceps tendon and brachial artery. There was no variation seen in distribution of median nerve in the flexor compartment of forearm and hand. Knowledge of such anatomical variation is of interest to the anatomist and surgeons.

Multiple unilateral variations in medial and lateral cords of brachial plexus and their branches

During routine dissection of the upper extremity of an adult male cadaver, multiple variations in branches of medial and lateral cords of brachial plexus were encountered. Three unique findings were observed. First, intercordal neural communications between the lateral and medial cords were observed. Second, two lateral pectoral nerves and one medial pectoral nerve were seen to arise from the lateral and medial cord respectively. The musculocutaneous nerve did not pierce the coracobrachialis. Finally, the ulnar nerve arose by two roots from the medial cord. Knowledge of such variations is of interest to anatomists, radiologists, neurologists, anesthesiologists, and surgeons. The aim of our study is to provide additional information about abnormal brachial plexus and its clinical implications.

Neuro-Anatomical Variation of Lateral Cord of Brachial Plexus

During the educational gross anatomy dissections of the infra-clavicular part of brachial plexus of a 50-year-old male cadaver in our department of anatomy,Andhra medical college, Visakhapatnam, we have encountered a neuroanatomical variation. The lateral cord of brachial plexus and its branches, had a different configuration. On the right side ,the median nerve received very few fibres from the lateral cord of brachial plexus during its formation. On both sides the musculo-cutaneous nerve has given an accessory branch which again joined the main trunk of the median nerve.This variation has clinical importance in median nerve lesions and its distinctive diagnosis. Lesions of the median nerve, if lesion was proximal to this accessory branches, muscles and cutaneous innervations related to this branch were normal.

Report of an unusual combination of arterial, venous and neural variations in a cadaveric upper limb

In this study an unusual combination of arterial, venous and neural variations discovered during dissection of cervical, axillary and brachial area of a cadaver is described. Variations are thoroughly described and literature is briefly reviewed. Lateral cord of brachial plexus was not formed; Eight Cervical root divided into anterior and posterior division before uniting with First Thoracic root and Upper Trunk was unusually short. Axillary artery gave origin to a superficial brachial artery and then continued as deep brachial artery. Multiple variations in typical axillary artery branches were present including existence of inferior pectoral artery. Cephalic vein was absent. A variety of interventions, from relative simple as central venous catheter placement to most complicated as brachial plexus injury repair demand thorough knowledge of area’s regional anatomy. Familiarity with anatomic variations allows more precise and careful interventions. Research on these variations is valuable for anatomists and embryologists but also for clinicians because it may provide useful information for non - typical cases but also helps in raising a high level of suspicion.

Ultrasound-guided anterior axilla musculocutaneous nerve block

This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla. Twenty patients (7 males and 13 females; mean age, 35years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated. Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication. The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

Catheter-over-needle method facilitates effective continuous infraclavicular block

To the Editor, We read with great interest the excellent article written by Dr. Lecours et al. which reported an observational cohort study of all ultrasound-guided single-injection infraclavicular blocks (ICBs) performed over a two-year period at their institution. The authors observed that ultrasound-guided ICB performed with a single injection posterior to the axillary artery is a reasonably safe technique associated with a high success rate regardless of the expertise of the anesthesiologist performing the block. Experience within our institution is consistent with this observation, and we would agree strongly that ICB performed by single injection posterior to the axillary artery is safe and effective. Further, this provides an excellent approach for placement of a continuous catheter using a catheter-over-needle technique. Here, with written consent from the patient, we report our recent experience of placing an infraclavicular catheter utilizing a 21G 9 95-mm catheter-over-needle unit (MultiSet UPK NanoLine 21156-40E, Pajunk, Germany) for a planned re-implantation of thumb after a rope-related farming accident. A high-frequency linear ultrasound transducer (13-6 MHz HFL38, M-Turbo ; SonoSite, Bothell, WA, USA) was placed in the deltopectoral grove parasagittally, where the axillary artery and the lateral cord of brachial plexus in its lateral aspect were easily identified (Figure). After raising a local anesthetic wheal, the catheter-over-needle unit was inserted cephalad to the probe and advanced in-plane caudally or inferiorly at approximately 45 to 60 from the ultrasound probe axis, through the pectoral muscles and toward the parasagittal plane between the axillary artery and the lateral cord. Hydrodissection with dextrose 5% in water was used to create sufficient space between the lateral cord and axillary artery to advance the needle/catheter unit into a more advantageous position, posterior to the axillary artery and directly adjacent to the posterior cord. Once the tip of the needle was positioned, and, following negative aspiration of blood or air, 20 mL of local anesthetic was injected to open the perivascular space. The needle was removed from the outer catheter, and a flexible, 20G 9 75-mm inner catheter was inserted through the cannula and Luer-locked onto the 18G catheter sheath such that both catheters were in situ. Before securing the catheter in place with a dressing (e.g., Tegaderm), a further 10 mL of local anesthetic was injected through the catheter to complete the block and confirm the spread. Instead of the planned thumb reimplantation, debridement of the thumb was performed. In the post anesthetic recovery room, a local anesthetic infusion was commenced and continued at 1 mL hr with an 8 mL bolus every hour until the next morning when the infraclavicular catheter was removed and the patient transitioned to oral analgesia. Throughout the infusion, the patient was pain-free, and the catheter remained in place with intact and dry dressings, as was our experience with an interscalene catheter placed using the catheterover-needle method. We have used this approach to place five infraclavicular catheters over the last three months, and in each case, the pain management was excellent. Catheter insertion has been uncomplicated and all have been removed as planned. Editor’s Note: The authors of the article: Can J Anesth 2013; 60: 244-52, respectfully declined an invitation to submit a reply to the above Letter to the Editor.

Variation in the Nerve Supply to Coracobrachialis Muscle - A Case Study

Coracobrachialis muscle is a muscle of the adductor compartment of arm. It is supplied by musculocutaneous nerve, a branch from the lateral cord of brachial plexus. The study was done between 2008-2012 [5 years] in J.J.M.M.C. and S.I.M.S. & R.C. The present case was found in a male cadaver aged around 60years. During the routine cadaveric dissection of undergraduate students in J.J.M.M.C Davangere, we found that coracobrachialis muscle was supplied by two accessory nerve twigs which were found to arise from lateral cord of brachial plexus. Musculocutaneous nerve normally supplies the coracobrachialis muscle which is a branch from lateral cord of brachial plexus. In our case it was noted that two accessory nerve twigs were found to arise from lateral cord of brachial plexus supplying coracobrachialis muscle which entered the muscle before the piercing of musculocutaneus nerve. The occurrence of accessory nerve supply to the coracobrachialis is a rare finding and is more of a phylogenetic importance. The knowledge of such type of variation is important for anatomists and surgeons operating in this region.