Background and aims There is scarce evidence regarding regional anesthesia in upper limb surgery for quadriplegic patients. Major concerns in this patient are respiratory compromise and autonomic dysreflexia. We present a case of a 58 year old man who presented with an olecranon fracture for surgical treatment. His medical history was significant for a C5-C6 tetraplegia after a car accident 37 years before. He reported to be using non-invasive mechanical ventilation (BiPAP) 7–8h/day. the patient had undergone previous urologic surgery and surgical scarotomies in which he suffered from episodes of autonomic dysreflexia and he also reported spontaneous episodes related to full bladder or rectum.

Methods We decided to place an ultrasound guided infraclavicular block using 15 ml of 0.5% levobupivacaine as a diaphragm sparing brachial plexus block in order to prevent an episode of autonomic dysreflexia. We preferred an infraclavicular rather than supraclavicular approach to prevent phrenic palsy.

Results Surgery was carried out uneventfully. the patient did not receive any sedation or opioids during the procedure following his preference.

Conclusions Infraclavicular approach to the brachial plexus could be a safe alternative as a diaphragm sparing block to prevent autonomic dysreflexia in high risk patients who also are at risk of respiratory failure.