Cervical Plexus Block

Indications

Superficial and deep procedures of the neck and supraclavicular fossa.

Examples:

Carotid endarterectomy

Thyroidectomy

Lymph node biopsy or excision

Plastic surgical procedures

Supplement to brachial plexus block for shoulder.

Check with surgeon for surgical expectations of block and duration of procedure.

Drugs and Equipment

Oxygen and resuscitation equipment

HR and BP monitoring

IV access, sedation

EMLA cream (optional)

Sterile prep (Chloraprep, Betadine, etc)

22g, 4-5 cm needle and syringe

Marking pen

Drugs:

            0.75 – 1.0% Lidocaine

            0.75 – 1.0% Mepivicaine

            0.25% Bupivicaine

Cervical Plexus Anatomy (C1-C4)

Cutaneous branches

            Superficial posterior occiput, neck, shoulder, clavicle, jaw

Ansa cervicalis complex

            Infrahyoid and geniohyoid muscles

Phrenic nerve

            Diaphragm

Contributions to the accessory (CN XI)

            Sternocleidomastoid and trapezius muscles

Direct muscular branches

            Prevertebral muscles of the neck

Technique

Supine

Head slightly extended and turned away from block site, towel under head.

Ipsalateral arm at patient’s side.

Stand at patient’s side, shoulder high.

Block can be performed as deep cervical block or superficial cervical block.

Deep Cervical Approach

Produces both motor and sensory blockade.

Line drawn from tip of mastoid process to transverse process of C6 (Chassaignac’s tubercle).

Second line drawn 0.5-1 cm posterior and parallel.

Locate and mark transverse process of C2, C3, and C4 (C2 is 1-2 cm caudal to mastoid).

22g, 5 cm needle inserted toward C4 transverse process (1.5-3.0 cm deep).

Repeat at level of C3 and C2.

Paresthesia may be obtained but is not necessary for block.

Once needles are positioned, aspirate for blood and/or CSF.

If negative, inject a total 15-24cc of local anesthetic solution divided between each needle.

If needle placement is difficult, one needle may be placed at C3 or C4 and 15-24cc of local anesthetic injected.

**Intraneural injection will manifest as intense, searing pain on injection – if this occurs, reposition needle before proceeding with block.

Superficial Cervical Approach

Produces sensory blockade.

Less complications compared to deep approach.

Relies on volume for block efficacy.

Locate midpoint of SCM, posterior border (C4).

Insert 4 cm, 22g needle.

5cc local anesthetic injected subcutaneously posterior and immediately deep to SCM.

Redirect needle superiorly and inferiorly along the border of the SCM and inject 5cc at each site.

Aspirate frequently and with each redirection to detect intravascular injection of local.

Assessment

Cervical nerve plexus block will produce anesthesia to the following:

            lateral occiput

            anterior / posterior neck and shoulder

            supraclavicular region

            skin covering each region

Ipsalateral phrenic nerve paralysis is common (may cause SOB / respiratory distress in patients with pulmonary disease)

Complications

Intravascular injection / injury

            Vertebral artery (loss of consciousness, seizure, temporary

      blindness)

            Carotid artery

            Internal jugular

            External jugular

Partial phrenic nerve block

CNS toxicity (tinnitus, disorientation, perioral numbness), CV collapse

Recurrent laryngeal nerve blockade

            Hoarseness

            Horner’s Syndrome (ptosis, miosis, anhydrosis)

Vagal nerve blockade

Epidural / Subarachnoid anesthetic (total spinal)

Brachial nerve plexus blockade

Hematoma

References

Questions