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Cervical plexus block

July 2018
Korean Journal of Anesthesiology 71(4)(4):274-288

DOI:10.4097/kja.d.18.00143

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CC BY-NC 4.0

Authors:

Justin Sangwook Ko

Samsung Medical Center

Seung Uk Bang

Catholic University of Korea

Hyungtae Kim

Asan Medical Center

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Cervical plexus block (CPB) has been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia. However, it is performed in narrow space of neck area containing many sensitive structures, multiple fascial layers, and complicated nerve innervation. Since intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion in nomenclature and definition of CPB, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPB can be performed more safely and accurately under ultrasound guidance. In this review, authors will describe the methods including ultrasound techniques and clinical applications of conventional deep and superficial CPBs, and discuss the controversial issues of intermediate CPB including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. And finally, authors will attempt to refine the classification of CPB methods based on the target compartments which can be easily identified under ultrasound guidance, with considering the effects of each method of CPB.

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Title: Cervical plexus block

Author information

Jin-Soo Kim1, Justin Sangwook Ko2, Seunguk Bang3, Hyungtae Kim4, and Sook Young Lee1

1Depatment of Anesthesiology and Pain Medicine, Ajou University College of Medicine,

Suwon, Korea, 2Depatment of Anesthesiology and Pain Medicine, Sungkyunkwan University

College of Medicine, Seoul, Korea, 3Depatment of Anesthesiology and Pain Medicine,

College of Medicine, The Catholic University of Korea, Seoul, Korea, 4Department of

Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea

Running title:

Corresponding author

Jin-Soo Kim, MD, PhD

Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine,

Worldcupro 164, Yongtongku, Kyungkido, Suwon 16499, Korea

Tel: 82-31-219-5748, Fax: 82-31-219-5579

Email: jskane@ajou.ac.kr

ORCID: https://orcid.org/0000-0003-4121-2475

Abstract

Cervical plexus block (CPB) has been used in various head and neck surgeries to provide

adequate anesthesia and/or analgesia. However, it is performed in narrow space of neck area

containing many sensitive structures, multiple fascial layers, and complicated nerve

innervation. Since intermediate CPB was introduced in addition to superficial and deep CPBs

in 2004, there has been some confusion in nomenclature and definition of CPB, particularly

the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has

expanded, CPB can be performed more safely and accurately under ultrasound guidance. In

this review, authors will describe the methods including ultrasound techniques and clinical

applications of conventional deep and superficial CPBs, and discuss the controversial issues

of intermediate CPB including nomenclature and associated potential adverse effects that

may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical

plexus. And finally, authors will attempt to refine the classification of CPB methods based on

the target compartments which can be easily identified under ultrasound guidance, with

considering the effects of each method of CPB.

Keywords: Airway obstruction; Cervical fascia; Cervical plexus; Cervical plexus block;

Phrenic nerve palsy; Ultrasonography.

Introduction

The cervical plexus block (CPB) provides effective anesthesia and analgesia to the head

and neck region [1-7], and the most common clinical use for CPB has been carotid

endarterectomy (CEA) [8-12]. Traditionally, CPB was classified as deep and superficial block

[13], but in 2004, Telford and Stoneham [14] suggested the “intermediate” CPB of sub-

investing fascial injection in addition to the superficial and deep CPBs on the basis of the

cadaveric study by Pandit et al. [15] In 2010, Choquet et al. [16] attempted to refine the

concept of intermediate CPB by using ultrasound technique. However, „superficial‟,

„intermediate‟ and „deep‟ are poorly defined anatomical terms that simply indicate the

topographic relationships of the tissue with respect to the skin; therefore, there has been some

confusion in nomenclature and definition of CPB, particularly the intermediate CPB.

As the role of ultrasound in the head and neck region has expanded, CPB can be performed

more safely and accurately under ultrasound guidance that easily identifies various important

landmarks including muscles, cervical vertebrae, large vessels, nerves, and the cervical

fasciae [17]. Particularly, understanding the detailed configuration of the cervical fasciae is

essential to successful CPB because certain cervical fasciae are known to have a substantial

role in diffusion of local anesthetic solution [15,18-20]. Nonetheless, the structural

characteristics of the cervical fasciae have not been fully investigated in the perspective of

regional anesthesia. Furthermore, there has been a disagreement in recognizing the deep

cervical fascia especially in the lateral cervical region [21-24], and also anatomical variations

exist [20, 25].

Accordingly, this review will describe the anatomy of the cervical fascial layers and

cervical plexus first, and describe the methods including ultrasound techniques and effects of

conventional deep and superficial CPBs, and intermediate CPB that is relatively new but has

some controversial issues. Moreover, this review will discuss potential adverse effects related

with CPBs that may often be neglected, and finally, attempt to refine the classification of

CPB methods based on the target compartments which can be easily identified under

ultrasound guidance, with considering the effects and potential adverse effects of each

method of CPBs

Anatomy

Cervical fasciae

The cervical fasciae are clinically important in predicting the spread of disease [26-28],

optimizing surgical management [29] and performing the regional anesthesia in the neck area

[15,18-20] and also are correlated with the chronic neck pain [30, 31]. However, descriptions

of fascial arrangements and definitions of spaces in the neck area are inconsistent and unclear,

and also the terminology is variable. According to the latest edition of Gray‟s Anatomy [32],

the fascia is described as “sheaths, sheets or other masses of connective tissue large enough to

be visible to the unaided eye”, and the Fascia Nomenclature Committee of Fascia Research

Congress describes it as “a sheath, a sheet, or any other dissectible aggregations of connective

tissue that forms beneath the skin to attach, enclose, and separate muscles and other internal

organs” [33]. Nonetheless, the cervical fasciae have been subject of controversy despite the

use of more recent technique or materials for preserving and studying fascial structure. As

Grodinsky and Holyoke [34] described in their pioneering study based on the cadaver

dissection in 1938, the inherent difficulties in dissecting out cervical fascial spaces and

obvious artificiality of grouping them may produce confusions in description of cervical

fasciae and the discrepancies among different authors. According to recent work by Guidera

et al. [35], the cervical fascia can be classified as superficial and deep cervical fasciae,

although, instead of superficial cervical fascia, more specific term “subcutaneous tissue” has

been suggested to reduce confusion with the „superficial layer‟ of the deep cervical fascia

[36]. The deep cervical fascia can be divided into three layers [35]: (a) superficial layer,

which was also called as the investing fascia but is now suggested as masticator fascia,

submandibular fascia, or sternocleidomastoid (SCM)-trapezius fascia, although it has been

argued that the SCM-trapezius fascia is incomplete between the SCM and trapezius muscles

[21,22]; (b) middle layer, which is suggested as strap muscle fascia or visceral fascia; and (c)

deep layer, which is suggested as perivertebral fascia instead of prevertebral fascia because

prevertebral fascia should be used for anterior part only. The carotid space containing major

vessels, deep cervical lymph nodes and nerve is very important structure that can be

influenced during CPB, and this space is usually referred to the “carotid sheath and its

contents” [36]. According to literatures [37,38], the carotid sheath is a definite histological

structure that is distinct from other fascial layers, and the common carotid sheath shows inter-

individual and/or site-dependent variations in the thickness. However, there is a disagreement

on whether the carotid sheath is formed by all three layers of deep cervical fascia, only the

deep or superficial layer of deep cervical fascia, or has no demonstrable layer of fascia [36].

Palliyalil et al. [39] described that the carotid sheath is a strong fibroelastic tissue barrier that

shields its contents from saliva and local infection after neck surgery, but local anesthetics

seem to infiltrate the carotid sheath [40]. Figure 1 shows schematic drawing of cervical

fasciae as Guidera et al. [35] suggested.

Cervical plexus

The cervical plexus is situated in a groove between the longus capitis and middle scalene

muscles underneath the prevertebral fascia but not in the interscalene groove as the anterior

scalene muscle is almost absent cranially above C4 or C3 level [42]. Two nerve loops which

are formed by union of the adjacent anterior spinal nerves from C2 to C4 give off four

superficial sensory branches in cranio-caudal order: lesser occipital (C2,3), great auricular

(C2,3), transverse cervical (C2,3) and supraclavicular nerves (C3,4) which initially run

posteriorly and soon pierce the prevertebral fascia. Afterwards, they pass through the

interfascial space between the SCM and the prevertebral muscles before going out to the

skins and superficial structures of the neck via the nerve point of the SCM muscle [43,44].

Thus, superficial branches of the cervical plexus travel relatively long distance from the

paravertebral space to their respective superficial endpoints - the skin and subcutaneous

tissues of neck, posterior aspect of the head and shoulders [45,46]. In contrast, the fibers

emanating anteromedially from the superior (C1-C2) and inferior (C2-3) roots unite at the

level of the omohyoid central tendon to form a loop, the ansa cervicalis [47]. The ansa

cervicalis is known to supply motor branches to the infrahyoid and SCM muscles [48] with a

great degree of variation in its origin and distribution [49]; however, ansa cervicalis has been

suspected to have an afferent neuronal composite [50]. Anterior rami of C3 and C4 forms a

loop and the branches of this loop join C5 to give rise to the phrenic nerve. The cervical

plexus is known to anastomose with spinal accessory nerve, hypoglossal nerve, facial nerve,

vagus nerve, glossopharyngeal nerve and sympathetic trunk [43,49,51]. Figure 2 shows

schematic drawing of deep and superficial cervical plexuses.

Cervical plexus block methods

CPB has been performed at deep, superficial or intermediate level, although „deep‟,

„superficial‟ and „intermediate‟ are poorly defined terms.

Deep cervical plexus block

The deep CPB is described as a paravertebral block targeting the C2-C4 spinal nerves

[13,53], and this can be achieved either by a single injection or by three separate injections

[13,53,54]. The deep CPB performed at the paravertebral space not only can block superficial

branches but also deep branches of cervical plexus resulting in the relaxation of neck muscles,

although, it has not been shown to be important clinically [10,14,55]. On the other hand, if

ansa cervicalis also has an afferent neuronal composite [50], deep CPB would have more

clinical significance in treating postoperative pain after neck surgeries involving infrahyoid

and/or SCM muscles, or a pain originating in the neck. Wan et al. [56] and Goldberg et al. [57]

reported that deep CPB in C2 or C3 transverse process could treat cervicogenic headache

effectively. The deep CPB also has been applied to the thyroid or parathyroid surgery [58,59],

oral and maxillofacial surgery [3], and CEA [60-64] to obtain adequate anesthesia and/or

analgesia. Deep CPB can produce major complications such as intravascular injection,

epidural or subarachnoid injection, and phrenic nerve palsy due to its deep endpoint [12,65].

But, with the introduction of ultrasound, the deep CPB has become a relatively safe and

simple procedure with several different ultrasound techniques [3,42,66,67]. For the

ultrasound-guided (USG) deep CPB, Perisanidis et al. [3] and Saranteas et al. [67] simply

injected local anesthetics into the space between the prevertebral fascia and the cervical

transverse process under ultrasound guidance, but Wan et al. [56] and Sandeman et al. [66]

injected local anesthetics after the needle touched the target cervical transverse process under

ultrasound guidance.

Superficial cervical plexus block

The superficial CPB is conventionally described as subcutaneous injection technique

performed at the mid-portion of the posterior border of the SCM muscle targeting superficial

branches of the cervical plexus [12,13]. This conventional subcutaneous infiltration of

superficial CPB can be performed using the ultrasound technique [68], and it is also possible

to block one or more superficial branches of the cervical plexus selectively, depending on the

types of surgery in the head and neck region by landmark [1,4,69,70] or ultrasound technique

[71-74]. The superficial CPB, unlike the deep CPB, is known to carry a low risk of

complications and is easy to master [12,59,75]. Nonetheless, during superficial CPB, it is

important to make sure that the needle tip is positioned in the subcutaneous tissue to avoid

adverse effects of deep block. [76,77]. Unilateral or bilateral superficial CPB can be used for

the postoperative analgesia after a variety of head and neck surgeries such as thyroidectomy

[1,78,79], minimally invasive parathyroidectomy [59], tympanomastoid surgery [4], anterior

cervical discectomy and fusion [5], infratentorial and occipital craniotomy [80]. And it can

also be used as a sole anesthetic modality for external ear surgery [74]. In our institution, we

have been applying landmark-based superficial CPB to various superficial head, neck and

upper chest wall surgeries both in pediatric and adult patients to obtain an anesthesia and/or

analgesia (Fig. 3). Superficial CPB also can be used as an adjuvant block for shoulder,

clavicle, breast and upper chest wall surgeries, particularly by blocking supraclavicular

branches.

Intermediate cervical plexus block

History

In 2002, Zhang and Lee [21] reported that the investing fascia does not exist in the space

between the SCM and trapezius muscles which is called posterior cervical triangle [81]. They

conducted a sectional anatomic investigation with the use of epoxy sheet plastinations in

cadavers, but, their results are still in controversy [24,35,36]. Interestingly, in the latest

edition of Gray‟s Anatomy [82], it is described that the investing fascia between SCM and

trapezius muscles is formed of areolar tissue which is indistinguishable from that in the

superficial cervical fascia. Nonetheless, in 2003, Pandit et al. [15] introduced a new concept

of sub-investing fascial (superficial to the prevertebral fascia but underneath the investing

fascia) injection technique as one method of superficial CPB. In this study, Pandit el al. [15]

hypothesized that there is a communication between superficial and deep spaces through the

prevertebral fascia, which may explain the efficacy of the superficial CPB comparable to that

of the deep or combined deep and superficial CPB during CEA [10,62]. In 2004, Telford and

Stoneham [14] suggested that Pandit‟s technique of sub-investing fascial injection might be

more correctly termed as an intermediate CPB, which can be implicated as a third type of

CPB. They expected that this intermediate CPB might also produce the effect of deep CPB

while avoiding some practical difficulties of deep CPB; however, this would be possible on

the contingency that a communication through the prevertebral fascia actually exists. In 2007,

Pandit et al. [12] stated clearly that an intermediate block is one where the injecting needle

pierces the investing fascia of the neck, deep to the subcutaneous layer, but superficial to the

prevertebral fascia. In this context, permeable nature of the prevertebral fascia must be an

important issue because it can eventually determine the characteristics of the intermediate

CPB; however, several articles [7,9,83-85] already have been published on the basis of the

Pandit‟s hypothesis [15] that the injectate of intermediate CPB can spread to deep tissues

through the prevertebral fascia, and thus intermediate CPB can have a deep CPB effects,

although there has been no clinical study verifying the permeable nature of the prevertebral

fascia.

Technique and nomenclature

Studies by Barone et al. [85], Ramachandran et al. [8] and Merdad et al. [83] used a blind

approach for the intermediate CPB targeting the space between investing fascia and

prevertebral fascia by using landmark, loss of resistance or pop technique, although Merdad

et al. [83] used the term „superficial‟ CPB instead of „intermediate‟ CPB. Nonetheless, it was

probably not easy even for very experienced practitioners to place the needle tip precisely at

the desired space without the aid of ultrasonography. Since Kefalianakis et al. [86] published

first report of USG CPB targeting the space between SCM and anterior scalene muscles for

CEA in 2005, USG CPB has become more popular because it can be performed safely and

accurately in the target space [87]. In 2010, Choquet et al. [16] advocated that the

intermediate CPB should target the posterior cervical space (PCS) at C4 level. The PCS

described by Choquet et al. [16] is the interfascial space between SCM and prevertebral

muscles which can be seen on cross-sectional imaging. They used the ultrasound technique

and contended that the PCS corresponds to the sub-investing fascial space described by

Pandit et al. [15]. The superficial branches of cervical plexus arising from deep tissues, pass

through this space after piercing the prevertebral fascia, and then, go out to the skins and

superficial tissues via posterior border of the SCM muscle [16].

Since Choquet et al. [16] introduced the intermediate CPB using ultrasonography, many

studies have been published under the name of USG intermediate CPB [3,9,11,63,84,85,88-

95]. In those studies, authors performed either posterior or anterior approach of intermediate

CPB to obtain the anesthesia and/or analgesia for CEA, surgeries involving SCM muscle, and

cervical esophagus diverticulectomy under ultrasound guidance. For the posterior approach

of USG intermediate CPB, after the target cervical level is identified by increment from the

C7 vertebra with ultrasound scanning, SCM and middle scalene muscles are positioned in the

middle of the screen. At this point, the needle is advanced into the PCS (between SCM

muscle and prevertebral fascia) in a lateromedial direction (in-plane technique) using the

anterior border of the middle scalene muscle as the landmark for placing the needle tip.

Afterwards, local anesthetic is injected slowly and carefully while observing the spread of

local anesthetic in the PCS [90,91]. Anterior approach of USG intermediate CPB may

provide similar results to other regional techniques during CEA [89]. According to Leblanc et

al. [92], USG intermediate CPB is easy to perform, safe and reliable. In contrast, some

authors [96-99] performed USG intermediate CPBs in the PCSs, but they described these as

USG superficial CPBs. In the review of regional anesthesia for CEA by Stoneham et al [55],

CPB is described as five techniques: superficial, deep, USG superficial, USG deep and USG

intermediate CPBs. In this review, Stoneham et al. [55] described the USG superficial CPB as

the method that involves advancing the block needle adjacent to cervical plexus underneath

the prevertebral fascia. However, if the block needle pierces the prevertebral fascia, it is not

the intermediate CPB as Telford and Stoneham, [14] and Pandit et al. [12,15] originally

suggested, nor the classical superficial CPB; therefore, the use of term „superficial‟ is not

appropriate in this occasion.

The reason for above discrepancies in the nomenclatures of the CPB methods seems to be

due to the location where the block is performed, and the branch of the cervical plexus being

blocked. CPB that is performed at the cervical paravertebral space (C2-4) can block both

superficial and deep branches of the cervical plexus simultaneously, although we term it deep,

rather than superficial CPB, given the position at which the block is performed. Accordingly,

the nomenclature of the CPB technique that is performed in the PCS resulting in interfascial

spread of local anesthetic would be more appropriate to be termed „intermediate‟ CPB than

„superficial‟ CPB, even though the intermediate and superficial CPBs are essentially targeting

same superficial branches of the cervical plexus.

Effects of the intermediate cervical plexus block

Importantly, intermediate CPB can provide different anesthetic and analgesic effects

compared to the superficial CPB. The cervical plexus (C2-C4) is known to supply sensation

to the SCM muscle including proprioception with variable anastomosis with the spinal

accessory nerve [43,100-104]. Therefore, SCM muscle seems to have a complex innervation,

but cervical branches of the nerve to the SCM muscle, after piercing the prevertebral fascia,

are known to anastomose with the spinal accessory nerve at the posterior surface or inside of

the SCM muscle [100,101,105]. While the spinal accessory nerve itself is also known to have

a sensory function [52,106,107], the cervical plexus (ansa cervicalis) is believed to constitute

another source of motor innervation to the SCM muscle in addition to the spinal accessory

nerve [48,52,108-110]. Therefore, it is possible that the USG intermediate CPB, which is

performed accurately in the PCS at proper cervical vertebral level, can block all four

cutaneous branches of cervical plexus and sensory/motor branches of the cervical plexus

supplying the SCM muscle simultaneously so that it can provide good anesthesia and

analgesia for neck surgeries manipulating [90] or resecting SCM muscle [91]. Similarly,

Yerzingatsian [111] suggested to deposit local anesthetic directly into the SCM muscle in

order to block the sensory branches of the cervical plexus which innervate the SCM muscle

during local anesthesia technique for thyroidectomy. According to Senapathi et al. [99], USG

intermediate CPB is more effective than multi-directional subcutaneous injection technique

of superficial CPB for reducing the pain after thyroidectomy, although authors used the term

„USG superficial CPB‟ instead of USG intermediate CPB. And also the pain associated with

the SCM muscle as in SCM syndrome [112] or the pain associated with trigger points in the

SCM muscle [113-115] can be theoretically treated by this technique. At our institution, the

posterior approach of USG intermediate CPB targeting the PCS at C4-5 level has been

performed in pediatric and adult patients regularly if required (Fig. 4). In contrast, the

classical superficial CPB performed subcutaneously would not have these intermediate block

effects. In this respect, although it is not currently clear whether the investing fascia (SCM-

trapezius fascia) exists or not in the posterior cervical triangle, it would be reasonable that the

superficial CPB should be defined as the technique that involves a multi-directional or single

subcutaneous injection targeting one or more superficial branches of the cervical plexus,

regardless of the use of ultrasound technique. In addition, although both superficial and

intermediate CPBs are essentially targeting same superficial branches of cervical plexus,

intermediate CPB may produce some adverse events that superficial CPB does not produce.

Cervical plexus block and carotid endarterectomy

The most common clinical use for CPB has been CEA. CEA is a validated intervention for

stroke prevention associated with symptomatic carotid stenosis [116,117], which involves

incisions of skin, platysma muscle, carotid sheath, and carotid artery. Since the first report of

CPB for CEA [118] in 1988, various techniques of CPB have been evaluated in CEA,

although the ideal anesthetic technique for CEA remains a matter of debate [54,119-121].

Stoneham et al. [10] in 1998 and Pandit et al. [62] in 2000 reported that the superficial CPB is

as effective as deep or combined deep and superficial CPB for CEA. However, during CEA

under CPB, supplementation of local anesthetic to subcutaneous or deep tissues by surgeon is

often performed regardless of type of CPB method [74,94,122], probably because in the neck

structures including the carotid sheath, there are some areas innervated by cranial nerves

where even deep CPB cannot reach [8,51,94,123-125], or incisional pain near the midline,

which presumably is mediated by contralateral fibers, may occur [8,74,123,126]. Seidel et al.

[19] demonstrated a constant anastomosis between the cervical branch of facial nerve and the

transverse cervical nerve of the cervical plexus. The pain associated with the incision of the

carotid sheath during CEA was completely relieved by lidocaine spray [124], and an

involvement of cranial nerves (glossopharyngeal and vagus nerves) and sympathetic trunk in

sensory innervations of the carotid artery and sheath was suggested [51,94,124]; therefore,

delivery of local anesthetic close to the carotid artery during CEA may be reasonable.

Recently, single USG intermediate CPB [62,84,89,92,95] or USG intermediate CPB

combined with USG infiltration of local anesthetic to the perivascular area of the carotid

artery [9,11,93,94] has become a new option to reduce the amount of intraoperative local

anesthetic supplementation by surgeon during CEA, while the use of deep CPB for CEA has

been decreased. However, direct infiltration of local anesthetic to the perivascular area of the

carotid artery can produce some adverse effects related with cranial nerve palsy

[9,11,93,94,127,128].

Safety issues of cervical plexus block

Phrenic nerve palsy

The phrenic nerve is formed from ventral rami of C3 to C5, and runs from lateral to medial

in a downward oblique direction on the surface of the anterior scalene muscle, beneath the

prevertebral fascia. According to Castresana et al. [129], combined deep and superficial CPB

produces acute abnormalities of diaphragmatic motion in 61% of patients, but, there seems to

be no possibility that conventional superficial CPB affects the phrenic nerve [53] as long as

the injection is made accurately in subcutaneous tissue [77]. One of the reasons why all

patients receiving deep CPB does not develop diaphragmatic motion abnormality might be

due to the anatomical variations including predominance of 5th cervical nerve and presence

or absence of accessory phrenic nerve [129]. On the other hand, the SCM muscle is the

accessory muscle of respiration, which is essential when the diaphragm is weak [130-132].

The deep CPB is known to be largely associated with diaphragmatic paralysis [129] that can

be superimposed with the relaxation of the SCM muscle; therefore, the deep CPB may have

worse effects on the respiratory function than we have previously known, particularly in

patients with clinically significant lung disease or suspected diaphragmatic motion

abnormalities [133].

The prevertebral fascia (deep layer of deep cervical fascia) forms a tubular sheath for the

vertebral column and the muscles associated with it, such as the longus colli and longus

capitis anteriorly, the scalenes laterally, and the deep cervical muscles posteriorly [13,43].

According to literatures, this prevertebral fascia seems to play a role as a barrier to the spread

of local anesthetics [134] or even abscesses [26,135] by forming the water-tight space [134],

suggesting that a suppuration in the prevertebral space does not extend rapidly in any

direction due to compactness of this compartment [26]. And also there are evidences that

local anesthetic distends the prevertebral fascia during stellate ganglion block [136] and that

local anesthetic is entrapped in PCS during intermediate CPB [3]. Recently, using fresh

cadavers, Seidel et al. [19] investigated the dissemination of injected dye solution that was

injected into the PCS using the ultrasonographic technique; consequently, the dye remained

in the PCS implicating that the prevertebral fascia is impermeable contrary to Pandit‟s

hypothesis [15]. Nonetheless, Seidel et al. [19] suggested that a clinical study is needed to

investigate whether phrenic nerve blocks are preventable with the intermediate CPB.

Unlike deep CPB [42,64] and interscalene brachial plexus block [137], both of which

inevitably require puncturing the prevertebral fascia and injecting local anesthetic near the

cervical spinal roots, the possibility that USG intermediate CPB affects the phrenic nerve

might seem to be low, probably due to aforementioned protective nature of the prevertebral

fascia [26,134,135], which is also shown in the cadaveric study by Seidel et al. [19], and the

location and course of the phrenic nerve [77]. Martusevicius et al. [9] performed USG

locoregional anesthesia technique similar to USG intermediate CPB in 60 patients without

producing arm weakness and breathing difficulty, and in the study by De Tran et al. [97],

despite the deposition of local anesthetic into the PCS between the SCM and scalene muscles

under ultrasound guidance, no instance of unintentional brachial plexus block, Horner‟s

syndrome or dyspnea was observed. Agreeably, two studies performed by Kim et al. [90,91]

also showed no signs of brachial plexus block, Horner‟s syndrome or dyspnea after single

USG intermediate CPB in adult patients undergoing robotic thyroidectomy and in pediatric

torticollis patients undergoing unipolar release of SCM muscle with myectomy. In addition,

Calderon et al. [89] described that although the diffusion of the local anesthetic in the PCS

was observed during USG intermediate CPB, the spread of local anesthetic beyond the

prevertebral fascia was not detected, which also may be a good evidence supporting that the

prevertebral fascia may have a protective nature. However, at present, evidences are

insufficient to authenticate the true nature of the prevertebral fascia, which must be

investigated in clinical trials.

Airway obstruction

Mechanical airway obstruction due to tissue edema or hematoma is a well-recognized

surgical complication after various neck surgeries including thyroidectomy [138] and CEA

[139,140]. Particularly during CEA, surgical procedures including dissection, traction, and

retraction can injure the facial nerve, hypoglossal nerve, vagus nerve and its branches

(recurrent and superior laryngeal nerves) or glossopharyngeal nerve within the operative field

[141-144]. Among them, bilateral injury of vagus nerve, recurrent laryngeal nerve or

hypoglossal nerve can result in fatal upper airway obstruction [141,145]. Although data of

cranial nerve blockades associated with single deep CPB is scant [59,61,127,146], it is

plausible that deep CPB can paralyze glossopharyngeal, vagus, hypoglossal, and accessory

nerves particularly when cephalad spread of local anesthetic occurs, because extensive neural

anastomoses exist between the lower cranial nerves and the upper cervical nerves, although

highly variable between individuals [51,53]. Accordingly, we should bear in mind that

bilateral deep CPB can cause not only bilateral phrenic nerve palsy but also fatal airway

obstruction by paralyzing vagus or hypoglossal nerve. More importantly, in patients with

preexisting contralateral vagus (or recurrent laryngeal) or hypoglossal nerve injury, even

unilateral deep CPB can lead to total airway obstruction; therefore, although, pre-existing

unilateral vocal cord paralysis is usually clinically asymptomatic [127,147] and unilateral

hypoglossal nerve palsy shows minimal disability [145], preoperative routine history taking

and physical examination of tongue and vocal cord would be necessary in patients receiving

deep CPB [59] as well as in patients undergoing CEA [148] regardless of anesthetic

techniques.

As described earlier, direct infiltration of local anesthetic into the paracarotid area during

CEA either by surgeon or anesthesiologist may be effective for blocking the incisional pain of

carotid sheath or artery [124,149] but it can also produce adverse effects related to the

blockade of cranial nerves [9,11,93,94,127,128] besides impairing of baroreceptor reflex [94].

Recently, USG techniques infiltrating local anesthetic to the paracarotid area have been

introduced in combination with subcutaneous infiltration or intermediate CPB in order to

decrease intraoperative supplementation of local anesthetic during CEA [9,11,93,94].

According to Casutt et al. [149], USG carotid sheath block by injecting mixture of local

anesthetic and contrast media to the ventral side of carotid artery leads to an extensive spread

of drug, which is confirmed by post-block CT image. And Martusevicius et al. [9] reported

that temporary hoarseness, facial palsy, and dysphagia occurred in 72%, 13%, and 12% of

patients who had received combined USG intermediate CPB and USG paracarotid infiltration

of local anesthetics, respectively. Accordingly, bilateral infiltration of local anesthetic to

paracarotid area may cause fatal airway obstruction.

Regarding the intermediate CPB, spread pattern of local anesthetic in the PCS may be

important. During the interfascial plane block, many factors may influence the spread of local

anesthetic and quality of the block, while precise needle placement, and deep understanding

of fascial tissue anatomy and structure are required basically [150]. Zhang and Lee [21]

contended that PCS actually is the extension of subcutaneous tissue and the carotid sheath

becomes attached to the subcutaneous fatty tissue without any clear demarcation by a fascia.

And also in the clinical setting, we have often seen that local anesthetics spread easily toward

the carotid sheath even when the tip of the injecting needle is placed between anterior scalene

muscle or longus capitis muscle and middle scalene muscle during posterior approach of the

USG intermediate CPB (Fig. 4). Tran et al. [97] compared USG and landmark-based

superficial CPBs in patients undergoing surgery of the shoulder and clavicle; however, the

USG CPB technique they used was actually USG intermediate CPB, with injection of 10 ml

of local anesthetics into the PCS, as described here, rather than USG superficial CPB, while

their landmark-based superficial CPB was virtually a subcutaneous CPB. They reported that

dyspnea, desaturation, and brachial plexus block were absent, but that hoarseness or difficulty

in swallowing occurred in 10% of patients in the ultrasound group. Leblanc et al. [92]

reported that dysphonia occurred in 12%, Horner‟s syndrome occurred in 4%, and

swallowing disorder occurred in 2% of patients after single USG intermediate CPB using 10

ml of local anesthetic for CEA, but they purposely advanced the needle tip close to the

carotid sheath for injection. In contrast, Alilet et al. [95] did not advance the needle tip close

to the carotid sheath during the single USG intermediate CPB using 10 ml of local anesthetic

for CEA, and they reported very low incidence of hoarseness (2.4%) and palsy of the

hypoglossal nerve (2.4%). Therefore, it can be postulated that the incidence of hoarseness and

dysphagia after single USG intermediate CPB may depend on the block techniques as well as

the injected volume of local anesthetic. On the other hand, when the intermediate CPB is

combined with the paracarotid infiltration of local anesthetics, much higher incidence of

hoarseness and dysphagia was produced [9,93,94].

Hoarseness (dysphonia) which is likely to be associated with blockades of vagus nerve or

its branches (recurrent and superior laryngeal nerves), difficulty in swallowing (dysphagia)

which is likely to be associated with vagus, glossopharyngeal, or hypoglossal nerve blockade,

and facial nerve blockade may be the result of medial and upward spread of local anesthetic

during the USG intermediate CPB. Temporary dysphonia due to ipsilateral blockade of vagus,

recurrent laryngeal or superior laryngeal nerve after USG intermediate CPB usually is not

clinically significant. However, bilateral blockade of vagus nerve, recurrent laryngeal nerve

or hypoglossal nerve can induce fatal airway obstruction. Therefore, bilateral intermediate

CPB might be dangerous and even unilateral CPB can lead to airway obstruction in patients

with preexisting contralateral vagus or hypoglossal nerve injury, which may require routine

preoperative examination. During the USG intermediate CPB, in order to avoid inadvertent

cranial nerve blockades, it would be advocated to place the needle tip in the PCS well outside

of the carotid sheath, to use small volume of local anesthetic, and to inject local anesthetic

slowly while observing the spread of local anesthetic, thereby restricting the medial spread of

the local anesthetic toward the carotid sheath [90,91], unless carotid sheath block is required.

Other adverse effects

Horner‟s syndrome does not have any clinical consequence in itself, but it is an unpleasant

side effect, although it may not be described as a complication [151]. The occurrence of the

Horner‟s syndrome after intermediate CPB may be debatable because the location of the

cervical sympathetic chains in relation to the prevertebral fascia, the permeable nature of the

prevertebral fascia, and the extent of the spread of local anesthetic in the PCS toward the

carotid sheath during intermediate CPB may influence. Usui et al. [42] and Civelek et al. [152]

described that the cervical sympathetic chains are situated immediately underneath the

prevertebral fascia covering the longus muscles, but, on the contrary, in the latest edition of

Gray‟s anatomy [153], it is described that the cervical sympathetic trunk lies on the

prevertebral fascia behind the carotid sheath. Nonetheless, the occurrence of Horner‟s

syndrome has been reported after superficial CPB [59], combined superficial and deep CPB

[59,63], single USG intermediate CPB [92,98], and combined USG intermediate CPB and

paracarotid infiltration of local anesthetic [9,11,94]. On the other hand, according to Lyons

and Mills [25], among 12 cadaveric neck dissections, the cervical sympathetic chain was

found within the carotid sheath in 2 cadavers. This anatomic variation may not only cause the

damage to sympathetic chain during neck dissection or simple catheterization of internal

jugular vein [154] but also influence on the occurrence of Horner‟s syndrome during CPB

with/without paracarotid infiltration of local anesthetic.

The most common cause of spinal accessory nerve palsy is iatrogenic insult during neck

surgeries, especially those located in the posterior cervical triangle [106,155]. Anatomically,

the spinal accessory nerve enters the posterior cervical triangle within 2 cm above Erb‟s point

and then courses obliquely across the posterior cervical triangle to end in the anterior surface

of the superior part of the trapezius muscle with many variations [156]. In the posterior

cervical triangle, the accessory nerve lies superficial to the prevertebral fascia [157], thus it

can be affected during superficial CPB [53] but, the intermediate CPB targeting the PCS

underneath the SCM muscle is not likely to affect the spinal accessory nerve [158].

Refining the classification of cervical plexus block

For a systematized nomenclature of CPB techniques, we can practically suggest three

classifications of CPB (Fig. 5), based on the anatomical studies regarding cervical fasciae,

nerve innervation and the relevant clinical reports as described in this review. The first

technique is the superficial CPB which involves a multi-directional or single subcutaneous

injection around the posterior margin of the SCM muscle targeting the superficial branches of

the cervical plexus, regardless of the use of ultrasonography. This superficial CPB also can be

performed to block selectively one or more superficial branches of the cervical plexus by

landmark or ultrasound technique. The superficial CPB is very useful, safe and easy to learn,

which every regional anesthesiologist should master. The second technique is the

intermediate CPB which involves the placement of the injecting needle into the PCS

(between the SCM muscle and prevertebral fascia) at the C4 level targeting both the

superficial branches of cervical plexus and presumably sensory/motor branches of the

cervical plexus supplying the SCM muscle. The USG intermediate CPB is simple to learn

and reproduce, but its potentiality of adverse effects should not be overlooked. Lastly, the

deep CPB involves the placement of needle between the prevertebral fascia and the cervical

nerve roots at C2-4 level targeting both superficial and deep branches of cervical plexus

simultaneously. In spite of some advantages, deep CPB may require the analysis of risks and

benefits before application. For the safe and successful intermediate CPB and deep CPB,

ultrasound technique is strongly recommended.

Summary

As we learn more about CPB, its indications are gradually expanding. However, CPB is

performed in the neck area which is highly complicated segment of the body with multiple

fascial layers in narrow space. Recently, a new and more specific terminology of cervical

fasciae has been suggested, but there is still a controversy over the recognition and

description of the cervical fasciae including the investing and prevertebral fasciae, and

carotid sheath. Furthermore, anatomical variations in cervical fascial layers can have a

significant influence on the effects of each method of CPB. Therefore, at current state, it

seems not to be easy to describe the true effects of each CPB approach, although most of

CPB methods are now being performed accurately and safely under ultrasound guidance. In

this review, we discussed in detail about the intermediate CPB that is a relatively new

technique but with some controversial issues. Although block effects and potential adverse

effects of the intermediate CPB mandate further investigations, we simply classified CPB as

three general approaches - superficial, intermediate and deep CPBs, based on the target

compartment of each approach which can be identified easily on ultrasound.

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Legends

Fig. 1. The layers of cervical fascia (C6 transverse section) as suggested by Guidera et al.

[35]. The illustration is adapted from Smoker et al. [41].

Fig. 2 Schematic drawing of deep cervical plexus and superficial cervical plexus. (A) Four

superficial branches of the cervical plexus are depicted as a yellow color, and deep branches

of cervical plexus (ansa cervicalis) are depicted as a green color. The cervical plexus is

known to anastomose with several cranial nerves and sympathetic trunk. (B) Superficial

cervical plexus is emerging behind the posterior border of the SCM (sternocleidomastoid)

muscle and innervates head, neck and shoulder areas. The illustration is adapted from

Restrepo et al. [52].

Fig. 3. Landmark-based superficial CPBs (cervical plexus blocks) have been performed for

ear, neck and upper chest wall surgeries to obtain adequate anesthesia and/or analgesia at our

institution. (A) Great auricular and lesser occipital nerve blocks were performed in 77-year-

old male patient undergoing excision of ear hemangioma. (B) Selective supraclavicular nerve

block was performed in 4-year-old female patient undergoing excision of the congenital

melanocytic nevus on right upper chest wall. (C) Great auricular and transverse cervical

nerve blocks were performed in 94-year-old female patient undergoing excision of the

squamous cell carcinoma on the right neck area. (D) Selective supraclavicular nerve block

was performed in 52-year-old male patient undergoing incision and drainage of the abscess

on right upper chest wall. To avoid deep injection, the needle is bent slightly.

Fig. 4. Ultrasound image of posterior approach of intermediate CPB (cervical plexus block)

at C4-5 level in a 3-year-old torticollis patient undergoing unipolar SCM release with

myectomy. Hydrodissection of the PCS (posterior cervical space) between the SCM

(sternocleidomastoid) muscle and prevertebral fascia by local anesthetic is seen, and local

anesthetic spreads to the area near the carotid sheath. CA: carotid artery; IJV: internal jugular

vein; LA: local anesthetic; SCM: sternocleidomastoid muscle. White arrow points:

prevertebral fascia

Fig. 5. Three different target areas of CPB (cervical plexus block) in the cervical fascial

spaces are depicted schematically (C4 transverse section). (A) The target area for superficial

CPB is subcutaneous tissue around the mid portion of posterior border of the SCM

(sternocleidomastoid) muscle. (B) The target area for intermediate CPB is the space between

the SCM muscle and the prevertebral fascia. (C) The target area for deep CPB is the space

between the prevertebral fascia and the target transverse process.

A Retrospective Analysis of Superficial Cervical Plexus Blockade for Children Undergoing Otologic Surgery

Article

Full-text available

Feb 2025

Superficial cervical plexus blocks (SCPB) are well documented for anterior and lateral neck surgeries in adults. Their role in the pediatric population is less clear. Our objective was to determine whether superficial cervical plexus blockade reduced postoperative nausea and vomiting (PONV) in children undergoing otologic surgery. This single‐center retrospective cohort study evaluated patients aged 1–18 years old undergoing cochlear implantation, tympanomastoidectomy, tympanoplasty, or myringoplasty via a postauricular incision over a 27‐month period. Patients undergoing bilateral surgery, concurrent surgery (exclusive of myringotomy or endoscopic otologic procedures), or transcanal‐only otologic procedures were excluded. The primary outcome was PONV as measured by antiemetic use or documented nausea or vomiting among patients who received a SCPB compared to patients who did not receive a block. Secondary outcomes included opioid use, length of stay in the postoperative anesthesia care unit and hospital, time to oral intake, postoperative pain scores, and adverse events. Multilinear regression analyzed the effect of independent variables on the primary outcome. Analyses were stratified by surgery type. A total of 237 patients met inclusion criteria; 121 patients (51%) received a SCPB. There was no statistically significant difference in PONV outcomes between the two groups (proportion difference 4.5%, 95% CI −7.5% to 16.5%) despite lower intraoperative opioid administration to patients in the SCPB group (intravenous morphine equivalents per kg −0.04 mg, 95% CI −0.08 to 0, p = 0.030). Addition of a SCPB did not reduce PONV for pediatric patients undergoing otologic surgery via a postauricular incision. No adverse events were attributed to the block in this study.

Role of superficial cervical plexus block with lignocaine and dexamethasone following modified radical mastoidectomy: A randomised controlled trial

Article

Full-text available

Feb 2025

Aims and Objectives The study aimed to compare the worst pain levels following superficial cervical plexus block (SCPB) with lignocaine and perineural dexamethasone versus no block using the PAIN OUT patient outcome questionnaire. Material and Methods This randomised, placebo-controlled trial included 46 patients, 18–70 years of age, of the American Society of Anesthesiologists (ASA) physical status I/II scheduled for mastoidectomy. The postoperative maximum pain intensity scores using the PAIN OUT patient outcome questionnaire were considered as the primary outcome. The patients received interventions as per group allocation. In group block (n = 23), an ultrasound-guided (USG) SCPB was administered using 5 ml of 2% lignocaine with 4 mg dexamethasone. In group control (n = 23), no block was performed, and only dressing was done. All patients received intravenous (IV) paracetamol 1 g every 6 h. In case any patient-reported pain, IV diclofenac was administered. Results During the study period of 24 hours, patients in group block experienced lower worst pain as compared to group control(p-value = 0.001). Similarly, the visual analogue scale score on movement was lower in group block at the following intervals: 15 min (p-value = 0.02), at 1 hour (p-value = 0.007), at 4 hours (p = 0.03), and 12 hours (p-value = 0.04) following surgery. Rescue analgesia was lower in group block versus group control (p-value < 0.01). Conclusion Postoperative SCPB with lignocaine and perineural dexamethasone provided a superior worst pain score during 24 hours using the PAIN OUT patient outcome questionnaire following modified radical mastoidectomy.

Acupuncture treatment of vascular cognitive impairment through peripheral nerve stimulation pathway: a scoping review

Article

Full-text available

Apr 2025

Objective This study aims to explore the central effects of acupuncture on vascular cognitive impairment (VCI) through peripheral nerve stimulation. Methods This scoping review followed the methodological framework proposed by Arksey and O’Malley and the PRISMA-ScR guidelines. A comprehensive search of databases, including PubMed, Web of Science, MEDLINE, and Embase, was conducted, including 79 studies on acupuncture interventions for VCI. Acupoints and their underlying anatomical structures related to peripheral nerves were summarized, and the potential pathways of acupuncture effects via different peripheral nerves were explored. Results The results showed that acupuncture, by stimulating specific acupoints on the head, face, torso, and limbs, significantly affects peripheral nerve networks, including the cervical, lumbar, and sacral plexuses, thoracic nerves, vagus nerve, trigeminal nerve and its branches. The nerve stimulation effects of acupuncture can enhance the regulation of cerebral blood flow, modulate neuroimmune responses, improve brain function, and promote neuroplasticity through multiple central nervous system pathways, ultimately improving cognitive function and treating VCI. Conclusion Acupuncture is a treatment modality that influences the central nervous system through peripheral nerve stimulation to treat VCI. A deeper understanding of the central effects induced by acupuncture-triggered neural reflexes can contribute to the improvement of existing therapies and help elucidate the scientific principles underlying acupuncture’s therapeutic effects.

Efficacy of adding dexmedetomidine as adjuvant with bupivacaine in ultrasound-guided intermediate cervical plexus block for thyroidectomy surgery: randomized controlled study

Article

Full-text available

Mar 2025
BMC Anesthesiol

Background One important aspect of a successful thyroidectomy recovery is the level of pain postoperatively. This research aimed to determine the effectiveness of an ultrasound-guided intermediate cervical plexus block (CPB) for thyroidectomy with dexmedetomidine added as an adjuvant to bupivacaine. The primary outcome was the duration of analgesia defined as the time till the first request for rescue analgesia. The secondary outcomes were the total amount of fentanyl consumed intraoperatively, total patient’s opioids requirements within 24 h postoperative, VAS, and complications. Methods This randomized controlled double-blinded study included 60 patients aged 18 to 60 years, all of whom underwent thyroidectomy for thyroid cancer. Patients were randomly allocated into two equal groups, the B Group (n = 30) received bilateral intermediate CPB, with 20 ml bupivacaine 0.25%, and the DB Group (n = 30) received bilateral intermediate CPB with 20 ml of bupivacaine 0.25% plus 1 µg/kg dexmedetomidine. Results The DB Group showed a significantly longer duration of analgesia (p < 0.001), significantly less total intraoperative fentanyl consumption (p = 0.005), and significantly less total postoperative morphine consumption (p < 0.001). Also, postoperative pain scores, heart rate, and mean arterial pressure were significantly lower in the DB group than in the B Group and sometimes points. Conclusions The addition of dexmedetomidine to bupivacaine in ultrasound-guided intermediate CPB for thyroidectomy significantly prolonged analgesia and reduced postoperative opioid consumption.

Local Anesthetic Infiltration, Awake Veno-Venous Extracorporeal Membrane Oxygenation, and Airway Management for Resection of a Giant Mediastinal Cyst: A Narrative Review and Case Report

Article

Full-text available

Dec 2024

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed.

Bilateral cervical plexus block in a pediatric patient undergoing thyroglossal duct cyst excision

Article

Apr 2025
MINERVA ANESTESIOL

Optimizing Tracheostomy Anesthesia: A Comparative Study of Nerve Blocks

Article

Mar 2025

A fascial compartment plus "cup-shaped" blocks provide surgical anesthesia for the excision of a huge mass at the posterior cervico-occipital region

Article

Feb 2025
MINERVA ANESTESIOL

Respiratory dysfunction in whiplash associated disorders (WAD) with cervical plexus syndrome - A case report

Article

Jan 2025

Whiplash Associated Disorders (WAD) represents a chronic post-traumatic pain syndrome from indirect flexion-extension trauma to the neck. The condition exhibits significant variability among affected individuals and can involve numerous secondary symptoms, including but not limited to myalgia, central sensitization, migraines, photophobia, jaw pain, dysphagia, joint stiffness, and tinnitus, while significant breathing problems are not commonly associated with or prominently considered in WAD. Herein, we present the diagnosis and successful surgical treatment of severe respiratory dysfunction and staccato speech in a patient with WAD, who over a period of more than ten years underwent multiple spirometry evaluations for breathing difficulties that correlated with the severity of neck pain. In 2019, his condition deteriorated, with significantly increased pain and dyspnea leading to further evaluations that included laboratory studies and consultations with specialists in neurosurgery, neurology, pulmonology, neurophysiology, ENT, general internal medicine, cardiology, radiology, speech pathology, physical medicine, orthopedic surgery, and hand surgery at three separate academic centers in Norway. Eventually, the patient was diagnosed with a condition that is regularly observed among patients referred to our office for evaluation and surgical treatment of chronic, whiplash related pain, and that we propose to label Cervical Plexus Syndrome. One year following exploration and neurolysis of sensory nerves to the right and left superficial cervical plexus, the patient remains pain free, with unimpeded speech and breathing as demonstrated by postoperative spirometry and video recordings. Although the underlying pathophysiology remains unclear, we report what we believe to be the first successful surgical treatment of serious respiratory dysfunction from pain generators in tissue that historically is considered anatomically and functionally separate from the mechanics of breathing. Further investigation will be needed to determine prevalence of respiratory dysfunction in chronic neck pain.

Bioelectronic Therapeutics: A Revolutionary Medical Practice in Health Care

Article

Jan 2025

Aberrant Innervation of the Sternocleidomastoid Muscle By the Transverse Cervical Nerve: A Case Report

Article

Full-text available

Apr 2015

During the routine cadaver dissection performed for educational and research purposes in our Department of Anatomy, we came across a variant innervation of the sternocleidoidomastoid muscle (SM). In an 82-year-old female formalin embalmed cadaver whose death was unrelated to the current study, after careful dissection of the anterior and right cervical region, we noticed the presence of two rami arising from the TCN and distributing to the posterior part of the SM's midportion. The TCN on the right side after emerging from the Erb's point coursed transversely lying on the SM's surface and giving off after a distance of 1.3 cm the first SM's ramus. The second SM's ramus was arising from the inferior branch of the TCN at a distance of 1.2 cm from the first SM's ramus. The TCN was anastomosing with the cervical branch of the right facial nerve as occurs usually, whereas the platysma at this region was partially fused with the SM's midportion. Furthermore, it must be emphasized that the right SM was innervated by the ipsilateral accessory nerve emerging from the SM's posterior border proximally, as well by cervical spinal rami not demonstrated in the current photographic documentation [Table/Fig-1]. The contralateral SM was innervated ABSTRACT Two aberrant rami originating from the right transverse cervical nerve and innervated the midportion of the sternocleidomastoid muscle (SM) were detected during routine cadaver dissection. Although SM is commonly innervated by the accessory nerve, as well as by cervical nerves, it is likely to be innervated additionally by other nerves such as hypoglossal nerve, ansa cervicalis, facial or external laryngeal nerve. Some considerations as regards the possible composition of the aberrant rami of the transverse cervical nerve detected in the current study, as well as the relevant literature is discussed. GeorGe PArASkevAS 1 , NikolAoS lAzAridiS 2 , ioANNiS SPyridAkiS 3 , koNStANtiNoS koutSoufliANiotiS 4 , PANAGiotiS kitSouliS 5 , as usual by the accessory nerve and cervical nerves. No pathology, abnormalities or evidence of previous surgical procedures on the cervical region were noted. DISCUSSION The SM as it is well-known when contracted produces the "wry neck" position with the ear approaching the tip of the shoulder and the chin rotating to the opposite side. SM is innervated by the spinal part of the accessory nerve as well as the second, third and sometimes fourth cervical spinal nerves [1]. These cervical nerves are thought to be sensory and especially proprioceptive for many years, whereas it has been proved that some of these cervical nerves' fibers are motor [2,3]. SM's innervation from other sources than the common ones has been described as well. Froment very early in 1899 reported the existence of a branch arising from the external laryngeal nerve going to the SM [4], whereas Maubrac in 1883 [5] and Richer in 1922 [6] referred to a small filament from the hypoglossal nerve supplying the SM. Similarly, Koizumi et al., mentioned a branch arising from the hypoglossal nerve at the origin of the superior root of the ansa cervicalis and distributed to the SM [7]. Paraskevas et al., noticed the SM's innervation by a ramus derived from the sternothyroid branch of the ansa cervicalis [8], whilst Hegazy noted that the superior root of the ansa cervicalis gave off ramus to the SM with an incidence of 24% [9]. Hayward hypothesized that in some cases of spasmodic torticollis treated with surgical intervention, the residual movement of the neck was attributed to the existence within the accessory nerve of fibers of vagal origin [10]. Moreover, Sklavounos observed a thin twig of the cervical branch of the facial nerve supplying a small portion of the most proximal part of the SM [11], whilst Cvetko noticed an aberrant branch arising from the posterior division of the facial nerve and entering the deep surface of the SM's upper third [12]. Our study case is unique since the presence of rami originating from the TCN and distributed to the SM, to the best of our knowledge has never been reported in the literature. As it is well known the TCN derived from the second and third cervical rami, divides into ascending branches uniting with the cervical branch of the facial nerve and supplying the upper anterior areas of the neck and keywords: Accessory nerve, Cervical nerves, Rami [Table/Fig-1]: The transverse cervical nerve on the right side (arrow heads) is seen to be emerging from Erb's point of the sternocleidomastoid muscle (SM) and provided two aberrant rami (asterisks) for the SM's midportion. (CBFN: cervical branch of facial nerve, P: platysma muscle, AN: accessory nerve, S: superior, I: Inferior, L: lateral, M: medial).

Effects of bilateral superficial cervical plexus block on sevoflurane consumption during thyroid surgery under entropy-guided general anesthesia: A prospective randomized study

Article

Full-text available

Apr 2018

Background: Bilateral superficial cervical plexus block (BSCPB) provides good postoperative analgesia, but its effect on anesthetic consumption is unknown. This study evaluated the effects of BSCPB on sevoflurane consumption during thyroid surgery. Methods: Fifty patients were randomly allocated into groups A and B of 25 each in this prospective double-blind study. Group A received BSCPB with 20 ml 0.25% bupivacaine, whereas group B received 20 ml saline immediately before entropy-guided general anesthesia. Intraoperative hemodynamic parameters, end-tidal sevoflurane concentration, minimum alveolar concentration, and sevoflurane consumption were recorded. Postoperative pain was assessed using a visual analog scale, and the time of the first request for analgesia was noted. All side effects were recorded. Results: Demographics were comparable. Mean sevoflurane consumption [for 30 min: group A = 7.2 (1.1) ml, group B = 8.8 (2.0) ml, P = 0.001; for 60 min: group A = 13.5 (1.7) ml, group B = 16.5 (3.9) ml, P = 0.002] and mean end-tidal sevoflurane concentration [for 30 min: group A = 1.2% (0.2%), group B = 1.4% (0.2%), P = 0.008; for 60 min: group A = 1.2% (0.1%), group B = 1.4% (0.2%), P = 0.010] were significantly lower in group A. Patients in group A had a longer duration of analgesia [361.6 (79.5) min vs. 151.0 (60.2) min, P < 0.001] compared to those in group B. Conclusions: Preinduction BSCPB during thyroid surgery significantly reduced sevoflurane consumption and increased the duration of postoperative analgesia.

Interfascial Plane Blocks: Back to Basics

Article

Full-text available

Mar 2018

Ultrasound-guided interfascial plane blocks are a recent development in modern regional anesthesia research and practice and represent a new route of transmission for local anesthetic to various anatomic locations, but much more research is warranted. Before becoming overtaken with enthusiasm for these new techniques, a deeper understanding of fascial tissue anatomy and structure, as well as precise targets for needle placement, is required. Many factors may influence the ultimate spread and quality of resulting interfascial plane blocks, and these must be understood in order to best integrate these techniques into contemporary perioperative pain management protocols.

Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy

Article

Full-text available

Jul 2017

Purpose Thyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy. Patients and methods Thirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured. Results The number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05). Conclusion Ultrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy.

Interfascial Plane Blocks: Back to Basics

Article

Mar 2019
Obstet Anesth Digest

( Reg Anesth Pain Med . 2018;43:341–346) Interfascial plane blocks have been a rapidly growing set of regional anesthesia techniques since the introduction of ultrasound use. The first interfascial plane block was the transversus abdominus plane block and the number of blocks has increased with varied locations. There are uncertainties around newer interfascial plane blocks, including the exact targets of the blocks and their role in safe opioid-free pain management. This article aimed to clarify the function and anatomy of the fascia, explain the uses and limitations of the interfascial plane blocks and clarify their role in a contemporary clinical context.

Postoperative Analgesic Effect of Ultrasound-Guided Intermediate Cervical Plexus Block on Unipolar Sternocleidomastoid Release With Myectomy in Pediatric Patients With Congenital Muscular Torticollis: A Prospective, Randomized Controlled Trial

Article

May 2018

Background and objectives: Unipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM. Methods: Thirty-two patients (1-7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward. Results: The FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1-7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 μg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups. Conclusions: Ultrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM. Clinical trial registration: This study was registered at ClinicalTrials.gov, identifier NCT02651311.

Sensory pathways in the spinal accessory nerve

Article

Mar 1999

We obtained samples of spinal accessory nerve from patients undergoing radical surgery for tumours or nerve grafting in the neck. These were analysed by light and electron microscopy for the type of fibre. All contained fibres consistent with non-proprioceptive sensory function including pain.

Analgesic Efficacy of Bilateral Superficial Cervical Plexus Block for Thyroid Surgery: Meta-Analysis and Systematic Review

Article

Dec 2017
BRIT J ANAESTH

Background: Thyroid surgery is moderately painful, but is increasingly being considered as a day-case procedure. Bilateral superficial cervical plexus block (BSCPB) provides an adjuvant technique to facilitate this approach, but there is great evidential heterogeneity in randomised controlled trials (RCTs) about its use. Methods: A systematic search, critical appraisal, and analysis of RCTs was performed. Trials investigating preoperative or postoperative BSCPB compared with control in patients undergoing thyroid surgery via neck incision were included. Odds ratio (OR) and 95% confidence interval (95% CI) were calculated for dichotomous data, whilst continuous data were analysed using standard mean difference. Primary outcome was rescue analgesic requirement in the first 24 postoperative hours. Secondary outcomes were visual analogue scale (VAS) scores at 0, 4, and 24 h, time until first analgesic request, intraoperative analgesic requirements, length of hospital stay, and incidence of postoperative nausea and vomiting (PONV). Results: Fourteen RCTs published between 2001 and 2016 including 1154 patients were included. The overall effect of BSCPB compared with control showed a reduction in analgesic requirement (OR 0.30; 95% CI 0.18, 0.51; P<0.00001). There was improvement in VAS scores (P<0.002) and time to first analgesic requirement in the BSCPB group (P<0.00001). Length of hospital stay was reduced by 6 h by use of BSCPB. There was no significant change in the incidence of PONV with its use (OR 0.82; 95% CI 0.49-1.37; P=0.44). Conclusions: BSCPB offers analgesic efficacy in the early postoperative period for up to 24 h after thyroid surgery, with reduced length of hospital stay, but without any beneficial effect on PONV.

Exercise testing in patients with diaphragm paresis

Article

Nov 2017
RESP PHYSIOL NEUROBI

Purpose: Diaphragm paresis (DP) is characterized by abnormalities of respiratory muscle function. However, the impact of DP on exercise capacity is not well known. This study was performed to assess exercise tolerance in patients with DP and to determine whether inspiratory muscle function was related to exercise capacity, ventilatory pattern and cardiovascular function during exercise. Methods: This retrospective study included patients with DP who underwent both diaphragmatic force measurements, and cardiopulmonary exercise testing (CPET). Results: Fourteen patients were included. Dyspnea was the main symptom limiting exertion (86%). Exercise capacity was slightly reduced (median VO2peak: 80% [74.5%-90.5%]), mostly due to ventilatory limitation. Diaphragm and overall inspiratory muscle function were correlated with exercise ventilation. Moreover, overall inspiratory muscle function was related with oxygen consumption (r=0.61) and maximal workload (r=0.68). Conclusions: DP decreases aerobic capacity due to ventilatory limitation. Diaphragm function is correlated with exercise ventilation whereas overall inspiratory muscle function is correlated with both exercise capacity and ventilation suggesting the importance of the accessory inspiratory muscles during exercise for patients with DP. Further larger prospective studies are needed to confirm these results.

One Hundred Percent Incidence of Hemidiaphragmatic Paresis Associated with Interscalene Brachial Plexus Anesthesia as Diagnosed by Ultrasonography

Article

Feb 1992
Surv Anesthesiol

Cervical plexus block

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