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Cervical Plexus Blocks Anatomy, Landmark and Ultrasound Guided blocks

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Page 1: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Cervical  Plexus  Blocks  

Anatomy,  Landmark  and  Ultrasound  Guided  blocks  

Page 2: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Indica=ons  for  cervical  plexus  blocks  

•  Caro=d  endarterectomy***  •  Lymph  node  dissec=ons  and  plas=c  repairs  (Neck)  •  Shoulder  surgery  (supplement  brachial  plexus)  

•  Tracheostomy  •  Thyroidectomy  and  Parathyroidectomy  

Page 3: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Indica=ons  

•  Central  venous  cannula=on  via  the  internal  jugular  or  subclavian  routes    

•  Injuries  to  the  ear,  neck  and  clavicular  region  including  clavicular  fractures  and  acromio-­‐clavicular  disloca=ons    •  Cervicogenic  headaches    

Page 4: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Anatomy  

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Cervical  Plexus  

•  Formed  by  the  ventral  rami  of  the  upper  four  cervical  (C1-­‐  4)  nerves  

•  The  rami  emerge  between  the  anterior  and  posterior  tubercles  of  the  transverse  processes  of  the  cervical  vertebrae,  crea=ng  a  groove  on  the  costo-­‐transverse  bars    

Page 6: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Prevertebral  fascia  Longus  capi=s  

Longus  cervicalis  

Scalenus    anterior  

Scalenus    medius  

Levator  scapulae  

Dorsal  ramus  

Anterior  ramus  

Anterior  tubercule  

Costotransverse  bar  Posterior  tubercle  

Vertebral  artery  

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Ant  and  Post  Rela=ons  

•  The  plexus  is  related  posteriorly  to  the  muscles  that  arise  from  the  posterior  tubercle  of  the  transverse  process  i.e.  the  levator  scapulae  and  scalenus  medius  

•  Anteriorly,  to  the  prevertebral  fascia,  the  internal  jugular  vein  and  the  sternocleidomastoid  

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The  superficial  plexus  

Branches  and  the  block  

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Superficial  Branches  

Superficial  (cutaneous)  branches,  supply    

cutaneous  fibres  to  the  neck  

•  Ascending  branches;  Lesser  occipital  (C2)  and  Greater  auricular  (C2,3)  

•  Transverse  branch;  Transverse  (anterior)  cutaneous  nerve  of  the  neck  (C2,3)  

•  Descending  branches;  Supraclavicular  (C3,4)  

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   Roots                                                                                        

LESSER  OCCIPITAL  C2  

GREATER  AURICULAR  C2,3  

ANT  CUT  N  OF  NECK  C2,3  

SUPRACLAVICULAR  C3,4  

C3  

C4  

C2  

C1  

   Loops                                                                                        

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Lesser  Occipital  C2  

Greater  Auricular  C2,3  

Supra-­‐clavicular  Nerves  C3,4  

Transverse  (Ant)  Cut  Nerves  of  the  Neck  C2,3  

Ascending  

Transverse  

Descending  

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Superficial  Plexus  Block  

Landmark  technique  

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Superficial  cervical  plexus  block  

•  The  superficial  cervical  plexus  block  consists  of  a  subcutaneous  injec=on  of  local  anaesthe=c  just  under  the  skin  

•  The  landmark  is  the  post  border  of  the  sternocleidomastoid  muscle  (SCM)  

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Post  border  of  Sternocleidomastoid  

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Mid-­‐point,  post  border  of  Sternocleidomastoid  muscle  

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Superficial  cervical  plexus  block  

•  The  mid-­‐point  of  the  SCM  is  marked  and  from  this  point  local  anaesthe=c  is  infiltrated  subcutaneously  along  the  superior  and  the  inferior  border  

•  Around  7-­‐10  mls  is  injected  along  the  en=re  border,  another  few  mls  can  also  be  injected  at  the  mid-­‐point  itself,  assuming  that  most  branches  exit  from  this  point    

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Superficial  plexus  block  

Ultrasound  Guided  

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US  Guided  

•  Not  only  easy  but  also  increases  the  success  rate  

•  Avoids  too  deep  needle  inser=on  and/or  inadvertent  injec=ons  into  the  important  surrounding  structures  in  the  neck  

•  Advantage  lies  in  the  ability  to  ensure  the  spread  of  local  anaesthe=c  in  the  correct  plane  

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US  Guided  

•  Transducer  is  placed  over  the  lateral  side  of  the  neck  at  the  midpoint  of  the  posterior  border  of  the  sternocleidomastoid  muscle  (SCM)  

•  The  view  should  be  such  that  the  tapering  end  of  the  SCM  is  visible  on  the  screen    

•  The  needle  is  introduced  from  the  posterior  aspect  through  the  skin  and  platysma  and  5-­‐10  mls  of  local  anaesthe=c  deposited  just  behind  the  posterior  border  of  the  SCM    

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SCM  

Needle  

Med

ial  

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The  deep  cervical  plexus  

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   Roots                                                                                        Hypoglossal  .n  

PHRENIC  NERVE  C345  

GENIOHYOID  

THYROHYOID  

DESCENDENS  HYPOGLOSSI  

DESCENDENS  CERVICALIS  

C5  

C3  

C4  

C2  

C1  

   Loops                                                                                        

 Branches  to  Sternocleidomastoid  

Branches  to  Trapezius,  Levator  Scapulae  and  Scalenus  medius  

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C1  

•  The  anterior  primary  ramus  of  C1  is  en=rely  motor.  The  nerve  descends  to  form  a  loop  with  the  ascending  branch  of  C2  in  front  of  the  transverse  process  of  the  atlas  

•  The  majority  of  the  fibres  in  this  loop  run  forward  to  join  the  hypoglossal  nerve  (XII  CN)  and  through  this,  C1  supplies  the  geniohyoid  and  thyrohyoid  muscles,  then  runs  downwards  as  the  descendens  hypoglossi,  from  which  the  nerve  to  the  anterior  belly  of  the  omohyoid  muscle  is  derived    

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C3  

C2  

Hypoglossal  Nerve  

Tongue  muscles  

 Geniohyoid  

Thyrohyoid  

Inferior  (Post)  belly  of  omohyoid  

Sternohyoid  

Sternothyroid  

Superior  (Ant)  belly  of  omohyoid  

C1  

DESCENDENS  HYPOGLOSSI  

DESCENDENS  CERVICALIS  

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Ansa  cervicalis  

•  Descendens  hypoglossi  joins  descendens  cervicalis,  derived  from  C2  and  3,  to  form  a  loop  termed  the  ansa  cervicalis,  which  lies  on  the  caro=d  sheath  

•  From  the  ansa,  nerve  fibres  pass  to  supply  sternohyoid,  sternothyroid  and  the  posterior  belly  of  omohyoid    

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Loop  2  and  3  

•  The  anterior  primary  ramus  of  C2  divides  into  an  ascending  branch,  which  joins  C1,  and  a  descending  branch,  which  loops  to  join  C3  (Loop  2)  

•  Loop  3  is  formed  by  the  anterior  primary  ramus  of  C3  and  C4.  Branches  from  this  loop  join  C5  to  give  rise  to  the  phrenic  nerve      

•  Each  root  also  receives  a  grey  ramus  communicans  from  the  superior  cervical  ganglion  

Page 28: Cervical)Plexus)Blocks) - · PDF fileIndicaons) • Central)venous)cannulaon )viathe) internal)jugular)or)subclavianroutes • Injuries)to)the)ear,)neck)and)clavicular) region)including)

Deep  Cervical  Plexus  

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Landmarks  

•  Complex  regional  technique,  involves  blocking  the  nerve  roots  of  C2,  C3  and  C4    

•  Roots  of  cervical  nerves  1  to  7  emerge  superior  to  the  transverse  process  of  each  cervical  vertebra    

•  In  an  adult,  the  larynx  overlies  cervical  vertebrae  4  to  6  

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Landmarks  

•  The  upper  border  of  the  larynx  (C4)  is  palpable  as  the  notch  in  the  thyroid  car=lage    

•  The  lower  border  of  the  larynx  (C6)  is  the  Cricoid  car=lage    

•  The  external  jugular  vein  oden  crosses  the  posterior  border  of  the  Sternocleidomastoid  muscle  at  the  level  of  C6    

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Classical  approach  

•  Pa=ents'  head  turned  to  the  contra-­‐lateral  side    •  Line  drawn  from  =p  of  mastoid  process  to  transverse  process  of  C6  (Chassaignac’s  tubercle)  

•  Second  line  drawn  1  cm  posterior  and  parallel  to  the  first  line    

•  Transverse  process  of  C2  is  located  1-­‐2  cm  caudal  to  the  mastoid  process  on  this  second  line.    

•  Transverse  processes  of  C3,  and  C4  are  at  a  distance  of  1.5cms  from  C2  and  from  each  other    

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Mastoid  process  

Cricoid  

Chassaignac’s  Tubercle    

1Cm  

1-­‐2  Cm  C2  

C3  

C4  

1.5  Cm  

1st  Line  2nd  Line,  1cm  behind  and  parallel  to  the  1st  

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Deep  cervical  plexus  block  

•  Using  a  22G,  1.5  inch  needle,  the  transverse  processes  are  located  by  entering  perpendicular  to  the  skin  

•  Depth  of  the  transverse  process  varies  with  the  body  habitus  of  the  pa=ent  (1.5  -­‐  3.0  cm  deep)  

•  Once  bone  is  contacted,  the  needle  is  pulled  back  slightly,  and  directed  in  the  cephalad  direc=on  

•  This  is  repeated  un=l  the  needle  is  walked  off  the  bone    

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C4  

C6  

Thyroid  Notch  

Crico-­‐  thyroid  notch  

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3  Injec=ons  

•  Ader  careful  aspira=on  for  blood  and/or  CSF,  5mls  of  LA  is  injected  slowly;  paresthesia  may  be  obtained  but  is  not  necessary  for  the  block    

•  This  is  repeated  at  the  other  two  transverse  processes    

•  During  injec=on,  the  pa=ent  should  be  communicated  with  con=nually,  to  help  detect  a  change  in  mental  status  that  could  occur  with  intravascular  injec=on    

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Single  injec=on  technique  

•  Involves  a  single  injec=on  at  the  C4  level  •  Landmark  described  for  the  classical  approach  can  be  used  or    

•  Line  drawn  from  the  cricoid  car=lage  to  the  point  where  the  external  jugular  vein  crosses  the  posterior  border  of  the  sternocleidomastoid,  this  will  be  at  the  level  of  C6.  A  line  from  the  thyroid  notch  is  then  drawn  parallel  to  the  line  for  C6  to  determine  the  level  of  C4.    

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Loca=ng  C4  

•  To  mark  C4,  the  mastoid  process  is  located,  and  a  mark  is  made  1cm  posterior  to  it.  A  line  is  then  drawn  from  this  mark  to  intersect  at  right  angles  to  the  line  drawn  back  from  the  thyroid  notch  for  C4    

•  Where  these  two  lines  cross  is  the  loca=on  of  the  C4  transverse  process  

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Single  injec=on  

•  Using  a  22G,  1.5  inch  needle,  the  transverse  process  of  C4  is  located  by  entering  perpendicular  to  the  skin  and  ader  careful  aspira=on  for  blood  and/or  CSF,  15-­‐20  mls  of  local  anaesthe=c  solu=on  is  injected  

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Deep  Cervical  plexus  

US  Guided  

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Ant   Post  

SCM  

Needle  

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Approach  1  

•  Takes  a  very  simple  view,  in  this  approach  LA  is  deposited  just  behind  the  caro=d  sheath  at  the  level  of  the  caro=d  bifurca=on.  The  injec=on  is  not  as  deep  as  described  for  classical  deep  cervical  plexus  block.    

•  No  publica=ons  based  on  this  approach,  combined  with  superficial  plexus  block,  this  might  work  very  well.    

•  Advantage  is  the  simplicity  and  safety  (  as  long  as  injec=on  into  the  caro=d  can  be  avoided)  

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Ant   Post  CA  

LA  

Needle  

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Approach  2  

•  Uses  the  findings  of  Winnie  and  colleagues  who  suggested  following  the  interscalene  groove  cranially  and  deposi=ng  the  LA  anaesthe=c  in  this  groove  

•  For  those  who  regularly  perform  interscalene  brachial  plexus  block,  this  is  a  logical  approach,  as  we  all  know  that  the  cervical  plexus  is  blocked  when  LA  overspills  

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Ant   Post  

Needle  

SA   SM  

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Approach  3  

•  Follows  the  classical  descrip=on  of  deep  cervical  plexus  block  and  here  the  C4  level  is  marked  and  the  transducer  is  placed  laterally  at  this  landmark  and  moved  posteriorly  =ll  the  transverse  process  of  C4  is  iden=fied    

•  The  needle  is  then  introduced  in  the  long  axis  from  the  posterior  end  of  the  probe  under  direct  vision.  Once  the  =p  of  the  needle  touches  the  bony  part,  it  is  par=ally  withdrawn  and  ader  aspira=on  10-­‐15  mls  of  LA  is  injected,  which  can  be  seen  spreading  along  the  transverse  vertebrae    

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Intermediate  cervical  plexus  block  

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Intermediate  Cervical  Plexus  Block  

•  Pandit  and  colleagues  in  their  cadaveric  study  showed  that  injec=ons  placed  below  the  inves=ng  fascia  of  the  neck  diffuse  into  the  deep  space,  whereas  injec=ons  placed  subcutaneously  did  not    

•  Injec=on  deep  to  the  inves=ng  layer  of  the  neck  is  termed  the  “intermediate”  cervical  plexus  block.    

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•  For  the  intermediate  block,  ader  the  usual  skin  prep,  the  needle  is  inserted  in  a  perpendicular  plane  at  the  midpoint  of  the  posterior  border  of  the  sternocleidomastoid  muscle  un=l  a  ‘loss  of  resistance’  or  ‘pop’  is  felt  as  the  needle  passed  the  inves=ng  layer  of  the  cervical  fascia  (~  1–2  cm  depth)  

•  The  needle  is  then  fixed  and  around  15-­‐  20  ml  of  LA  is  slowly  injected  ader  careful  aspira=on    

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Deep  Cervical  Plexus  Block  

Cervical  nerve  roots  

Sternocleidomastoid  muscle  

Vertebral  body  

Thyroid  gland  

Trachea    Oesophagus    

Caro=d  Sheath  

Fascia  of  caro=d  sheath  

Pretracheal  fascia  

Deep  Cervical  Fascia  

Inves=ng  fascia  of  the  neck  

Skin  

Spinous  and  transverse  process  of  vertebra  

Intermediate  Cervical  Plexus  Block  

Superficial  Cervical  Plexus  Block  

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US  Guided  Intermediate  block  

•  The  approach  is  similar  to  superficial  cervical  plexus  block  but  involves  deeper  injec=on.    

•  An  anempt  is  made  to  iden=fy  the  inves=ng  fascia  of  the  neck  in  the  interscalene  groove  and  LA  deposited  under  the  fascia.    

•  A  click  or  “pop”  can  oden  be  felt  when  the  needle  pierces  this  fascia,  10-­‐15mls  of  LA  is  deposited  at  this  level    

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Inves=ng  Fascia  

Needle  

SCM  


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