Regional Anesthesia and Acute Pain Medicine

E   Original Clinical Research Report

Ultrasound-Guided Clavipectoral Fascial Plane Block

With Intermediate Cervical Plexus Block for Midshaft
Clavicular Surgery: A Prospective Randomized
Controlled Trial
Qian Zhuo, MD,* Yanya Zheng, MD,* Zixuan Hu, MD,† Juncheng Xiong, MD,* Yanqin Wu, MD,*
Yi Zheng, MD,* and Liangrong Wang, MD†

BACKGROUND: Regional anesthesia such as interscalene brachial plexus block (ISBPB)

with intermediate cervical plexus block (ICPB) is generally a preferred choice for clavicular
surgery. However, various studies have shown that these blocks, especially ISBPB, could
cause phrenic nerve paralysis and decrease diaphragmatic motion. The study aimed to
evaluate the efficacy of clavipectoral fascial plane block (CPB), an alternative technique
to ISBPB, with ICPB, in reducing hemidiaphragmatic paralysis during midshaft clavicular
surgery.
METHODS: Forty patients scheduled for right midshaft clavicular surgery were randomized (1:1)
into an ultrasound-guided ISBPB with ICPB (BC) group or ultrasound-guided CPB with ICPB (CC)
group. Five milliliter of 0.375% ropivacaine was used for ICPB, another 20 mL for ISBPB or
CPB, and no administration of additional sedative or general anesthetic was planned. Primary
outcome was measured by the incidence of hemidiaphragmatic paralysis using M-mode ultra-
sonography, while secondary outcomes were measured by bedside pulmonary function test, the
success rate of block, the time required for the block procedure and onset of block, and motor
block score in right upper extremity.
RESULTS: In comparison with BC group, the incidence of hemidiaphragmatic paralysis post-
block was decreased in CC group (50% vs 0%; P < .001), and measurement of bedside pulmo-
nary function was significantly improved. There was a 100% success rate for anesthetic block in
both BC and CC groups, and CC group showed lower motor block score in upper extremity and
less block procedure time than BC group (7.1 ± 1.2 vs 3.2 ± 0.6 minutes; P < .001). Moreover,
no significant differences were found between time of onset of block and other anesthetic com-
plications in the 2 groups.
CONCLUSIONS: Ultrasound-guided CPB with ICPB could significantly reduce hemidiaphrag-
matic paralysis and provide an adequate surgical anesthesia with fewer complications such
as motor block in upper extremity during right midshaft clavicular surgery. (Anesth Analg
2022;135:633–40)

KEY POINTS
• Question: Can ultrasound-guided clavipectoral fascial plane block with intermediate cervical
plexus block reduce hemidiaphragmatic paralysis during clavicular surgery?
• Findings: Ultrasound-guided clavipectoral fascial plane block with intermediate cervical
plexus block decreased the incidence of hemidiaphragmatic paralysis while providing an
adequate surgical anesthesia for midshaft clavicular surgery with minimal motor block in
upper extremity.
• Meaning: Ultrasound-guided clavipectoral fascial plane block with intermediate cervi-
cal plexus block appears to be a promising anesthetic technique for midshaft clavicular
surgery.

GLOSSARY
ANOVA = analysis of variance; ASA = American Society of Anesthesiologists; BMI = body mass
index; CI = confidence interval; CL = clavicle; CONSORT = Consolidated Standards of Reporting
Trials; CPB = clavipectoral fascial plane block; FEV1 = forced expiratory volume in 1 second;
FVC = forced vital capacity; HR = heart rate; ICPB = intermediate cervical plexus block; IQR = inter-
quartile range; ISBPB = interscalene brachial plexus block; LA = local anesthetics; MAP = mean
arterial pressure; NA = not applicable; PACU = postanesthesia care unit; PEFR = peak expiratory
flow rate; PM = pectoral major muscle; SCL = subclavius muscle; SD = standard deviation; SMD =
standardized mean difference; VAS = visual analog scale

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 Ultrasound-Guided CPB for Clavicular Surgery
A
bout 81% of all clavicular fractures occur
in the midshaft,1 with surgical repair being
considered the standard treatment option.2
Considering the dermatomal distribution of cervi-
cal and brachial plexus branches, which innervates
regions around the clavicle,3 different regional anes-
thesia techniques have been utilized.4,5 Among these,
the combination of interscalene brachial plexus block
(ISBPB) and intermediate cervical plexus block (ICPB)
is considered a preferred technique.4 ICPB, which
targets the posterior cervical space between the ster-
nocleidomastoid muscle and the prevertebral fascia,
has been considered superior to the traditional super-
ficial cervical plexus block.4 It is characterized by its
improved success rate and minimal diaphragmatic
paralysis.4,6 However, due to the close anatomical rela-
tion to the phrenic nerve,7,8 ISBPB has been reported
to potentially cause phrenic nerve paralysis, which
may be detrimental for patients, especially those with
preexisting compromised pulmonary reserve.8,9 Thus,
an alternative method that provides adequate anes-
thesia while reducing diaphragmatic paralysis would
be necessary for clavicular surgery.
The clavipectoral fascial plane block (CPB) is a
novel regional anesthesia technique for clavicular
surgery that was first described in 2017 by Valdes.10
During the study, he injected 10 to 15 mL of local anes-
thetic under ultrasound guidance between the clavi-
pectoral fascia and the periosteum on the medial and
lateral aspects of the injury site and concluded that
this was an effective anesthetic technique. Similarly,
the combination of CPB with skin infiltration was
demonstrated to successfully achieve adequate anes-
thetic block for clavicular surgery in a case report by
Ince et al,11 hence making CPB a promising alternative
to ISBPB.11–15 Theoretically, the combination of CPB
and ICPB seems to be a feasible and applicable choice
of anesthesia for clavicular fracture, but to the best of
our knowledge, no prospective and randomized stud-
ies are available yet.
From the *Department of Anesthesiology, Wenzhou People’s Hospital,
Wenzhou, China; and †Department of Anesthesiology, The First Affiliated
Hospital of Wenzhou Medical University, Wenzhou, China.
Accepted for publication November 15, 2021.
Funding: The study was funded by the Wenzhou Municipal Science and
Technology Bureau (No. Y2020762).
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Clinical trial number and registry URL: chictr.org.cn, NO: ChiCTR2000038423.
Address correspondence to Liangrong Wang, MD, Department of
Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University,
No. 2, Fuxue Rd, Lucheng District, Wenzhou 325000, Zhejiang, China.
Address e-mail to arerong1984@126.com.
Copyright © 2022 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005911
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Here, we hypothesized that ultrasound-guided
CPB with ICPB would significantly reduce hemidia-
phragmatic paralysis while providing adequate sur-
gical anesthesia for midshaft clavicular surgery. The
primary outcome was a measure of the incidence of
hemidiaphragmatic paralysis, whereas secondary
outcomes evaluated bedside pulmonary function test,
the success rate of block, time required for the block
procedure and onset of block, and motor block score
in right upper extremity.
METHODS
This prospective single-centre parallel group, ran-
domized controlled trial was approved by the Clinical
Research Ethics Committee of Wenzhou People’s
Hospital (No. 2020-163) on August 20, 2020 and written
informed consent was obtained from all subjects partici-
pating in the trial. The trial was registered before patient
enrollment at www.chictr.org.cn (ChiCTR2000038423,
principal investigator: Qian Zhuo, date of registration:
September 22, 2020). The study was performed accord-
ing to Declaration of Helsinki criteria at Wenzhou
People’s Hospital, Wenzhou, China, from October 2020
to December 2020.
Patient Enrollment
The patients with right-sided midshaft clavicular frac-
tures receiving elective or emergency open reduction
and internal fixation were recruited. Inclusion crite-
ria included American Society of Anesthesiologists
(ASA) physical status I or II, ages between 20 and 60
years and body mass index (BMI) between 18 and
28 kg/m2. Patients were excluded when they had a
known allergy to local anesthetic, coagulation disor-
ders, pregnancy, infection near the block procedure
area, moderate to severe decline in preoperative
pulmonary function (ie, preexisting chronic obstruc-
tive pulmonary disease and unstable asthma). Other
exclusion criteria were a medical history of phrenic
nerve or diaphragmatic injury, preoperative chest
radiograph indicating pleural effusion, pneumotho-
rax or elevation of the ipsilateral hemidiaphragm and
poor cooperation during pulmonary function test.
Randomization and Group Allocation
Forty patients were randomly assigned into 2 groups
(BC group and CC group) using a computer-gener-
ated table of random numbers in a 1:1 ratio (www.
random.org). The allocations were sealed in opaque
envelopes by investigator Y.Z., and only opened
before regional anesthesia by the attending anesthesi-
ologist (Q.Z.) who was not involved in data collection.
Twenty patients in BC group received ultrasound-
guided ISBPB with ICPB, while 20 patients received
ultrasound-guided CPB with ICPB in CC group.
No administration of additional sedative or general
ANESTHESIA & ANALGESIA
 E  Original Clinical Research Report
anesthetic was planned during the surgery. Data col-
lection and assessment were done by other investiga-
tors who were not aware of the group allocation.
Regional Anesthesia Techniques
The patient was placed in a supine position with
the head turned to the contralateral side, and shoul-
der was padded with a small pillow. Under sterile
aseptic conditions, a 6 to 15 MHz linear array probe
(SonoSite X-Porte; FUJIFILM SonoSite Inc) was used
for regional anesthesia. All patients received 0.03 mg/
kg intravenous midazolam against anxiety and 3 L/
min nasal oxygen throughout the procedure. Local
anesthetic solution of 0.375% ropivacaine was used
for regional anesthesia.
During CPB, ultrasound probe was placed on both
inner and outer one-third of the anterior surface of the
clavicle. Using in-plane technique, the 22-gauge nee-
dle was inserted and advanced into the space between
periosteum of the clavicle and clavipectoral fascia in
a caudal to cephalad direction. Two 10-mL aliquots of
local anesthetic solution were injected at the 2 sites.
The ultrasound landmarks and the in-plane needle
path are shown in Figure 1.
For ICPB, the transducer was placed over the neck
in the transverse orientation, and the lateral taper-
ing end of sternocleidomastoid muscle was identi-
fied at the C6 intervertebral level. After negative
aspiration for blood, 5 mL of local anesthetic solu-
tion was injected along the posterior border of ster-
nocleidomastoid muscle using an in-plane technique.
Importantly, the anesthetic solution was injected into
the interfascial space between the sternocleidomas-
toid muscle and the prevertebral fascia, adjusting the
Figure 1. Ultrasound landmarks to identify clavipectoral fascia and
in-plane needle technique for CPB. The ultrasound image shows the
CL, PM, and SCL. The arrows are showing the body of the needle
and LA. CL indicates clavicle; CPB, clavipectoral fascial plane block;
LA, local anesthetics; PM, pectoral major muscle; SCL, subclavius
muscle.
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needle to avoid the spread of local anesthetic solution
to the carotid artery.
To perform ISBPB, the high-frequency probe was
positioned at the level of cricoid cartilage to visualize
the brachial plexus between the anterior and middle
scalene muscles. ISBPB was performed with 21-gauge
short bevel needle using an in-plane technique. A
total of 20 mL of local anesthetic was injected in every
5-mL aliquots after negative aspiration, and needle
was adjusted to achieve its spread between the C5
and C6 nerve roots.
Preoperative Visit
During preoperative visit, the patients were instructed
to practice voluntary sniff and bedside pulmonary
function test using a hand-held spirometer (EasyOne;
GE Medical Systems).
Bedside Pulmonary Function Test
Patients were required to perform 3 sets of forced vital
capacity (FVC), forced expiratory volume in 1 second
(FEV1), and peak expiratory flow rate (PEFR) mea-
surements in a sitting position, and the average base-
line values were obtained. Postblock pulmonary test
was similarly conducted at 30 minutes and 4 hours
after block.
Diaphragmatic Excursion Measurement
Patients were placed in a supine position, and the dia-
phragmatic excursion measurement was performed
by the same investigator (Y.Z.) on the right hemidia-
phragm as previously described.16,17 In detail, a 2 to 5
MHz low-frequency curvilinear transducer (SonoSite
X-Porte; FUJIFILM SonoSite Inc) was positioned at
right anterior axillary line in the subcostal area for
longitudinal scanning. Using the liver as an acoustic
window, the probe was manipulated until the dia-
phragm was visualized. Then, M-mode ultrasonog-
raphy was used to detect diaphragmatic excursion
along a line selected perpendicular to the diaphragm.
Three representative images of diaphragmatic excur-
sion were saved during tidal and deep breathing,
respectively. Excursion amplitude was defined as the
upright-perpendicular distance from the minimum
to the maximum point of diaphragm excursion.17
Diaphragmatic excursion measurements were per-
formed before block and at 30 minutes and 4 hours
after block, respectively.
Outcome Measurements
Primary outcome was measured by the incidence of
hemidiaphragmatic paralysis at 30 minutes and 4
hours after block. Hemidiaphragmatic paralysis was
defined as greater than 50% reduction in diaphrag-
matic excursion compared with the preblock value
during deep breathing,17 and/or the paradoxical
 Ultrasound-Guided CPB for Clavicular Surgery
movement of diaphragm during sniff at either 30 min-
utes or 4 hours.
Secondary outcomes included (1) bedside pul-
monary function test: FVC, FEV1, and PEFR were
measured as described earlier. (2) The success rate of
block: a nerve block was considered successful when
no other analgesic agent was used to complement the
block. In contrast, block failure was defined as inabil-
ity to achieved adequate surgical anesthesia after
30 minutes of local anesthetic administration, and
requiring general anesthesia to complete the surgery.
The pain score on postanesthesia care unit (PACU)
admission was also evaluated using a visual analog
scale (VAS) from 0 to 10. (3) Time required for the
block procedure and onset: time of block procedure
was recorded as time in minutes from skin contact
of ultrasound probe to withdrawal of block needle,
whereas time of onset was defined as the interval
in minutes between withdrawal of block needle and
complete cold insensitivity on the blocked clavicle.
(4) Motor block score in right upper extremity: motor
function was evaluated before block, then at 30 min-
utes and 4 hours after block in the distribution of the
axillary nerve (shoulder abduction), musculocutane-
ous nerve (elbow flexion), radial nerve (wrist exten-
sion), median nerve (wrist flexion), and ulnar nerve
(thumb/finger adduction) using a 3-point scale
(0 = normal strength, 1 = paresis, or 2 = paralysis),18
with a maximal total motor block score of 10.
Other Measurements
Vital signs including mean arterial pressure (MAP)
and heart rate (HR) were recorded before block (T0)
as baselines, 10 minutes after block (T1), at skin inci-
sion (T2) and periosteum stripping (T3). Other safety
outcomes were documented during the surgery and
PACU stay, which included the following: (1) block-
related complications, such as Horner syndrome,
peumothorax, hoarseness, local hematoma, local
anesthetic systemic toxicity, paresthesia, prolonged
weakness in upper extremity, and new-onset pain;
(2) adverse events, such as respiratory depression,
hypotension, hypertension, bradycardia, tachycardia,
nausea and vomiting. Here, respiratory depression
was defined as oxygen saturation <95%, hypotension
and hypertension were respectively defined as a more
than 30% drop and rise in blood pressure compared to
baselines, bradycardia was defined as HR lower than
60 beats per minute, while tachycardia was defined as
HR larger than 100 beats per minute.
Statistical Analysis
Data analysis was performed using SPSS version
17.0 software. Distribution of continuous vari-
ables was assessed with the Kolmogorov-Smirnov
test. Continuous and normally distributed data are
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expressed as mean ± standard deviation (SD), and
categorical data are expressed as number (%). The
standardized mean differences between the 2 groups
were described in regard to demographic characteris-
tics. A 2-way repeated measures analysis of variance
(ANOVA) with Bonferroni post hoc tests was used to
compare groups over time for variables with repeated
measurements (hemidiaphragmatic excursion, FVC,
FEV1, PEFR, MAP, and HR), and the Student t test
was employed to compare other quantitative data
(operation duration, time of block and onset) across
groups. VAS and motor block score were presented
as median (interquartile range [IQR]) and compared
between the 2 groups with the Mann-Whitney U test.
The Fisher exact test was used to compare categorical
data (the incidence of hemidiaphragmatic paralysis,
block failure rate, the incidence of block-related com-
plications, and adverse events) between the 2 groups.
For categorical outcome (the incidence of paradoxical
movement) that was measured before block, 30 min-
utes and 4 hours after block, a Bonferroni-corrected
significance criterion of 0.05/2 = 0.025 was used to
determine statistical significance to control type I
error for multiple testing, and a P < .05 was consid-
ered statistically significant for all other outcomes.
The sample size was calculated with the incidence
of hemidiaphragmatic paralysis as the primary vari-
able using G*power 3.1.19 In our preliminary study,
1 and 5 cases in 10 developed hemidiaphragmatic
paralysis after CPB with ICPB and ISBPB with ICPB,
respectively. We accepted a 2-tailed significance level
of .05 and power of 80%, thus, making a minimal sam-
ple size required to be 20 cases per group. As there
was no long-term follow-up in the study, we had not
adjusted the sample size for potential dropout.
RESULTS
Of the 51 potentially eligible patients, 40 patients
were enrolled and allocated randomly into 2 groups
(BC or CC group), with 20 cases in each group.
The Consolidated Standards of Reporting Trials
(CONSORT) flowchart diagram of the study was
demonstrated in Figure 2. All 40 patients completed
the study and were included in the final analysis,
and the 2 groups were similar in demographic data
(Table 1).
Preblock baseline diaphragmatic excursion and
bedside pulmonary function were normal in all
patients. However at 30 minutes and 4 hours after
block, hemidiaphragmatic excursions were signifi-
cantly decreased in BC group (normal breathing:
P = .001 at 30 minutes, P < .001 at 4 hours versus
baseline; deep breathing: P < .001 at 30 minutes,
P < .001 at 4 hours versus baseline), but no statistical
significances were found in CC group. Compared to
CC group, hemidiaphragmatic excursion amplitudes
ANESTHESIA & ANALGESIA
 E  Original Clinical Research Report

Figure 2. CONSORT flowchart diagram of the study. CONSORT indicates Consolidated Standards of Reporting Trials.

were impaired in BC group at 30 minutes and 4 hours
after block (Table 2).
Similarly, at 30 minutes and 4 hours after block,
the pulmonary function measurements (FVC, FEV1,
and PEFR) were significantly decreased compared to
baselines in BC group (FVC, FEV1: P < .001 at both 30
minutes and 4 hours versus baseline; PEFR: P = .002
at 30 minutes, P = .001 at 4 hours versus baseline) but
not in CC group, with these parameters being larger
in CC group than BC group (Table 2). More patients
in BC group developed hemidiaphragmatic paralysis
and a paradoxical movement of diaphragm (P < .001
at both 30 minutes and 4 hours versus baseline) with
none recorded in CC group after block. None of these
patients with hemidiaphragmatic paralysis showed
signs of respiratory distress or hypoxia.
All patients had a successful nerve block hence no
general anesthesia was needed. Success rates of block
were therefore considered 100% with VAS scores on
PACU admission still zero in both groups (Table  3).
As shown in Table 3, the average onset time of block
did not differ between the 2 groups, but time required
for the block procedure was shortened in CC group
compared to BC group. The motor block score in BC
group was significantly increased at 30 minutes and 4
hours postblock (Table 3), while 1 subject in CC group

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 Ultrasound-Guided CPB for Clavicular Surgery

ICPB; (2) anesthetic block technique using CPB with

Table 1. Patient Characteristics
ICPB provided adequate surgical anesthesia for mid-
BC group CC group
Items (n = 20) (n = 20) SMD shaft clavicular surgery with minimal motor block in
Age (y) 45 ± 11 43 ± 13 0.108 upper extremity and shortened time required for the
Male sex 16 (80%) 14 (70%) 0.232 block procedure.
BMI (kg/m2) 24 ± 5 25 ± 3 0.124 As reported previously, no patient developed par-
ASA physical
status tial or complete hemidiaphragmatic paralysis after
 I 12 (60%) 11 (55%) ICPB using 0.2 mL/kg of 0.25% ropivacaine at the
 II 8 (40%) 9 (45%) C4-5 level.6 This could be attributed to the water tight
Item BC group (n = 20) CC group (n = 20) P value
barrier formed by prevertebral fascia, which limits
Operation 105 ± 18 115 ± 24 .125a
duration (min) the spread of local anesthetics.20–22 To selectively block
Data are expressed as mean ± standard deviation, or as number (%).
the supraclavicular branches of the cervical plexus,
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body which innervates the skin over the clavicle, and at the
mass index; SMD, standardized mean difference. same time markedly reduce diaphragmatic paralysis,
a
Compared by Student t test.
a more distal ICPB is recommended.23 We therefore
complained of mild weakness in the blocked upper performed ICPB at a distal level of C6 with relatively
extremity. low local anesthetic volume of 5 mL in patients with
The hemodynamics parameters were stable clavicle fracture to minimize the incidence of abnor-
throughout the study and no significant differences mal diaphragmatic movement, and, as expected, the
were found between 2 groups (Supplemental Digital regional anesthesia CPB with ICPB technique showed
Content 1, Table 1, http://links.lww.com/AA/D819). overwhelmingly decreased rate of hemidiaphrag-
No significant differences were observed in the block- matic paralysis.
related complications and adverse events during sur- Diaphragmatic paralysis would lead to signifi-
gery and PACU stay between 2 groups (Supplemental cant reductions in pulmonary mechanics including a
Digital Content 1, Table 2, http://links.lww.com/ 21% to 34% decrease in FVC, 17% to 37% decrease in
AA/D819). FEV1, and 15.4% decrease in PEFR,8 but the develop-
ment of clinically significant symptoms was reported
DISCUSSION to be rare in patients with phrenic nerve paralysis.8,24
The main findings of this study were as follows: (1) Similarly, although some of our patients had hemi-
ultrasound-guided CPB with ICPB was associated diaphragmatic paralysis, none developed signs of
with less hemidiaphragm paralysis and improved hypoxia or respiratory distress. This could be due to
pulmonary function in comparison to ISBPB with the anatomical variations including the presence of

Table 2. Diaphragmatic Excursion and Pulmonary Function Measurements

Items Timepoints BC group (n = 20) CC group (n = 20) Mean difference (95% CI) P value
Hemidiaphragmatic excursion Preblock 1.8 ± 0.6 1.8 ± 0.5 −0.04 (−0.37 to 0.29) .822a
during normal breathing (cm) 30 min postblock 1.2 ± 0.6 1.5 ± 0.4 0.35 (0.01–0.68) .044a
4 h postblock 1.0 ± 0.4 1.6 ± 0.5 0.61 (0.31–0.90) <.001a
Hemidiaphragmatic excursion Preblock 4.4 ± 1.0 4.2 ± 0.9 −0.23 (−0.37 to 0.82) .445a
during deep breathing (cm) 30 min postblock 2.6 ± 1.2 3.6 ± 1.0 1.03 (0.29–1.76) .007a
4 h postblock 2.8 ± 1.1 3.7 ± 1.0 0.89 (0.22–1.57) .011a
Paradoxical movement (n [%]) Preblock 0 (0) 0 (0) NAb
30 min postblock 7 (35) 0 (0) −35% (−57 to −12) .008b
4 h postblock 7 (35) 0 (0) −35% (−57 to −12) .008b
FVC (l) Preblock 3.2 ± 0.7 3.4 ± 0.7 0.18 (−0.29 to 0.64) .447a
30 min postblock 2.0 ± 0.6 2.9 ± 0.9 0.87 (0.39–1.34) .001a
4 h postblock 2.2 ± 0.7 2.9 ± 0.8 0.70 (0.24–1.16) .004a
FEV1 (l) Preblock 2.5 ± 0.5 2.3 ± 0.5 −0.18 (−0.51 to 0.13) .244a
30 min postblock 1.6 ± 0.4 2.2 ± 0.4 0.59 (0.32–0.86) <.001a
4 h postblock 1.5 ± 0.4 2.1 ± 0.5 0.59 (0.29–0.89) <.001a
PEFR (L/min) Preblock 393.3 ± 102.3 361.7 ± 91.1 −31.6 (−93.9 to 30.4) .309a
30 min postblock 287.8 ± 85.9 353.0 ± 101.5 65.24 (5.03–125.46) .034a
4 h postblock 282.3 ± 91.8 355.7 ± 100.1 73.40 (11.04–134.86) .021a
Hemidiaphragmatic paralysis 10 (50) 0 (0) −50% (−70 to −24) <.001c
(n [%])
Data are expressed as mean ± standard deviation or as number (%).
Abbreviations: CI, confidence interval; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; NA, not applicable; PEFR, peak expiratory flow
rate.
a
Compared by 2-way repeated measures analysis of variance.
b
Compared by Fisher exact test, with a significance level of .05/2 = 0.025 for multiple comparison.
c
Compared by Fisher exact test.

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 E  Original Clinical Research Report
Table 3. Block Characteristics
BC group CC group
Items (n = 20) (n = 20)
Block failures (n [%]) 0 (0) 0 (0)
VAS score on PACU admission 0 [0–0] 0 [0–0]
Time of block (min) 7.1 ± 1.2 3.2 ± 0.6
Time of onset (min) 4.6 ± 1.1 4.2 ± 0.8
Preblock motor block score 0 [0–0] 0 [0–0]
Motor block score at 30 min 8 [7.25–9] 0 [0–0]
postblock
Motor block score at 4 h 8 [8–9] 0 [0–0]
postblock
Data are expressed as mean ± standard deviation, median [interquartile
range], or as number (%).
Abbreviations: NA, not applicable; PACU, postanesthesia care unit; VAS,
visual analog scale.
a
Compared by Fisher exact test.
b
Compared by Mann-Whitney U test.
c
Compared by Student t test.
an accessory phrenic nerve,7 which was reported to
present in 61.8% cadaveric specimens.25 Another con-
sideration is the possibility of compensatory contrac-
tion of the accessory muscle of respiration including
the intercostal muscle, which helped maintain normal
physiological functions of the lungs despite hemidia-
phragmatic paralysis.26
CPB provides pain relief via blocking of sensory
nerves branches within the clavipectoral fascia and
clavicle plane.3 To achieve sensory block of skin,
which is innervated by supraclavicular nerve, a com-
bination of CPB with ICPB was hypothesized to be an
effective and feasible anesthetic technique for clavicu-
lar surgery. As shown in this study, CPB with ICPB
provided similar adequate surgical anesthesia with
block technique using ISBPB with ICPB. Interestingly,
as shown in Supplemental Digital Content 2, Figure
1, http://links.lww.com/AA/D820, adequate skin
anesthesia appeared to be achieved by single block
of CPB. We therefore speculate that relatively large
volume of local anesthetic injected into clavipectoral
fascia plane could infiltrate the subcutaneous tissue or
cephalad along the investing layer of the deep cervi-
cal fascia,27 causing supraclavicular nerve block.
Furthermore, our results also demonstrated the
added advantage of shortened block procedure time,
which could be explained by the anatomic location of
injection with the clavicle serving as a natural back-
stop. As expected, patients receiving ISBPB with
ICPB developed significant decline in motor function
of blocked upper extremity, while single case who
received CPB with ICPB developed mild weakness
along median nerve dermatomes, and explanation to
this phenomenon needs further studies.
Several limitations of this study should be
addressed. First, young, relatively thin patients
without any known comorbidities were enrolled for
this study. The outcomes are likely to be different
in patients with known conditions such as obesity,
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Copyright © 2022 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
elderly, or concomitant significant lung diseases.
We suggest studies should therefore be replicated
P value in these groups to ensure an accurate conclusion to
NAa be drawn. Second, our study only enrolled patients
NAb with right-sided clavicular fractures since the liver’s
<.001c acoustic window rather than the spleen was preferen-
.242c
NAb tially used to visualize the diaphragm. Thus, patients
<.001b scheduled for left clavicle surgery were not screened
in our current study. Finally, the effects of single CPB
<.001b
procedure on diaphragmatic movement and pulmo-
nary function measurements were not studied.
In conclusion, ultrasound-guided CPB with ICPB
could significantly reduce hemidiaphragm paraly-
sis while providing an adequate surgical anesthesia
for midshaft clavicular surgery, and this regional
anesthesia technique is advantageous for its ease
to perform and minimal motor block in upper
extremity.E
DISCLOSURES
Name: Qian Zhuo, MD.
Contribution: This author helped with concept and design;
analysis and interpretation of the data; drafting of the manu-
script; critical revision of the manuscript for important intel-
lectual content; and final approval.
Name: Yanya Zheng, MD.
Contribution: This author helped with concept and design;
acquisition, analysis, and interpretation of the data; drafting of
the manuscript; critical revision of the manuscript for impor-
tant intellectual content; and final approval.
Name: Zixuan Hu, MD.
Contribution: This author helped with concept and design;
analysis of the data; drafting of the manuscript; critical revision
of the manuscript for important intellectual content; and final
approval.
Name: Juncheng Xiong, MD.
Contribution: This author helped with concept and design;
acquisition, analysis, and interpretation of the data; drafting of
the manuscript; critical revision of the manuscript for impor-
tant intellectual content; and final approval.
Name: Yanqin Wu, MD.
Contribution: This author helped with concept and design;
analysis and interpretation of the data; drafting of the manu-
script; critical revision of the manuscript for important intel-
lectual content; and final approval.
Name: Yi Zheng, MD.
Contribution: This author helped with concept and design;
interpretation of the data; drafting of the manuscript; critical
revision of the manuscript for important intellectual content;
and final approval.
Name: Liangrong Wang, MD.
Contribution: This author helped with concept and design;
acquisition and interpretation of the data; drafting of the man-
uscript; critical revision of the manuscript for important intel-
lectual content; and final approval.
This manuscript was handled by: Michael J. Barrington, MB
BS, FANZCA, PhD.
REFERENCES
1. O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK.
Clavicle fractures: a comparison of five classification sys-
tems and their relationship to treatment outcomes. Int
Orthop. 2011;35:909–914.
 Ultrasound-Guided CPB for Clavicular Surgery
2. Vautrin M, Kaminski G, Barimani B, et al. Does candidate
for plate fixation selection improve the functional outcome
after midshaft clavicle fracture? A systematic review of 1348
patients. Shoulder Elbow. 2019;11:9–16.
3. Choi DS, Atchabahian A, Brown AR. Cervical plexus block
provides postoperative analgesia after clavicle surgery.
Anesth Analg. 2005;100:1542–1543.
4. Arjun BK, Vinod CN, Puneeth J, Narendrababu MC.
Ultrasound-guided interscalene block combined with inter-
mediate or superficial cervical plexus block for clavicle sur-
gery: a randomised double blind study. Eur J Anaesthesiol.
2020;37:979–983.
5. Dillane D, Ozelsel T, Gadbois K. Anesthesia for clavicular
fracture and surgery. Reg Anesth Pain Med. 2014;39:256.
6. Kim HY, Soh EY, Lee J, et al. Incidence of hemi-diaphrag-
matic paresis after ultrasound-guided intermediate cervical
plexus block: a prospective observational study. J Anesth.
2020;34:483–490.
7. Castresana MR, Masters RD, Castresana EJ, Stefansson
S, Shaker IJ, Newman WH. Incidence and clinical signifi-
cance of hemidiaphragmatic paresis in patients undergoing
carotid endarterectomy during cervical plexus block anes-
thesia. J Neurosurg Anesthesiol. 1994;6:21–23.
8. Urmey WF, McDonald M. Hemidiaphragmatic paresis
during interscalene brachial plexus block: effects on pul-
monary function and chest wall mechanics. Anesth Analg.
1992;74:352–357.
9. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney
CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the
efficacy and respiratory consequences of ultrasound-
guided interscalene brachial plexus block. Br J Anaesth.
2008;101:549–556.
10. Valdes L. Analgesia for clavicular surgery/fractures. In
Symposia 01: postoperative analgesia for orthopedic upper
and lower limb surgery. Symposium conducted at the 36th
annual European Society of Regional Anaesthesia and
Pain Therapy (ESRA) congress, Lugano, Switzerland. 2017
September.
11. Ince I, Kilicaslan A, Roques V, Elsharkawy H, Valdes L.
Ultrasound-guided clavipectoral fascial plane block in
a patient undergoing clavicular surgery. J Clin Anesth.
2019;58:125–127.
12. Yoshimura M, Morimoto Y. Use of clavipectoral fascial
plane block for clavicle fracture: two case reports. Saudi J
Anaesth. 2020;14:284–285.
13. Atalay YO, Mursel E, Ciftci B, Iptec G. Clavipectoral fas-
cia plane block for analgesia after clavicle surgery. Rev Esp
Anestesiol Reanim (Engl Ed). 2019;66:562–563.
640   
www.anesthesia-analgesia.org
Copyright © 2022 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
14. Kukreja P, Davis CJ, MacBeth L, Feinstein J, Kalagara
H. Ultrasound-guided clavipectoral fascial plane block
for surgery involving the clavicle: a case series. Cureus.
2020;12:e9072.
15. Ueshima H, Ishihara T, Hosokawa M, Otake H. Clavipectoral
fascial plane block in a patient with dual antiplatelet ther-
apy undergoing emergent clavicular surgery. J Clin Anesth.
2020;61:109648.
16. Spiesshoefer J, Herkenrath S, Henke C, et al. Evaluation of
respiratory muscle strength and diaphragm ultrasound:
normative values, theoretical considerations, and practical
recommendations. Respiration. 2020;99:369–381.
17. Sivashanmugam T, Maurya I, Kumar N, Karmakar MK.
Ipsilateral hemidiaphragmatic paresis after a supraclavicu-
lar and costoclavicular brachial plexus block: a randomised
observer blinded study. Eur J Anaesthesiol. 2019;36:787–795.
18. Tedore TR, YaDeau JT, Maalouf DB, et al. Comparison of the
transarterial axillary block and the ultrasound-guided infra-
clavicular block for upper extremity surgery: a prospective
randomized trial. Reg Anesth Pain Med. 2009;34:361–365.
19. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a
flexible statistical power analysis program for the social,
behavioral, and biomedical sciences. Behav Res Methods.
2007;39:175–191.
20. Seidel R, Schulze M, Zukowski K, Wree A. Ultrasound-
guided intermediate cervical plexus block. Anatomical
study. Anaesthesist. 2015;64:446–450.
21. Levitt GW. Cervical fascia and deep neck infections.
Laryngoscope. 1970;80:409–435.
22. Warshafsky D, Goldenberg D, Kanekar SG. Imaging
anatomy of deep neck spaces. Otolaryngol Clin North Am.
2012;45:1203–1221.
23. Balaban O, Dülgeroğlu TC, Aydın T. Ultrasound-guided
combined interscalene-cervical plexus block for surgical
anesthesia in clavicular fractures: a retrospective observa-
tional study. Anesthesiol Res Pract. 2018;2018:7842128.
24. Knoblanche GE. The incidence and aetiology of phrenic
nerve blockade associated with supraclavicular brachial
plexus block. Anaesth Intensive Care. 1979;7:346–349.
25. Loukas M, Kinsella CR Jr, Louis RG Jr, Gandhi S, Curry
B. Surgical anatomy of the accessory phrenic nerve. Ann
Thorac Surg. 2006;82:1870–1875.
26. Bonnevie T, Gravier FE, Ducrocq A, et al. Exercise testing
in patients with diaphragm paresis. Respir Physiol Neurobiol.
2018;248:31–35.
27. Ince I, Kilicaslan A, Roques V, Elsharkawy H, Valdes L. The
clavipectoral fascia plane block: reply to Dr. Altinpulluk. J
Clin Anesth. 2020;61:109681.
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