CERVICAL PLEXUS

ANESTHESIA

G. Fanelli, D. Lugani, A. Casati

Safe and Effective
anesthesia for neck
surgery ?
Indications:

• carotid surgery
• soft tissues surgery of the neck (biopsy,
exploration)
• unilateral thyroid and parathyroid surgery
• diagnosis and therapy of chronic shoulder and neck
pain
Contraindications:
• local anesthetics allergy
• severe chronic pulmonary disease
• coagulopathy
• infection at the site of injection
• preexistent neurologic disease
• lack of patient consent / collaboration
Anatomy:
• Superficial cervical plexus
• Deep cervical plexus
Superficial
Cervical
Plexus
Deep
Cervical
Plexus
TECHNIQUES
SUPERFICIAL CERVICAL PLEXUS

Blockade of the superficial branches at

their emergence site
 DEEP CERVICAL PLEXUS

Blockade of C2-C4 spinal nerve roots

Local anesthetics
• Deep cervical plexus
• Mepivacaine 2% - 5 ml at each level
• Ropivacaine 0,75% - 5 ml at each level

• Superficial cervical plexus

• Mepivacaine 1% - 15 ml single injection
• Ropivacaine 0,5% - 15 ml single injection
Landmarks
Complications:

• intrathecal injection
• epidural injection
• intravascular injection
• phrenic nerve paralysis
• block of other nerves of the neck
 SINGLE INJECTION
with NERVE STIMULATOR ?

Only paresthesias are elicitable,

NOT muscle twitches !

 GENERAL
ANESTHESIA
or
REGIONAL
ANESTHESIA

?
 CEA
Intranesthetic concerns
• Blood pressure close monitoring and control
• Continuous neurologic monitoring
• EEG
• Consciousness
• Arm strenght and motility
 General anesthesia
Advantages:
• Good patient comfort
Disadvantages:
• Monitoring of cerebral function during carotid
cross-clamping impossible
• Increased risk for hypotension
 Regional anesthesia
Advantages:
• Continuous cerebral function monitoring
• Increased hemodynamic stability
Disadvantages:
• Need of patient collaboration (block
placement, drapes, lateral head position)
• Difficult airway management in case of
seizure or loss of consciousness
 CE A

GENERAL
ANESTHESIA

REGIONAL
ANESTHESIA
 CERVICAL PLEXUS
BLOCK
or
CERVICAL EPIDURAL
ANESTHESIA

?
 Cervical plexus block
Advantages:
• Lower incidence of pulmonary side effects
• Unilateral block
 Cervical plexus block
Disadvantages:
• Higher risk of intravascular or intrathecal
injection
• Discomfort for the patient during the execution
of the block
Cervical epidural anesthesia
Advantages:
• Better patient comfort during the execution
of the block
• Continuous epidural anesthesia for long-
lasting procedures and post-operative
analgesia
 Cervical epidural anesthesia
Disadvantages (1):
• Possible bilateral phrenic nerve block
• Bilateral arm block
• Bradycardia
• Asymmetric anesthesia distribution
 Cervical epidural anesthesia
Disadvantages (2):
• Higher incidence of hypotension
• Placement and removal of catheter impossible
during heparine therapy
• Adequate training in epidural catheter
placement
• Higher anesthetic drug plasma levels
• Risk for total spinal block
Prospective, randomized comparison
of deep or superficial cervical plexus
block for carotid endarterectomy
surgery
MD Stoneham ,AR Doyle JD Knighton, P Dorje JC Stanley
Anesthesiology, 1998: 89;907-912
 DEEP SUPERFICIAL
CERVICAL CERVICAL
PLEXUS VS PLEXUS
BLOCK BLOCK

?
Supplementary lidocaine requirements
during surgery
5
Superficial block
M e dia n m l 1 % lido c a .

4 Deep block

0
Deep
Superficial
Total
Site of LA injection
 Dermatomes affected by blocks
20
18
16 Superficial block
N um be r o f pa tie nts

Deep block
14
12
10
8
6
4
2
0
C2
C3
C4
C5
Dermatomes
C6
 CONSIDERATIONS
• Deep block is superior in terms of less
postoperative pain
• Effectiveness of deep block is increased if
paresthesia is elicited during block placement
• Deep block has been reported to cause
diaphragmatic dysfunction in 61% of patients
MD Stoneham ,AR Doyle JD Knighton, P Dorje JC Stanley
Anesthesiology, 1998: 89;907-912
Paresthesia occuring during deep
cervical block placement (n=20)
12 Paresthesia
No paresthesia
10

4
2
0
Number
Suppl. 1% lid.
Patients requiring
P.O. analgesia
 CONCLUSIONS
“Carotid endarterectomy may be performed
satisfactorily during superficial or deep
cervical plexus block placement with no
differences in terms of supplemental local
anesthetic requirements”

MD Stoneham ,AR Doyle JD Knighton, P Dorje JC Stanley

Anesthesiology, 1998: 89;907-912
Cervical plexus block:
first choice technique
for neck surgery
 CEA
ANESTHESIA TECHNIQUE
PRIORITY RANK
1st. Cervical plexus block
2nd. Cervical epidural anesthesia (if adequate
training)
3rd. General anesthesia (if adequate cerebral
monitoring)
 CEA
PRIORITY RANK
1st. Cervical plexus block
2nd. Cervical epidural anesthesia (if adequate
training)
3rd. General anesthesia (if adequate cerebral
monitoring)