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CervicalPlexusBlocks

Anatomy,LandmarkandUltrasound

Guidedblocks

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Indica=ons

Centralvenouscannula=onviatheinternaljugularorsubclavianroutes

Injuriestotheear,neckandclavicularregionincludingclavicularfracturesandacromio-claviculardisloca=ons

Cervicogenicheadaches

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Anatomy

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CervicalPlexus

Formedbytheventralramioftheupperfourcervical(C1-4)nerves

Theramiemergebetweentheanteriorandposteriortuberclesofthetransverse

processesofthecervicalvertebrae,

crea=ngagrooveonthecosto-transversebars

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PrevertebralfasciaLonguscapi=s

Longuscervicalis

Scalenusanterior

Scalenusmedius

Levatorscapulae

Dorsalramus

Anteriorramus

Anteriortubercule

CostotransversebarPosteriortubercle

Vertebralartery

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AntandPostRela=ons

Theplexusisrelatedposteriorlytothemusclesthatarisefromtheposteriortubercle

ofthetransverseprocessi.e.thelevator

scapulaeandscalenusmedius

Anteriorly,totheprevertebralfascia,theinternaljugularveinandthesternocleidomastoid

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Thesuperficialplexus

Branchesandtheblock

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SuperficialBranches

Superficial(cutaneous)branches,supply

cutaneousfibrestotheneck

Ascendingbranches;Lesseroccipital(C2)

andGreaterauricular(C2,3)

Transversebranch;Transverse(anterior)cutaneousnerveoftheneck(C2,3)

Descendingbranches;Supraclavicular(C3,4)

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Roots

LESSEROCCIPITAL

C2

GREATER

AURICULARC2,3

ANTCUTNOF

NECKC2,3

SUPRACLAVICULARC3,4

C3

C4

C2

C1

Loops

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LesserOccipitalC2

GreaterAuricularC2,3

Supra-clavicularNerves

C3,4

Transverse(Ant)CutNerves

oftheNeckC2,3

Ascending

Transverse

Descending

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SuperficialPlexusBlock

Landmarktechnique

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Superficialcervicalplexusblock

Thesuperficialcervicalplexusblockconsistsofasubcutaneousinjec=onof

localanaesthe=cjustundertheskin

Thelandmarkisthepostborderofthesternocleidomastoidmuscle(SCM)

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Postborderof

Sternocleidomastoid

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Mid-point,postborderofSternocleidomastoid

muscle

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Superficialcervicalplexusblock

Themid-pointoftheSCMismarkedandfromthispointlocalanaesthe=cisinfiltrated

subcutaneouslyalongthesuperiorandthe

inferiorborder

Around7-10mlsisinjectedalongtheen=reborder,anotherfewmlscanalsobeinjectedat

themid-pointitself,assumingthatmost

branchesexitfromthispoint

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Superficialplexusblock

UltrasoundGuided

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USGuided

Notonlyeasybutalsoincreasesthesuccessrate

Avoidstoodeepneedleinser=onand/orinadvertentinjec=onsintotheimportant

surroundingstructuresintheneck

Advantageliesintheabilitytoensurethespreadoflocalanaesthe=cinthecorrectplane

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USGuided

Transducerisplacedoverthelateralsideoftheneckatthemidpointoftheposteriorborderof

thesternocleidomastoidmuscle(SCM)

TheviewshouldbesuchthatthetaperingendoftheSCMisvisibleonthescreen Theneedleisintroducedfromtheposterioraspectthroughtheskinandplatysmaand5-10

mlsoflocalanaesthe=cdepositedjustbehindtheposteriorborderoftheSCM

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SCM

Needle

Medial

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Thedeepcervicalplexus

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RootsHypoglossal.n

PHRENICNERVEC345

GENIOHYOID

THYROHYOID

DESCENDENS

HYPOGLOSSI

DESCENDENS

CERVICALIS

C5

C3

C4

C2

C1

Loops

Branchesto

Sternocleidomastoid

Branchesto

Trapezius,

LevatorScapulae

andScalenus

medius

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C1

TheanteriorprimaryramusofC1isen=relymotor.ThenervedescendstoformaloopwiththeascendingbranchofC2infrontofthetransverseprocessoftheatlas

Themajorityofthefibresinthislooprunforwardtojointhehypoglossalnerve(XIICN)andthroughthis,C1suppliesthegeniohyoidandthyrohyoidmuscles,thenrunsdownwardsasthedescendenshypoglossi,from

whichthenervetotheanteriorbellyoftheomohyoidmuscleisderived

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C3

C2

HypoglossalNerve

Tonguemuscles

Geniohyoid

Thyrohyoid

Inferior(Post)

bellyofomohyoid

Sternohyoid

Sternothyroid

Superior(Ant)bellyof

omohyoid

C1

DESCENDENSHYPOGLOSSI

DESCENDENSCERVICALIS

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Ansacervicalis

Descendenshypoglossijoinsdescendenscervicalis,derivedfromC2and3,toforma

looptermedtheansacervicalis,whichlieson

thecaro=dsheath

Fromtheansa,nervefibrespasstosupplysternohyoid,sternothyroidandtheposterior

bellyofomohyoid

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Loop2and3

TheanteriorprimaryramusofC2dividesintoanascendingbranch,whichjoinsC1,andadescendingbranch,whichloopstojoinC 3(Loop2)

Loop3isformedbytheanteriorprimaryramusofC3andC4.BranchesfromthisloopjoinC5togiverisetothephrenicnerve

Eachrootalsoreceivesagreyramuscommunicansfromthesuperiorcervicalganglion

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DeepCervicalPlexus

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Landmarks

Complexregionaltechnique,involvesblockingthenerverootsofC2,C3andC4

Rootsofcervicalnerves1to7emergesuperiortothetransverseprocessofeach

cervicalvertebra

Inanadult,thelarynxoverliescervicalvertebrae4to6

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Landmarks

Theupperborderofthelarynx(C4)ispalpableasthenotchinthethyroidcar=lage

Thelowerborderofthelarynx(C6)istheCricoidcar=lage

TheexternaljugularveinoencrossestheposteriorborderoftheSternocleidomastoid

muscleatthelevelofC6

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Mastoidprocess

Cricoid

ChassaignacsTubercle

1Cm

1-2CmC2

C3

C4

1.5Cm

1stLine2ndLine,1cmbehindand

paralleltothe1st

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Deepcervicalplexusblock

Usinga22G,1.5inchneedle,thetransverseprocessesarelocatedbyenteringperpendicular

totheskin

Depthofthetransverseprocessvarieswiththebodyhabitusofthepa=ent(1.5-3.0cmdeep) Onceboneiscontacted,theneedleispulledbackslightly,anddirectedinthecephaladdirec=on

Thisisrepeatedun=ltheneedleiswalkedoffthebone

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C4

C6

ThyroidNotch

Crico-thyroid

notch

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3Injec=ons

Aercarefulaspira=onforbloodand/orCSF,5mlsofLAisinjectedslowly;paresthesiamaybeobtainedbutisnotnecessaryfortheblock

Thisisrepeatedattheothertwotransverseprocesses

Duringinjec=on,thepa=entshouldbecommunicatedwithcon=nually,tohelpdetect

achangeinmentalstatusthatcouldoccurwithintravascularinjec=on

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Singleinjec=ontechnique

Involvesasingleinjec=onattheC4level Landmarkdescribedfortheclassicalapproachcanbeusedor

Linedrawnfromthecricoidcar=lagetothepointwheretheexternaljugularveincrossestheposteriorborderofthesternocleidomastoid,this

willbeatthelevelofC6.Alinefromthethyroid

notchisthendrawnparalleltothelineforC6todeterminethelevelofC4.

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Loca=ngC4

TomarkC4,themastoidprocessislocated,andamarkismade1cmposteriortoit.Aline

isthendrawnfromthismarktointersectat

rightanglestothelinedrawnbackfromthethyroidnotchforC4

Wherethesetwolinescrossistheloca=onoftheC4transverseprocess

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Singleinjec=on

Usinga22G,1.5inchneedle,thetransverseprocessofC4islocatedbyentering

perpendiculartotheskinandaercareful

aspira=onforbloodand/orCSF,15-20mlsoflocalanaesthe=csolu=onisinjected

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DeepCervicalplexus

USGuided

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Ant Post

SCM

Needle

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Approach1

Takesaverysimpleview,inthisapproachLAisdepositedjustbehindthecaro=dsheathatthelevelofthecaro=dbifurca=on.Theinjec=onisnotasdeepasdescribedforclassicaldeep

cervicalplexusblock. Nopublica=onsbasedonthisapproach,combinedwithsuperficialplexusblock,thismightworkverywell.

Advantageisthesimplicityandsafety(aslongasinjec=onintothecaro=dcanbeavoided)

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Ant PostCA

LA

Needle

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Approach2

UsesthefindingsofWinnieandcolleagueswhosuggestedfollowingtheinterscalenegroovecraniallyanddeposi=ngtheLAanaesthe=cinthisgroove

Forthosewhoregularlyperforminterscalenebrachialplexusblock,thisisalogical

approach,asweallknowthatthecervicalplexusisblockedwhenLAoverspills

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Ant Post

Needle

SA SM

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Approach3

Followstheclassicaldescrip=onofdeepcervicalplexusblockandheretheC4levelismarkedandthetransducerisplacedlaterallyatthislandmarkandmovedposteriorly=llthetransverseprocessofC4isiden=fied

Theneedleisthenintroducedinthelongaxisfromtheposteriorendoftheprobeunderdirectvision.Oncethe=poftheneedletouchesthebonypart,itispar=allywithdrawnandaeraspira=on10-15mlsof

LAisinjected,whichcanbeseenspreadingalongthetransversevertebrae

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Intermediatecervicalplexus

block

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IntermediateCervicalPlexusBlock

Panditandcolleaguesintheircadavericstudyshowedthatinjec=onsplacedbelowthe

inves=ngfasciaoftheneckdiffuseintothe

deepspace,whereasinjec=onsplacedsubcutaneouslydidnot

Injec=ondeeptotheinves=nglayeroftheneckistermedtheintermediatecervical

plexusblock.

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Fortheintermediateblock,aertheusualskinprep,theneedleisinsertedinaperpendicularplaneatthemidpointoftheposteriorborderofthesternocleidomastoid

muscleun=lalossofresistanceorpopisfeltastheneedlepassedtheinves=nglayerofthecervicalfascia(~12cmdepth)

Theneedleisthenfixedandaround15-20mlofLAisslowlyinjectedaercarefulaspira=on

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USGuidedIntermediateblock

Theapproachissimilartosuperficialcervicalplexusblockbutinvolvesdeeperinjec=on.

Anaemptismadetoiden=fytheinves=ngfasciaoftheneckintheinterscalenegrooveandLAdepositedunderthefascia.

Aclickorpopcanoenbefeltwhentheneedlepiercesthisfascia,10-15mlsofLAis

depositedatthislevel

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Inves=ngFascia

Needle

SCM