Cervical plexus Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio), FICA

Halsted – 1884 Kappis Labat – popularized What made it as big hero Carotid endarterectomy

Cervical plexus Superficial and Deep Anatomy or ANESTHESIA

In anatomy – there is one cervical plexus What is special !! The cervical plexus gives all its motor nerves earlier to be as only sensory nerves later – This difference enable us to block the sensory component which we call it as SCPB

Indications Carotid endarterectomy Lymph node dissections Plastic repairs (Neck) Shoulder surgery (supplement brachial plexus) Tracheostomy Thyroidectomy Parathyroidectomy

Other indications Injuries to the ear, neck and clavicular region Including clavicular fractures and acromio- clavicular dislocations Cervicogenic headaches Alone or as Supplement

Anatomy Spinal nerves emerge from the intervertebral foramina and pass behind the vertebral artery and vein in the gutter formed by the anterior and posterior tubercles of the corresponding transverse process of the cervical vertebrae. Anterior and posterior rami -Ventral – ascending and descending branches -Loop – plexus – fascial sheath Communication with sympathetic chain and cranial N

ANATOMY

Anatomy – superficial The superficial cervical plexus (SCP) originates from the anterior rami of the C2-C4 spinal nerves and gives rise to 4 terminal branches lesser occipital greater auricular transverse cervical supraclavicular nerves sensory innervation to the skin and superficial structures of the anterolateral neck and sections of the ear and shoulder

Accessory nerve

Distribution of skin anesthesia

Technique of blockade Middle of the posterior border of sternocleido mastoid muscle Face to one side Lift the head and valsalva SCM prominent with EJV Subcutaneous – 5-8 ml both sides Accessory nerve close !!

USG guided

Beware what are below

Both sides we can do No motor effects Alone - difficult for surgeon – no motor block Less side effects Accessory !!!

Deep cervical plexus block Para vertebral block of C2 C3 C4 nerves !! Mastoid to chassaignac ( C6) – line Posterior line – 1 cm Caudad – 1.5 cm each – Lower border of mandible – C4 Transverse process hit, withdraw 2 mm, inject

Inject deep to deep fascia -

Probe placement for deep cervical plexus

Other approaches

Behind carotid sheath place probe lateral

Trace interscalene groove and deposit above

Classical - TP Needle

Drugs for deep cervical plexus block

Single injection Thyroid notch – C4 Go up by 2 cm Give ml of local anesthetic

Dangers Phrenic nerve block Vertebral artery Epidural – no above Subarachnoid 60 % incidence of phrenic nerve palsy after DCPB- hemidiaphragmatic paresis and heavy sensation Oxygen, reassurance Bilateral ??

Complications

Total reversible blindness has also been described after similar inadvertent injections of small amounts (1 mL) of local anesthetic into a vertebral artery. Carotid sheath compression by injecting the local anesthetic anterior to the transverse processes has been demonstrated by Labat to possibly impair blood flow to the brain Carotid artery Stenosis ??

Complications Hematoma can compress pharynx and larynx Hoarseness secondary to vagal nerve block or recurrent laryngeal nerve involvement probably occurs more often than previously thought. SCPB -2-3%. May be 60 % with DCPB Horner's syndrome- middle cervical ganglion affected in DCPB Dysphagia may occur with pharyngeal plexus block

Can decrease complications by Caudad only

Summary Anatomy Types SCPB technique DCPB – technique Complications Overall, simple safe technique

Thank you all