Cervical plexus block (2023)

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Cervical plexus block (1)

Korean Journal of Anesthesiology

Korean Anesthesia J.2018 august 71 sek. 4): 274-288.

Published online July 4, 2018. doi:10.4097/kja.d.18.00143


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Cervical plexus blocks (CPBs) are used in various head and neck surgeries to provide adequate anesthesia and/or analgesia. However, the block is performed in a narrow space in the neck area that contains many delicate structures, many layers of fascia and complex innervation. Since intermediate CPBs were introduced in 2004 in addition to superficial and deep CPBs, there has been some confusion regarding the nomenclature and definition of CPBs, particularly intermediate CPBs. In addition, CPB can be performed more safely and accurately under ultrasound guidance with the increasing role of head and neck ultrasound. In this review, the authors will describe methods including ultrasound techniques and clinical applications of conventional deep and superficial CPB. In addition, the authors will discuss controversial issues regarding indirect CPBs, including nomenclature and related potential side effects, which can often be neglected by focusing on the anatomy of the cervical fascia and cervical plexus layers. Finally, the authors will try to improve the classification of CPB methods based on target areas that can be easily identified under ultrasound guidance, taking into account the results of each CPB method.

Keyword:Airway obstruction, cervical fascia, cervical plexus, cervical plexus obstruction, phrenic nerve palsy, ultrasound


Cervical plexus block (CPB) provides effective anesthesia and analgesia of the head and neck region [1-7]. the most common clinical application of CPB was carotid endarterectomy (CEA) [8–12]. Traditionally, CPB is classified as deep and superficial [13], ale w 2004 r. Telford i Stoneham [14] proposed an indirect CPB involving sub-study fascial injection in addition to superficial and deep CPB based on a cadaver study by Pandit et al. [15] And 2010, Choquet et al. [16] attempted to improve the concept of CPB intermediates using ultrasound technology. However, the terms "superficial", "intermediate" and "deep" are ill-defined anatomical terms that only indicate the topographic position of the tissue relative to the skin. Therefore, there has been some confusion in the nomenclature and definition of CPB, especially intermediate CPBs.

With the increasing role of ultrasound in the head and neck region, CPB can be performed more safely and accurately under ultrasound guidance, allowing for easy localization of various important landmarks, including muscles, cervical vertebrae, great vessels, nerves, and the cervical region. fascia [17In particular, an understanding of the detailed configuration of the cervical fascia is essential for success with CPB, as some cervical fascia are known to play an important role in the diffusion of local anesthetic solution [15,18–20]. However, the structural features of the cervical fascia have not been fully explored for regional anesthesia. In addition, there was disagreement about the exact identification of the deep cervical fascia, especially in the lateral cervical region [21–24], and there are also anatomical differences [2].20,25]

Accordingly, this review first describes the anatomy of the cervical fascia and cervical plexus layers, then the methods of performing CPB including ultrasound techniques, then the results of conventional deep and superficial CPB, and a related new but controversial CPB intermediate. In addition, this review will discuss the potential adverse effects of CPB, which are often overlooked, and finally attempt to improve the classification of CPB methods based on target areas easily identifiable under ultrasound guidance, taking into account effects and potential adverse effects for each CPB method.


cervical fascia

Examination of the cervical fascia layers is clinically important for predicting disease spread [26-28], optimizing surgical treatment29] and conduction of regional anesthesia in the neck area [15, 18-20] and changes in the cervical fascia may play an important role in the pathogenesis of chronic neck pain [15, 18-20].30,31] However, descriptions of fascial alignment and definitions of fascial spaces in the neck region are inconsistent and unclear, and terminology varies. According to the 41st issue of Gray's Anatomy [32], fascia is described as "sheaths, sheets, or other masses of connective tissue large enough to be visible to the naked eye," and the Fascia Nomenclature Committee for the Fascia Research Conference describes it as "sheaths, sheets, or other removable aggregates of connective tissue , which form under the skin to attach, trap and separate muscles and other internal organs" [33] However, the structural classification of the cervical fascia has been controversial despite the use of newer techniques and materials to preserve and study the structure of the fascia. Like Grodinsky and Holyoke [34] described in their pioneering study based on an autopsy in 1938, the inherent difficulties in dissecting the cervical fasciae spaces and their apparently artificial clustering may cause confusion in the description of the cervical fascia and discrepancies between different authors. According to a recent work by Guidery et al. [35], the cervical fascia can be classified as superficial and deep, although instead of using the term "superficial cervical fascia", the more specific term "subcutaneous tissue" has been suggested to avoid confusion with its superficial deep cervical fascia [36] The deep cervical fascia can be divided into three layers [35]: (a) the superficial layer, also called ependymal fascia, but now referred to as masseter fascia, submandibular fascia, or sternocleidomastoid fascia (SCM) - trapezius fascia, although it has been argued that the SCM-trapezius fascia between the SCM and the trapezius muscle is incomplete [21,22]; (b) the middle layer, which is proposed to be called the cingulate fascia or the visceral fascia, and (c) the deep layer, which is proposed to be called the paravertebral fascia instead of the prevertebral fascia, because the term "pre-spinal fascia " should only be used in the front part. The carotid space, containing the great vessels, deep cervical lymph nodes, and nerves, is a very important structure that can be damaged during CPB and is commonly referred to as the "carotid sheath and contents" [36] According to the literature [37,38], the carotid sheath is a distinct histological structure distinct from the other fascial layers, and the common carotid sheath varies in thickness between individuals and/or by location. However, there is disagreement as to whether the cervical sheath consists of all three layers of the deep cervical fascia and only the deep or superficial layer of the deep cervical fascia, or whether there is no proven fascial layer at all [36] Palliyalil i in. [39] reported that the carotid sheath is a strong fibroelastic tissue barrier that protects the contents from saliva and local infections after neck surgery, but local anesthetics appear to penetrate the carotid sheath [40]Grave. 1shows a schematic drawing of the cervical fascia as Guidera et al. [35] suggested.

Cervical plexus block (2)

Cervical fascial layer (C6 cross-section) according to Guider et al. [35] Illustration adapted from Smoker and Harnsberger [41]

cervikal plexus

The cervical plexus lies in the sulcus between the long head and the median, beneath the prevertebral fascia, but not in the intersphenoidal sulcus because the anterior scalene is almost absent cranially near the C4 and C3 levels.42] Two neural loops, formed at the junction of adjacent anterior spinal nerves C2 to C4, give off four superficial sensory branches, arranged in craniocaudal order as follows: minor occipital (C2, C3), major auricular (C2, C3), nerves transverse cervical (C2, C3) and supraclavicular (C3, C4). They first run backwards and soon pierce the prevertebral fascia. They then pass through the interfascial space between the SCM and the prespinal muscles before reaching the skin and superficial structures of the neck via the nerve point of the SCM muscle [43,44] Thus, the superficial branches of the cervical plexus cover a relatively large distance from the paravertebral space to their respective superficial endpoints, including the skin and subcutaneous tissue of the neck and back of the head and shoulders.45,46] Instead, fibers from the superior (C1-C2) and inferior (C2-C3) roots join at the level of the medial scapulohyoid tendon to form a loop, the ansa cervicalis.47] Ansa cervicalis is known to supply the motor branches of hypothyroidism and the muscles of the SCM [48] with a high degree of diversification of origin and distribution [49]; However, the ansa cervicalis is suspected of having an afferent neuronal complex [50] The anterior ridge of C3 and C4 forms a loop, and the branches of this loop join at C5 to form the phrenic nerve. The cervical plexus is known to anastomose with the accessory spinal nerve, the hypoglossal nerve, the facial nerve, the vagus nerve, the glossopharyngeal nerve, and the sympathetic trunk.43,49,51]Grave. 2shows a schematic drawing of the deep and superficial cervical plexuses.

Cervical plexus block (3)

Schematic drawing of the deep cervical plexus and the superficial cervical plexus. (A) The four superficial branches of the cervical plexus are shown in yellow, and the deep branches of the cervical plexus (ansa cervicalis) are shown in green. The cervical plexus is known to anastomose with many cranial nerves and the sympathetic trunk. (B) The superficial cervical plexus arises behind the posterior margin of the SCM (stereocleidomastoid) muscle and innervates the head, neck, and shoulder regions. Illustration taken from Restrepo et al. [52]

Cervical plexus blockade methods

CPB can be performed at a deep, superficial, or intermediate level, although these terms are not well defined.

Deep cervical plexus block

Deep CPB is described as a paravertebral block targeting the C2-C4 spinal nerves [13,53], which can be achieved with a single injection or three separate injections [13,53,54] Deep CPB performed in the paravertebral space can block not only the superficial branches but also the deep branches of the cervical plexus, causing relaxation of the neck muscles, although this has not been shown to be clinically significant.10,14,55] Furthermore, if the ansa cervicalis also has a complex of afferent neurons [50], deep CPB would be of greater clinical relevance in the treatment of postoperative pain after neck surgery involving hypothyroidism and/or SCM muscles or pain originating from the neck. Wan et al. [56] oraz Goldberg i in. [57] reported that deep CPBs in the transverse process of C2 or C3 can effectively treat cervicogenic headache. Deep CPB has also been used during thyroid or parathyroid surgery [58,59], oral and maxillofacial surgery [3] and CEA [60–64] for adequate anesthesia and/or analgesia. Deep CPB can cause serious complications such as intravascular injection, epidural or spinal injection, and phrenic nerve palsy due to the deep endpoint.12,65]; However, with the introduction of ultrasound, deep CPB has become a relatively safe and simple procedure [3,42,66,67] For ultrasound-guided deep CPB, Perisanidis et al. [3] and Saranteas et al. [67] simply injected local anesthetic into the space between the prevertebral fascia and the transverse process of the cervix under ultrasound guidance, but Wan et al. [56] and Sandeman et al. [66] injected local anesthetic after the needle touches the transverse process of the target cervix under ultrasound guidance.

Superficial cervical plexus block

Superficial CPB has traditionally been described as a subcutaneous injection technique performed in the medial posterior margin of the SCM muscle, targeting the superficial branches of the cervical plexus.12,13] This conventional subcutaneous infiltration technique for superficial CPB can be performed using an ultrasound-guided technique [68], and depending on the type of head and neck surgery, it is also possible to selectively block one or more superficial branches of the cervical plexus using landmarks [1,4,69,70] or ultrasound technique [71-74]. It is known that superficial CPB, in contrast to deep CPB, is associated with a low risk of complications and is easy to manage [12,59,75] During superficial CPB, however, it is important that the needle tip be placed in the subcutaneous tissue to avoid the unwanted effects of a deep block.76,77] Unilateral or bilateral superficial CPB can be used as postoperative analgesia after various head and neck surgeries, such as thyroidectomy.1,78,79], minimally invasive parathyroidectomy [59], tympanomastoid surgeon [4], anterior discectomy and cervical fusion [5] and hypogastric and occipital craniotomy [80] Can also be used as a single anesthetic method during external ear surgery [74] Superficial CPB can also be used as a supportive block in shoulder, clavicle, chest, and upper chest wall surgeries, especially in cases of supraclavicular branch occlusion. At Ajou University Hospital, we use a landmark based superficial CPB for various treatments on the head, neck and upper chest wall, both in children and adults, to achieve anesthesia and/or analgesia (Grave. 3).

Cervical plexus block (4)

Breakthrough superficial cervical plexus blocks were performed at Ajou University Hospital for ear, neck, and upper chest surgery to achieve adequate anesthesia and/or analgesia. (A) A 77-year-old man undergoing resection of a turbinate hemangioma underwent block of the great auricular and inferior occipital nerves. (B) Selective supraclavicular nerve block was performed in a 4-year-old girl undergoing resection of a congenital melanocytic nevus in the right upper chest wall. (C) A 94-year-old female patient undergoing resection of squamous cell carcinoma in the right cervical region underwent a major cervical and transverse cervical nerve block. (D) A 52-year-old man undergoing incision and drainage of a right upper chest wall abscess underwent a selective supraclavicular nerve block. To avoid a deep puncture, the needle was slightly bent.

Intermediate cervical plexus block


In 2002, Zhang and Lee [21] reported that there is no layer lining the deep fascia in the space between the SCM and the trapezius muscle, in an area called the posterior cervical triangle [81] They performed a cross-sectional anatomical study using epoxy sheet lamination on cadavers, but their results are still controversial [24,35,36] Interestingly enough, in the 41st issue of Gray's Anatomy [82] described that the investing fascia between the SCM and the trapezius muscle is formed by sparse tissue indistinguishable from the superficial cervical fascia. However, in 2003, Pandit et al. [15] introduced a new concept of the subinvestor fascia injection technique (superficial to the prevertebral fascia but below the investor fascia) as a superficial CPB method. In this study, Pandit et al. [15] hypothesized that there is communication between the superficial and the deep spaces via the prevertebral fascia, which may explain why the effectiveness of superficial CPB is comparable to that of deep CPB and combined deep and superficial CPB during CEA [10,62] W 2004 r. Telford i Stoneham [14] expected that this intermediate CPB could also provide the same results as deep CPB while avoiding some of the practical difficulties associated with deep CPB. However, this would be possible if communication via the prevertebral fascia existed. In 2007, Pandit et al. [12] expressly stated that an intermediate block is one in which the injection needle penetrates the ependymal fascia of the neck, deep in the subcutaneous layer but superficial to the prespinal fascia. In this context, the permeable nature of the prevertebral fascia should be an important consideration, as it may ultimately determine the characteristics of interstitial CPB. However, several papers [7,9,83–85] have already been published based on Pandit's hypothesis [15] that injection of indirect CPB can spread to deep tissue through the prevertebral fascia, and thus indirect CPB may have similar effects to deep CPB, although no clinical trials have been conducted to test the penetrating nature of the prevertebral fascia.

Technique and nomenclature

Research by Barone et al. [85], Ramachandran i in. [8] and Merdad et al. [83] used a blind approach to indirect CPB, targeting the space between the fascial lining and the prespinal fascia using landmarks and loss of resistance or the pop technique, although Merdad et al. [83] used the term “superficial” CPB instead of “intermediate” CPB. However, it was probably not easy even for very experienced specialists to place the needle tip exactly in the desired space without the help of ultrasound. Because Kefalianakis et al. [86] published the first report of CPB ultrasound targeting the space between the SCM and the anterior stapes muscles for CEA in 2005. CPB ultrasound has grown in popularity because it can be performed safely and precisely in the target area [87] And 2010, Choquet et al. [16] argued that an intermediate CPB should target the posterior cervical space (PCS) at the C4 level. PCS described by Choquet et al. [16] is the interfascial space between the SCM and the prespinal muscles that can be seen on cross-sectional imaging. They used an ultrasound technique and argued that the PCS corresponded to the subfascial space described by Pandit et al. [15] The superficial branches of the cervical plexus, coming from the deep tissue, pass through this space after piercing the prevertebral fascia, leaving the skin and the superficial tissue through the posterior edge of the SCM muscle [16]

Fordi Choquet et al. [16] introduced indirect CPB using the ultrasound technique, many studies were published under the name ultrasound indirect CPB [3,9,11,63,84,85,8895] In these studies, the authors performed a posterior or anterior approach to achieve an indirect CPB to provide anesthesia and/or analgesia for CEA [63,84,92-95], operations involving the SCM muscle [90,91] and diverticulum of cervical esophagus [88] under ultrasound guidance. For posterior ultrasound access for indirect CPBs, after the target level of the cervical spine with elevation from the C7 vertebra has been determined by ultrasound, the SCM and soleus medius are placed in the center of the screen. At this point, the needle is inserted into the PCS (the space between the SCM and the prespinal muscles) in a lateral to medial direction (plane technique), using the anterior edge of the medial stapes as a reference point for needle tip placement. The local anesthetic is then injected slowly and carefully while watching the spread of the anesthetic in the PCS [90,91] Anterior approach for indirect CPB US can provide similar results to other peripheral techniques for CEA [89] According to Leblanc et al. [92], indirect CPB ultrasound is easy to perform, safe and reliable. On the other hand, some authors [9699] performed an indirect CPB ultrasound in PCS but referred to it as a superficial CPB ultrasound. In a review of block anesthesia for CEA by Stoneham et al. [55], CPB is described as five techniques: superficial, deep, superficial US, deep US and indirect CPB US. In this review, Stoneham et al. [55] described CPB superficial ultrasound as a method of inserting a needle block adjacent to the cervical plexus under the prevertebral fascia. However, if the locking pin penetrates the prevertebral fascia, it is no longer classified as indirect CPB as argued by Telford and Stoneham, [14] and Pandit et al. [12,15] originally proposed, nor the classical CPB surface. Therefore, the use of the term "superficial" is not appropriate in this case.

The reason for the above discrepancies in the nomenclature of CPB methods seems to be the location of the block and the blocked branch of the cervical plexus. CPB performed in the cervical paravertebral space (C2-C4) can simultaneously block both the superficial and deep branches of the cervical plexus [53], although we call it deep rather than surface CPB given the position where the block is executed. Thus, the nomenclature for the CPB technique performed in PCS, resulting in spread of the local anesthetic, would more appropriately be called indirect CPB than superficial CPB, even though indirect and superficial CPB target essentially the same superficial branches of the cervical plexus.

Impact on the intermediate cervical plexus

Importantly, interstitial CPBs may provide different anesthetic and analgesic effects compared to superficial CPBs. The cervical plexus (C2–C4) is known to provide sensory innervation to the SCM muscle, including proprioception, via variable anastomosis with the accessory spinal nerve.43,100104] Therefore, the SCM muscle appears to have complex innervation, but it is known that the cervical branches of the nerve supplying the SCM muscle, after piercing the prevertebral fascia, anastomose with the accessory spinal nerve on the posterior surface or inside The SCM muscle [100,101,105] Although it is known that the accessory spinal nerve itself also has a sensory function [52,106,107], it is believed that the cervical plexus (ansa cervicalis) is another, next to the accessory spinal nerve, another source of motor innervation of the SCM muscle [48, 52, 108-110]. Therefore, it is possible that indirect CPB ultrasound, accurately performed in the PCS at a specific level of the cervical vertebrae, can exclude all four cutaneous branches of the cervical plexus and the sensory-motor branches of the cervical plexus that also supply the SCM muscle, providing adequate anesthesia and analgesia for manipulative procedures.90] or SCM muscle resection [91] Likewise Jerzingacy [111] suggested applying local anesthesia directly to the SCM muscle to block the sensory branches of the cervical plexus that innervate the SCM muscle during local anesthesia before thyroidectomy. According to Senapathi et al. [99], indirect CPB ultrasound is more effective than the multidirectional subcutaneous injection technique of superficial CPB in reducing pain after thyroidectomy, although the authors used the term “surface CPB ultrasound” instead of indirect CPB ultrasound. In addition, pain associated with the SCM muscle, similar to the SCM syndrome [112] or pain associated with trigger points in the SCM muscle [113115] can theoretically be treated with this technique. At the University Hospital of Ajou, children and adults routinely have a posterior access, if necessary, an indirect CPB ultrasound, targeting the C4-C5 PCS (Grave. 4). In contrast, classical superficial CPB performed subcutaneously would not produce such indirect blocking effects. Therefore, although it is currently unclear whether the trapezoidal fascia of the SCM is present in the posterior cervical triangle, it would be reasonable to define superficial CPB as a multidirectional or single subcutaneous injection technique targeting one or more superficial branches of the cervical plexus, regardless of the use of ultrasound technology. In addition, although both superficial and indirect CPBs essentially target the same superficial branches of the cervical plexus, indirect CPBs may cause some adverse effects that superficial CPBs do not.

Cervical plexus block (5)

Posterior approach ultrasound image of a C4-5 IPC block in a 3-year-old patient with torticollis undergoing unipolar sternocleidomastoid release (SCM) with myectomy. Using local anesthesia, a hydrotomy of the posterior cervical space between the SCM muscle and the prevertebral fascia is observed, and a local anesthetic is distributed around the carotid sheath. CA: carotid artery, IJV: internal jugular vein, LA: local anesthetic. White arrows indicate: prevertebral fascia.

Carotid plexus block and carotid endarterectomy

The most common clinical use of CPB was CEA. CEA is a validated intervention for stroke prevention associated with symptomatic carotid artery stenosis [116,117], which includes incisions in the skin, platypus muscle, carotid artery, and carotid artery. Since the first CPB report for CEA [118] in 1988, various techniques for using CPB were evaluated in CEA, although the ideal anesthetic technique for CEA remains a matter of debate.54,119121] Stonehama i in. [10] in 1998 and Pandit et al. [62] reported in 2000 that superficial CPB is as effective for CEA as deep or combined deep and superficial CPB. However, during CEA for CPB, the surgeon will often perform subcutaneous or deep local anesthesia, regardless of the type of CPB method.74,94,122], probably because within the structures of the neck, including the cervical sheath, there are some areas innervated by cranial nerves that are not reached even by deep CPB [8,51,94,123125] or cutting pain near the midline, possibly caused by opposing fibers,8,74,123,126] Seidel i in. [19] showed stable anastomosis of the cervical branch of the facial nerve with the transverse cervical nerve of the cervical plexus. The pain associated with the incision of the cervix during CEA was completely relieved with lidocaine spray.124Cranial nerves (glossopharyngeal and vagus nerves) and the sympathetic trunk have been suggested to be involved in the sensory innervation of the carotid artery and vagina [51,94,124]; Therefore, it may be prudent to administer a local anesthetic near the carotid artery during CEA. A recent single temporary CPB ultrasound [62,84,89,92,95] or indirect CPB ultrasound combined with infiltration of a local anesthetic USG in the perivascular region of the carotid artery [9,11,93,94] has become a new option to reduce the amount of intraoperative refilling of local anesthetic by the surgeon during CEA, while the use of deep CPB for CEA has decreased. However, direct infiltration of a local anesthetic into the perivascular area of ​​the carotid artery may cause some side effects of cranial nerve palsy.9,11,93,94,127,128]

Safety considerations related to cervical plexus block

Paralysis of the phrenic nerve

The phrenic nerve emerges from the ventral crest from C3 to C5 and runs laterally medial to laterally down the surface of the anterior scalene beneath the prevertebral fascia. According to Castresana et al. [129], combined deep and superficial CPB causes acute diaphragmatic movement disorders in 61% of patients. Notably, conventional topical CPBs do not appear to affect the phrenic nerve [53], provided that the injection is made precisely in the subcutaneous tissue [77One of the reasons that not all patients receiving deep CPB develop diaphragmatic movement disorders may be due to anatomical differences, including dominance of the fifth cervical nerve and the presence or absence of an accessory phrenic nerve.129] In addition, the SCM muscle is an additional respiratory muscle, necessary for the weakening of the diaphragm [130132] Deep CPB is known to be strongly associated with diaphragmatic paralysis [129], which in combination with relaxation of the SCM muscles may lead to a worse than previously assumed effect on airway function, especially in patients with clinically significant lung disease or suspected diaphragmatic movement disorders.133]

The prevertebral fascia (the deep layer of the deep cervical fascia) forms the tubular sheath of the spine and its associated muscles, such as the long and long cap muscles in front, the scalene muscles in the side, and the deep cervical muscles in the back.13,43] According to the literature, the prevertebral fascia appears to play a barrier role in the spread of local anesthetics.134] or even boils [26,135] create an airtight space [134], suggesting that the bulge in the prevertebral space does not extend sharply in any direction due to the compactness of this space [26] There is also evidence that local anesthesia can stretch the prevertebral fascia during stellate ganglion blocks [136] and that the local anesthetic is trapped in the PCS during the intervention of the CPB [3] More recently, using fresh cadavers, Seidel et al. [19] studied the propagation of an injectable dye solution injected into a PCS using an ultrasound technique. Therefore, the dye remained in the PCS, suggesting that the prevertebral fascia is impermeable, contrary to Pandit's hypothesis [15] Nevertheless, Seidel et al. [19] have suggested that a clinical trial is needed to see if phrenic nerve block can be prevented with intermittent CPB.

Unlike deep CPBs [42,64] og mesoscale brachial plexus block [137], which inevitably requires puncture of the prevertebral fascia and injection of a local anesthetic near the roots of the cervical spine, the likelihood of indirect CPB on ultrasound affecting the phrenic nerve may seem low, possibly due to the previously mentioned protective nature of the prevertebral fascia.26,134,135], which can also be seen in the examination of the corpses by Seidel et al. [19] and the location and course of the phrenic nerve [77] Martusevicius i in. [9] performed a regional anesthesia ultrasound technique similar to indirect CPB ultrasound in 60 patients, which did not cause arm weakness or respiratory distress, and in a study by Tran et al.97], despite local anesthetic deposition in the PCS between the SCM and the scalene muscle under ultrasound guidance, no cases of inadvertent brachial plexus block, Horner's syndrome, or dyspnea were observed. Consistent with these findings, two studies by Kim et al. [90,91] also showed no evidence of brachial plexus block, Horner's syndrome, or dyspnea after a single mid-CPB ultrasound examination in adult patients undergoing robotic thyroidectomy and in children and adolescents with rheumatic disease undergoing unipolar SCM muscle release with myectomy. In addition, Calderon et al. [89] reported that although diffusion of local anesthetic in PCS was observed during indirect CPB ultrasound, no diffusion of the anesthetic beyond the prevertebral fascia was detected, which may also be an important element supporting the thesis that the prevertebral fascia has protective properties. However, currently there is insufficient evidence to confirm the true nature of the prevertebral fascia, which needs to be explored in clinical trials.

Airway obstruction

Mechanical airway obstruction due to tissue edema or hematoma is a well-known surgical complication after various neck surgeries, including thyroidectomy.138] and CEA [139,140] Especially during CEA, surgical procedures involving dissection, traction, and retraction may cause damage to the facial nerve, the hypoglossal nerve, the vagus nerve and its branches (retrograde and superior laryngeal nerves), or the glossopharyngeal nerve in the operative field.141144Among them, bilateral damage to the vagus nerve, recurrent laryngeal nerve, or hypoglossal nerve can lead to fatal upper airway obstruction [1].141,145Although data on cranial nerve blocks associated with isolated deep CPBs are sparse [59,61,127], it is likely that deep CPB may paralyze the glossopharyngeal, vagus, hypoglossal, and accessory nerves, especially when there is diffusion of anesthetic to the head, as there are extensive anastomoses between the inferior cranial and superior cervical nerves, although this is very likely a variable between individuals [51,53Therefore, it is important to remember that bilateral deep CPB can cause not only bilateral phrenic nerve paralysis, but also fatal airway obstruction by paralysis of the vagus or hypoglossal nerve. Most importantly, in patients with preexisting contralateral vagal (or recurrent laryngeal) or hypoglossal nerve injury, even unilateral deep CPB can result in complete airway obstruction. therefore, although pre-existing unilateral vocal cord paralysis is usually clinically asymptomatic [127,146], and unilateral hypoglossal nerve palsy causes minimal disability [145], routine preoperative history taking and physical examination of the tongue and vocal folds will be important in patients receiving deep CPB [59] as well as in patients undergoing CEA [147] regardless of the anesthetic technique.

As previously described, direct infiltration of a local anesthetic into the neck region during CEA by the surgeon or anesthesiologist can effectively block the pain associated with carotid sheath or arterial incision [1].124,148], but can also cause cranial nerve block side effects [9,11,93,94,127,128], in addition to decreased baroreceptor reflex [94Ultrasound techniques for infiltration of a local anesthetic in the neck region in conjunction with subcutaneous infiltration or indirect CPB have recently been introduced to reduce intraoperative supplementation of local anesthetic during CEA [9,11,93,94] According to Casutt et al. [148], ultrasound blockade of the cervical sheath by injecting a mixture of local anesthetic and contrast medium into the ventral side of the carotid artery causes extensive spread of the local anesthetic, which is confirmed by CT imaging after the blockade. Martusevicius et al. [9reported that transient hoarseness, facial paralysis, and dysphagia occurred in 72%, 13%, and 12% of patients, respectively, who received a combined indirect CPB infiltration and local anesthetic ultrasound. Therefore, bilateral infiltration of local anesthetic in the neck region can result in fatal airway obstruction.

Regarding indirect CPB, the spread pattern of the local anesthetic in PCS may be important. During a block at the interfascial level, many factors can affect the distribution of local anesthetic and the quality of the block, therefore precise needle placement and a deep understanding of fascial anatomy and tissue structure are required.149] Zhang i Li [21] argued that the PCS is actually an extension of the subcutaneous tissue and that the carotid sheath is connected to the subcutaneous adipose tissue without clearly delimiting the fascia. In the clinical setting, we have often observed that local anesthetic agents easily spread towards the carotid sheath, even when the tip of the injection needle is positioned between the scalene anterior or long head muscle and the scalene median during a posterior CPB indirect ultrasound approach (Grave. 4). Tran i ind. [97] compared ultrasound and CPB based on superficial landmarks in patients undergoing shoulder and clavicle surgery. However, the CPB ultrasound technique they used was actually an indirect CPB ultrasound method where 10 mL of anesthetic was injected into the PCS as described here, and not superficial CPB ultrasound, whereas landmark superficial CPB was essentially subcutaneous CPB. They reported no dyspnoea, desaturation, or brachial plexus block, but hoarseness or difficulty swallowing occurred in 10% of patients in the ultrasound group. Leblanc et al. [92] reported that dysphonia occurred in 12%, Horner's syndrome in 4%, and dysphagia in 2% of patients after a single interventional CPB ultrasound examination with 10 ml of local anesthetic for CEA, but intentionally inserting the needle tip near the carotid artery. Alilet et al. [95] failed to insert the needle tip near the cervical sheath during a single indirect CPB ultrasound with 10 ml local anesthetic for CEA and reported a very low incidence of hoarseness (2.4%) and hypoglossal palsy (2.4%). Therefore, it can be assumed that the occurrence of hoarseness and dysphagia after a single mid-CPB ultrasound examination may depend on blocking techniques as well as on the amount of local anesthetic injected. In contrast, when intermittent CPB was combined with cervical infiltration of local anesthetics, a significantly higher incidence of hoarseness and dysphagia was observed.9,93,94]

Hoarseness (dysphonia) possibly due to blockade of the vagus nerve or its branches (recurrent and superior laryngeal nerves), difficulty swallowing (dysphagia) possibly due to blockade of the vagus nerve and blockade of the facial nerve may be due to inward and upward spread of the local anesthetic during the ultrasound intervention in CPB. Transient dysphonia caused by ipsilateral vagus nerve, recurrent laryngeal block, or superior laryngeal nerve after indirect CPB on ultrasound is usually not clinically significant. However, bilateral blockade of the vagus, recurrent laryngeal or hypoglossal nerves can cause fatal airway obstruction. Therefore, bilateral intermittent CPB can be dangerous, and even unilateral CPB can lead to airway obstruction in patients with preexisting contralateral vagal or hypoglossal nerve damage, which may require routine preoperative testing. During ultrasound intervention in CPB, to avoid inadvertent cranial nerve blockade, it is recommended to place the needle tip of the PCS well beyond the carotid sheath, use a small amount of local anesthetic and inject the anesthetic slowly while observing local anesthetic spread, thus limiting medial spread of local anesthetic in the cervical sheath [90,91] unless cervical sheath lock is required.

Other negative effects

Horner's syndrome itself has no clinical consequences, but it is an unpleasant side effect, although it cannot be described as a complication.150The incidence of Horner's syndrome after intermittent CPB is debatable due to the position of the cervical sympathetic chains relative to the prevertebral fascia, the permeability of the prevertebral fascia, and the degree of local anesthetic spread from the PCS to the carotid sheath during the procedure. CPB's intervention may have some effect. Usui et al. [42] and Civelek in in. [151] described that the sympathetic chains in the neck lie directly under the prevertebral fascia covering the long muscles. on the contrary, in the 41st edition of Gray's Anatomy [152], it has been reported that the carotid sympathetic trunk lies in the prevertebral fascia posterior to the carotid artery. However, Horner's syndrome has been reported after superficial CPB [59], combined surface and deep CPB [59,63], indirect CPB ultrasound [92,98] and combined indirect CPB ultrasound and cervical infiltration of local anesthetic [9,11,94] But according to Lyons and Mills [25], out of 12 sections of the neck of the cadavers, in 2 cadavers the cervical sympathetic chain was found in the carotid artery. This anatomical variation may not only cause damage to the sympathetic chain during neck dissection or simple internal jugular vein catheterization [153], but it also affects the occurrence of Horner's syndrome during CPB with/without local anesthetic infiltration in the carotid artery.

The most common cause of accessory spinal nerve palsy is iatrogenic trauma during neck surgery, particularly operations located in the posterior cervical triangle.106,154] Anatomically, the accessory spinal nerve enters the posterior cervical triangle 2 cm above Erb's point, then runs diagonally along the posterior cervical triangle and terminates on the anterior surface of the upper trapezius muscle with many variations.155] In the posterior cervical triangle, the accessory nerve lies superficial to the prevertebral fascia [156]; Thus, the superficial CPB may be affected [53], but indirect CPB targeting the PCS below the SCM muscle is unlikely to affect the spinal accessory nerve [157]

Clarifying the classification of cervical plexus block

For a systematic naming of CPB techniques, we can propose three practical CPB classifications (Grave. 5), based on anatomical studies of the cervical fascia, nerve innervation and relevant clinical reports described in this review. The first technique is superficial CPB, which consists of a multi-directional or single subcutaneous injection in the area of ​​the posterior lip of the SCM muscle, directed at the superficial branches of the cervical plexus, regardless of the use of the ultrasound technique. This superficial CPB can also be performed to selectively block one or more superficial branches of the cervical plexus using a landmark or ultrasound technique. Surface CPB is a very useful, safe and easy-to-learn tool that every regional anesthesiologist should know. The second technique is indirect CPB, which involves placing a needle in the PCS (between the SCM muscle and the prevertebral fascia) at the C4 level, targeting both the superficial branches of the cervical plexus and possibly the cervical sensory-motor branches of the uterus. plexus that supplies the SCM muscle. Intermediate CPB ultrasound is easy to learn and reproduce, but the possibility of side effects should not be overlooked. Finally, deep CPB involves placing a needle between the prevertebral fascia and the cervical nerve roots at the C2-C4 level while targeting both the superficial and deep branches of the cervical plexus. Despite some advantages, deep CPBs may require a risk-benefit analysis before implementation. To ensure safe and effective intermediate and deep CPB, the use of ultrasound technique is strongly recommended.

Cervical plexus block (6)

Three different target areas for cervical plexus block (CPB) in the cervical fascial spaces are illustrated schematically (Section C4). (A) The target area for superficial CPB is the subcutaneous tissue around the medial posterior margin of the sternocleidomastoid muscle (SCM). (B) The target area for indirect CPB is the space between the SCM muscle and the prevertebral fascia. (C) The target area for deep CPB is the space between the prevertebral fascia and the target transverse process.


CPB is performed in the neck area, which is very complex and requires many layers of fascia in a tight space. A new, more specific terminology for the cervical fascia has recently been proposed, but there is still disagreement about the exact identification and description of the cervical fascia, including the investing and prevertebral fascia and the carotid sheath. In addition, anatomical differences in the layers of the cervical fascia can significantly influence the results of any CPB method. Therefore, it is currently difficult to describe the actual results of each CPB approach, although most CPB methods are now performed accurately and safely under ultrasound guidance. In this review, we have covered in detail indirect CPB, which is a relatively new technique but has some controversial issues. Although the obstructive effects and potential adverse effects of indirect CPB require further investigation, we simply classified CPB into three general approaches, superficial, intermediate, and deep, based on the target area of ​​each approach, which is easily identified by ultrasound.

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Articles fromKorean Journal of Anesthesiologygiven here courtesyThe Korean Society of Anesthesiologists


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