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 12-15 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 sensationOxygen, reassurance

Bilateral ??

Complications

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