CERVICAL PLEXUS BLOCK

Richard Bryant MD

Disclosures None

Objectives Anatomy of the cervical plexus Cervical plexus blocks Literature review Utility of cervical plexus blocks

Case 72 yo African male with symptomatic

hypercalcemia secondary to hyperparathyroidism

ROS: CAD with 2 vessel fixed stenosis, CHF EF 30-35%, Multiple CVAs (most recent 3 months ago)

Vitals: normal Surgery: Right parathyroidectomy

Cervical Plexus

http://intranet.tdmu.edu.ua/data/kafedra/internal/anatomy/classes_stud/en/nurse/1/13%20Spinal%20nerves.%20Nerve%20plexuses.htm

History Halsted at Bellvue Hospital in New York

1884 First published by Kappis in Germany

1912 describing a posterior approach 1914 Heidenhein described the lateral

approach 1922 NEJM - local/regional analgesia to

be the safest method for thyroidectomy

Cervical PlexusThe cervical plexus represents nerves from the anterior rami of C1 – C4

Superficial (4 primary braches)• Lesser occipital n.• Greater auricular n.• Supraclavicular n.• Transverse cervical n.

Deep (primarily muscular innervation)• C1 innervates thyrohyoid,

geniohyoid• Ansa cervicalis (C1 – C3 loop)

innervates sternohyoid, omohyoid, sternothyroid

• Segmental branches innervate scalene muscles

• Phrenic (C3 – C5) innervates the diaphragm and pericardium

http://www.studyblue.com/notes/note/n/neck/deck/4588539

Lesser Occipital Nerve Arises primarily

from C2 with some C3 braches

Innervates the posterior/lateral aspect of the scalp and along woth the greater auricular provides sensation to the posterior aspect of the ear

http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

Greater Auricular Nerve Arises from C2 – C3 Anterior branch –

innervates the skin supplying the anterior surface of the ear, and the skin overlying the parotid gland

Posterior branch – innervates the skin overlying the mastoid process and posterior aspect of the ear

http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

Supraclavicular Nerve Arises from C3 – C4 Medial branch – Innervates

the skin and clavicle from sternoclavicular joint to mid clavicle.

Intermediate branch – Innervates clavical and skin from superior aspect of pectoralis major out to anterior deltoid

Lateral branch – Innervates distal clavical and skin supplying the superior and posterior aspect of the deltoid

http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

Transverse Cervical Nerve Arises from C2 – C3 Provides cutaneous

and deep innervation to the anterior/medial and posterior/later apects of the neck

http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

Superficial Cervical Plexus Block

www.nysora.com Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders

Superficial Cervical Plexus Block

Position: supine/sitting Landmarks: sternocleidomastoid muscle Local: 10 ml Block is generally performed starting at

the midpoint on the posterior/lateral border of the sternocleidomastoid muscle.

Deep Cervical Plexus Block

www.nysora.com Ellis H, Feldman S. Anatomy for Anaesthetists, 4th edn, 1983

Deep Cervical Plexus Block Position: Supine/sitting Landmarks: Mastoid process,

Chassaignac tubercle Local: 3-4 ml injected each at C2, C3, C4 Classically the block is performed using a

paresthesia eliciting technique to obtain a paravertebral block of C2 – C4.

Intermediate Cervical Plexus Block

Basically ultrasound guided superficial cervical plexus block

Ensures deeper components of the SCP are anesthetized

Ultrasound of SCP

Intermediate Cervical Plexus Block

Position: Supine/Sitting Landmarks: Posterior border of the

sternocleidomastoid muscle at the level of the external jugular vein

Local: 5-15 mL

THYROIDECTOMY UNDER LOCAL OR REGIONAL ANESTHESIAIGOR BRICHKOV, MD, PAUL LOGERFO, MD

The technique used for local/regional anesthesia for thyroid surgery is described. The experience with a large number of patients undergoing local/regional anesthesia is incorporated in describing this technique.

Local or regional anesthesia for thyroid surgery has beenused since the 19th century. Thomas Peel Dunhill originallypopularized this technique; his experience with itcan be found elsewhere. 1-3 Local anesthesia has been offeredto patients undergoing thyroid surgery at this institutionfor the past 15 years. The resurgence of this approachbegan with patients' desire to avoid generalanesthesia when undergoing thyroid surgery. The use oflocal anesthesia was originally thought to limit the extentof procedures being performed because the ability to extenddissections beyond that of uncomplicated thyroidectomywas not considered feasible. However, with additionalexperience, we found that a wide range of thyroidand parathyroid surgery could be performed under localanesthesia. We have performed 800 thyroidectomies underlocal anesthesia (approximately 95% of patients), withconversion to general anesthesia in only 1% of patients.This technique has proven safe and effective when comparedto general anesthesia. 4

Surgery JournalYear: 2011 | Volume: 6 | Issue: 1 | Page No.: 7-12DOI: 10.3923/sjour.2011.7.12  

Day Case Thyroidectomy under Local/Regional Block in a Tropical Sub-Urban Teaching Hospital in a Developing Country-Preliminary ReportMusa Adewale , Philip A.O. Adeniyi , Lasisi Akeem , Agboola Oladeji and Oyegunle Ayodele

 

Abstract: Throidectomy is routinely performed under general anaesthesia and patient is often admitted for a few days. This has been found unnecessary because complications following thyriodectomy are very rare. Day case surgery is an ideal way of utilizing heath resources to maximum, cheap and conserves hospital beds. A prospective study performing thyroidectomy under regional anaesthesia as day cases. Department of Surgery, Endocrine Unit, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. In a 36 month period, April 2007 to March 2010, about 150 patients with simple nodular/multinodualr goiter were strictly selected for the study. Patients selected for the surgery were 135 females and 15 males with age range of 27-55 years and a mean age of 40.5 years±9.3 SD. Three had nodular goiter, seven with isthmus enlargement and 140 had simple multinodular goiter (two as recurrent). Three had lobectomy, seven had isthmusectomy with bilateral partial lobectomies; the remaining had near total thyroidectomy including the patients with recurrent goiter. There were no complications, all were discharged between 6-8 h post operative except one of the patients with recurrent goiter who had two pints of blood and was discharged at 20 h, post surgery. She also had transient hypocalcaemia. Thirty five patients had headache which responded to simple analgesic. About 95% of the patients were satisfied with procedure and would recommend it to others, 3% were satisfied but would not recommend it while 2% were indifferent. Day case thyroidectomy is safe and feasible even in rural and sub-urban centres. The earlier part of this study was partly presented at the 43rd Scientific Conference of the International College of Surgeons Annual Conference, Nigerian section in July, 2008.

Surgery. 1998 Dec;124(6):975-8; discussion 978-9.Local/regional anesthesia for thyroidectomy: evaluation as an outpatient procedure.Lo Gerfo P.SourceColumbia University College of Physicians and Surgeons, New York, NY, USA.AbstractBACKGROUND: The purpose of this paper was to review my evolving experience with local/regional anesthesia in an outpatient setting.METHODS: Two hundred three consecutive patients during a 9-year period who chose to undergo thyroid operation under regional/local anesthesia were reviewed. Early discharge was offered to patients who were observed for 6 hours without neck swelling and who had no surgical reasons for delaying discharge.RESULTS: In group A there were 2 patients who were given inhalation anesthesia during operation compared with none in groups B and C. The average length of stay in group A was 0.49 days, 0.55 days in group B, and 0.24 days in group C. Eighty-five percent of the patients whose operation began before 1300 hours were discharged within 6 hours versus only 50% of those operated on later in the day. Forty-seven percent of patients in group A, 65% of group B, and 77% of patients in group C were discharged within 6 hours of operation. On the basis of previous experience with general anesthesia, discharge time is not significantly influenced by the type of anesthesia chosen. There were no readmissions to the hospital, but 2 episodes of postoperative bleeding required reoperation. Survey showed that 95% of patients rated the level of pain equivalent or less severe than dental procedures under local anesthesia, and all patients would choose local again.CONCLUSIONS: These data suggest that thyroidectomy can be performed with the patient under local/regional anesthesia, with low morbidity and high patient satisfaction. Most patients can be discharged within 6 to 8 hours, and these discharges were not associated with readmissions.

Head and NeckRegional Anesthesia andThyroidectomy: Local Anesthesia forThyroidectomies?Guest Reviewers: R. Russell Martin, COL, MC, USA, andAlan Sbar, MAJ, MC, USA, General Surgery Service, Brooke ArmyMedical Center, Fort Sam Houston, TexasCHARACTERISTICS OF PATIENTS HAVING THYROID SURGERY UNDERREGIONAL ANESTHESIA. Specht MC, Romero M, Barden CB, Esposito C, FaheyTJ III. J Am Coll Surg 2001;193:367-372.Objective: To examine and compare patient characteristics and outcomes for patients undergoing thyroid surgery with either regional or general anesthesia.Design: A retrospective review of 175 consecutive thyroid surgeries performed at a single institution with a single primary surgeon over 3 years.Setting: The New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, New York.Participants: A total of 175 consecutive patients undergoing thyroid surgery from February 1977 to May 2000.

Results: Regional anesthesia was discussed preoperatively with all patients prior to surgery, and the patient’s decision was used to assign the subjects into a regionalanesthesia and general anesthesia group. The only absolute contraindications to regional anesthesia in this series were substernal goiter and inability of a patient tocommunicate. The patient characteristics of the 2 groups were compared with regard to age, gender, Body Mass Index (BMI), anesthesia class, pathology, size of tumor, and type of operation (hemi vs. total thyroidectomy). Operative time and length of stay was compared, and perioperative complications were assessed in both groups. The only demographic difference between the 2 groups was BMI, in which 2% of the regional group and 23% of the general group were considered obese. All other characteristics measured showed no statistical difference or trends. Operative time was significantly longer in the general anesthesia group, although this difference disappeared when the obese patients as a subgroup were factored out. Length of stay was significantly shorter in the regional anesthesia group (0.95 vs. 1.30 days), and many patients chose to go home the same day. Perioperative complications, which included transient or permanent hypocalcemia and vocal cord paralysis, hematoma, infection, and conversion to general anesthesia, were few and did not show a statistically significant difference.

Conclusions: In patients who undergo thyroid surgery, regional anesthesia can be considered a safe alternative to general anesthesia. The only contraindications to regional anesthesia as set forth by the authors were substernal goiter (possibly requiring sternal split) and inability to communicate verbally with the anesthesiologist. Operative times were similar, and there was no increased incidence of complications, whereas length of stay was significantly shorter in the regional group.

LOCAL/REGIONAL ANESTHESIA FOR THYROIDECTOMY: EVALUATION

AS AN OUTPATIENT PROCEDURE. Lo Gerfo P. Surgery 1998;124:975-979.Objective: To review the experience of a single surgeon in the use of local/regional anesthesia for thyroid surgery.Design: A retrospective review of patients undergoing thyroid surgery by the author under local/regional anesthesia from 1988 to 1993, with patients added prospectively to the database thereafter, with the intention of discharge on the day of surgery. Setting: Columbia University College of Physicians and Surgeons, New York, New York.Participants: Consecutive patients undergoing thyroid surgery from 1988 to 1997 under local/regional anesthesia.Results: The patients were divided into 3 groups based on surgery date: Group A from 1988 to 1993, Group B from 1993 to 1996, Group C from 1996 to 1998.Groups A, B, and C had 40, 70, and 93 patients, respectively, for a total n of 203. The records were assessed for type of surgery, operative time, duration of hospital stay, and complications to include anesthetic complications, hypocalcemia, nerve injury, wound infection, mortality, and reoperation for bleeding. Although the groups were divided into smaller periods of time throughout the review, the numbers of patients in each group increased, showing a general increase in the number of patients receiving local/regional anesthesia per year. There is a slight trend away from thyroid lobectomy toward total thyroidectomy in the last group of thestudy. A trend of higher anesthesia class could be seen from Group A to Group C. Operative times were compared with patients undergoing general anesthetic from1996 to 1997. Overall times were increased by 25% when compared with patients undergoing general anesthesia. The duration of hospital stay ranged from 0.24 to 0.55 days, with the percentage of patients treated as outpatients (stay of less than 6 hours) rising steadily from 47% to 77% over the time of the study.Mortality was 0, and all complications together were 7%. The greatest percentage of complications (5%) was that of transient hypocalcemia. There was a 12% incidence of transient hypocalcemia in the patients undergoing total thyroidectmy. Complications of local anesthesia requiring conversion to general anesthesia were seen in 1%, and entirely in the earlier time period of the study. In addition, 1 patient suffered a permanent nerve injury and 2 required reoperation for bleeding. There were no wound infections.

Conclusions: The author has shown that patients undergoing thyroid surgery can be safely operated on with local/regional anesthesia. Low complication rates are shown in this series, and they are comparable to that of general anesthesia. In his experience, 70% of patients chose local anesthesia when offered, and patient satisfaction with local anesthesia was reported as near universal. The increase in operative time is attributed to patient intolerance to pressure, which limited the speed of dissection; however, this increase was offset by the elimination of induction and wakeup from general anesthesia. In the hands of these thyroid surgeons, outpatient thyroid surgery (6-hour hospital stay) was safe.

Ultrasound Med Biol. 2013 Jun;39(6):981-6. doi: 10.1016/j.ultrasmedbio.2013.01.002. Epub 2013 Mar 15.Combination of high-resolution ultrasound-guided perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block for carotid surgery.Rössel T, Kersting S, Heller AR, Koch T.SourceDepartment of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany. thomas.roessel@uniklinikum-dresden.deAbstractAll previously documented regional anesthesia procedures for carotid artery surgery routinely require additional local infiltration or systemic supplementation with opioids to achieve satisfactory analgesia because of the complex innervation of the surgical site. Here, we report a reliable ultrasound-guided anesthesia method for carotid artery surgery. High-resolution ultrasound-guided regional anesthesia using a 12.5-MHz linear ultrasound transducer was performed in 34 patients undergoing carotid endarterectomy. Anesthesia consisted of perivascular regional anesthesia of the internal carotid artery and intermediate cervical plexus block. The internal carotid artery and the nerves of the superficial cervical plexus were identified, and a needle was placed dorsal to the internal carotid artery and directed cranially to the carotid bifurcation under ultrasound visualization. After careful aspiration, local anesthetic was spread around the internal carotid artery and the carotid bifurcation. In the second step, local anesthetic was injected below the sternocleidomastoid muscle along the previously identified nerves of the intermediate cervical plexus. The necessity for intra-operative supplementation and the conversion rate to general anesthesia were recorded. Ultrasonic visualization of the region of interest was possible in all cases. Needle direction was successful in all cases. Three to five milliliters of 0.5% ropivacaine produced satisfactory spread around the carotid bifurcation. For intermediate cervical plexus block, 10 to 20 mL of 0.5% ropivacaine produced sufficient intra-operative analgesia. Conversion to general anesthesia because of an incomplete block was not necessary. Five cases required additional local infiltration with 1% prilocaine (2-6 mL) by the surgeon. Visualization with high-resolution ultrasound yields safe and accurate performance of the block. Because of the low rate of intra-operative supplementation, we conclude that the described ultrasound-guided perivascular anesthesia technique is effective for carotid artery surgery.Copyright © 2013 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

Tex Heart Inst J. 2010;37(3):297-300.Carotid endarterectomy with intermediate cervical plexus block.Barone M, Diemunsch P, Baldassarre E, Oben WE, Ciarlo M, Wolter J, Albani A.SourceDepartment of Anesthesia & Perioperative Medicine, Umberto Parini Hospital, Aosta 11100, Italy. marco.barone@yahoo.itAbstractDuring carotid endarterectomy, the use of locoregional anesthesia to achieve a combined superficial and deep cervical plexus block can cause cardiovascular, respiratory, and neurologic complications. Seeking to reduce risk and find an easier procedure, we applied locoregional anesthesia and an intermediate cervical plexus block in a series of patients who underwent carotid endarterectomy. From 2006 through 2007, 183 patients underwent primary carotid endarterectomy at our hospital. Mean age was 75.9 +/- 9.9 yr; mean body mass index, 27.3 +/- 6.7 kg/m(2); and median American Society of Anesthesiologists physical status classification, P3 (range, P2-P4). All procedures combined an intermediate cervical plexus block with subcutaneous infiltration of the incision line. We inserted a 15-mm, 25G needle to its full length, perpendicular to the skin along the posterior border of the sternocleidomastoid muscle, midway between the mastoid process and the clavicle. We injected 10 mL of 0.75% ropivacaine solution for 3 to 5 minutes. This block was systematically combined with subcutaneous infiltration of the incision line with the ropivacaine (0.75%, 10 mL), and sometimes also with 2% topical lidocaine intraoperatively. If necessary, intraoperative sedation, analgesia, or both were given to patients to improve their compliance. Intraoperative topical lidocaine was required in 59 patients (32.2%), and intravenous midazolam, fentanyl, or both were required in 29 patients (15.8%). Two procedures were converted to general anesthesia (1.1%). No perioperative deaths or complications occurred. Postoperatively, 2 patients experienced strokes and 1 sustained a myocardial infarction (total rate, 1.6%). We found the intermediate cervical plexus block to be feasible, effective, and safe, with low perioperative and postoperative complication rates. Herein, we report our findings.KEYWORDS: Anesthesia/methods/utilization, cervical plexus, endarterectomy, carotid/adverse effects/methods, injections, intramuscular, nerve block/adverse effects/methods, safety, treatment outcome

Br J Anaesth. 2007 Aug;99(2):159-69. Epub 2007 Jun 18.Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications.Pandit JJ, Satya-Krishna R, Gration P.SourceNuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK. jaideep.pandit@physiol.ox.ac.ukAbstractCarotid endarterectomy is commonly conducted under regional (deep, superficial, intermediate, or combined) cervical plexus block, but it is not known if complication rates differ. We conducted a systematic review of published papers to assess the complication rate associated with superficial (or intermediate) and deep (or combined deep plus superficial/intermediate). The null hypothesis was that complication rates were equal. Complications of interest were: (1) serious complications related to the placement of block, (2) incidence of conversion to general anaesthesia, and (3) serious systemic complications of the surgical-anaesthetic process. We retrieved 69 papers describing a total of 7558 deep/combined blocks and 2533 superficial/intermediate blocks. Deep/combined block was associated with a higher serious complication rate related to the injecting needle when compared with the superficial/intermediate block (odds ratio 2.13, P = 0.006). The conversion rate to general anaesthesia was also higher with deep/combined block (odds ratio 5.15, P < 0.0001), but there was an equivalent incidence of other systemic serious complications (odds ratio 1.13, P = 0.273; NS). We conclude that superficial/intermediate block is safer than any method that employs a deep injection. The higher rate of conversion to general anaesthesia with the deep/combined block may have been influenced by the higher incidence of direct complications, but may also suggest that the superficial/combined block provides better analgesia during surgery.

Eur J Vasc Endovasc Surg. 2007 Jan;33(1):50-4. Epub 2006 Sep 8.The superficial cervical plexus block for postoperative pain therapy in carotid artery surgery. A prospective randomised controlled trial.Messner M, Albrecht S, Lang W, Sittl R, Dinkel M.SourceDepartment of Anesthesiology, Friedrich-Alexander Universität, Erlangen, Germany. messner@gmx.liAbstractOBJECTIVES: Rapid and reliable neurological evaluation soon after carotid artery surgery is feasible with modern methods of general anesthesia, but postoperative pain therapy remains a challenge. Use of opioids can mask neurological deficits. We investigated whether superficial cervical plexus block reduced postoperative opioid consumption after carotid endarterectomy.DESIGN: Prospective, randomised, double-blinded, placebo controlled trial.METHODS: 46 patients undergoing unilateral carotid endarterectomy under general anesthesia were randomized to either superficial cervical block with ropivacaine (n=23) or placebo (n=23). A patient controlled analgesia device (PCA) delivering morphine was provided for all patients. Subjective pain levels (visual analog scale, VAS) were recorded. The primary outcome was total morphine consumption on discharge from the recovery room. Secondary outcomes included arterial pCO2 (as an indicator of central nervous effects of morphine) and patient satisfaction.RESULTS: No adverse effects of the superficial cervical plexus block were reported. Four patients in the placebo group were excluded because of other drug use post-operatively. Per protocol analysis compared 23 patients in ropivacaine group and 19 patients in the placebo group. The ropivacaine group had a significant reduction in morphine consumption (3.8+/-2.0 versus 12.9+/-4.0, p<0.001), lower maximal pain scores (2.6+/-2.0 versus 5.8+/-1.6, p<0.001), and paCO2 levels (39.0+/-2.6 versus 41.9+/-3.4, p=0.008) at discharge from the recovery room. Patient satisfaction (1=very good to 6=insufficient) was substantially higher in the ropivacaine group (1.7+/-0.7 versus 3.1+/-1.2, p<00.01).CONCLUSION: The significant and clinically relevant lower morphine consumption and pain score, as well as the substantially higher patient satisfaction demonstrate that superficial cervical plexus block provides effective pain relief for patients undergoing carotid endarterectomy.

World J Surg. 2010 Oct;34(10):2338-43. doi: 10.1007/s00268-010-0698-7.Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations.Shih ML, Duh QY, Hsieh CB, Liu YC, Lu CH, Wong CS, Yu JC, Yeh CC.SourceDivision of General Surgery, Department of Surgery, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC. judeshih@gmail.comAbstractBACKGROUND: We investigated the analgesic efficacy of bilateral superficial cervical plexus block in patients undergoing thyroidectomy and to determine whether it reduces the adverse effects of general anesthesia.METHODS: We prospectively recruited 162 patients who underwent elective thyroid operations from March 2006 to October 2007. They were randomly assigned to receive a bilateral superficial cervical block (12 ml per side) with isotonic saline (group A; n = 56), bupivacaine 0.5% (group B; n = 52), or levobupivacaine 0.5% (group C; n = 54) after induction of general anesthesia. The analgesic efficacy of the block was assessed with: intraoperative anesthetics (desflurane), numbers of patients needing postoperative analgesics, the time to the first analgesics required, and pain intensity by visual analog scale (VAS). Postoperative nausea and vomiting (PONV) for 24 h were also assessed by the "PONV grade." We also compared hospital stay, operative time, and discomfort in swallowing.RESULTS: There were no significant differences in patient characteristics. Each average end-tidal desflurane concentration was 5.8, 3.9, and 3.8% in groups A, B, and C, respectively (p < 0.001). Fewer patients in groups B and C required analgesics (A: B: C = 33:8:7; p < 0.001), and it took longer before the first analgesic dose was needed postoperatively (group A: B: C = 82.1:360.8:410.1 min; p < 0.001). Postoperative pain VAS were lower in groups B and C for the first 24 h postoperatively (p < 0.001). Incidences of overall and severe PONV were lower, however, there were not sufficient numbers of patients to detect differences in PONV among the three groups. Hospital stay was shorter in group B and group C (p = 0.011). There was no significant difference in operative time and postoperative swallowing pain among the three groups.CONCLUSIONS: Bilateral superficial cervical plexus block reduces general anesthetics required during thyroidectomy. It also significantly lowers the severity of postoperative pain during the first 24 h and shortens the hospital stay.

Semin Cardiothorac Vasc Anesth. 2010 Mar;14(1):49-50. doi: 10.1177/1089253210363010.Postoperative recovery advantages in patients undergoing thyroid and parathyroid surgery under regional anesthesia.Suri KB, Hunter CW, Davidov T, Anderson MB, Dombrovskiy V, Trooskin SZ.SourceUMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.AbstractThyroid or parathyroid surgery may be performed using general anesthesia or regional anesthesia. Ninety-five (95) patients underwent thyroid or parathyroid surgery using general anesthesia (n=64) or bilateral superficial cervical plexus block with sedation (n=31) and completed a postoperative questionnaire regarding the perioperative experience. Patients undergoing parathyroid surgery under regional anesthesia (n=24) were more likely to experience better energy levels (p=0.012) and earlier return to work (p=0.045) postoperatively. Overall, 96% of patients undergoing either type of surgery with either type of anesthetic reported satisfaction with the anesthetic.

Kathmandu Univ Med J (KUMJ). 2009 Jul-Sep;7(27):242-5.Cervical epidural anaesthesia for thyroid surgery.Khanna R, Singh DK.SourceDepartment of Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. dr_rahul_khanna@rediffmail.comAbstractBACKGROUND: Cervical epidural anaesthesia is a regional anaesthesia technique which has been used for upper limb surgery, upper thoracic wall surgery, carotid artery surgery and neck dissections. Anaesthesia for thyroid surgery can be complicated due to the altered functional status of the thyroid or its large size.OBJECTIVE: This prospective study was designed to assess the effectiveness and safety of cervical epidural anaesthesia for thyroid surgery.MATERIALS AND METHODS: Cervical epidural anaesthesia was attempted in 9 patients and the results compared with 44 patients who underwent thyroid surgery under conventional general anaesthesia with endotracheal intubation. The epidural catheter was placed in the C(7) - T(1) vertebral interspace and 10 - 15 ml of 1% Lignocaine with adrenaline was injected.RESULTS: The technique of cervical epidural anaesthesia was successfully used in 8 out of 9 patients in whom it was attempted All patients were maintained in a state of conscious - sedation and effective analgesia was obtained in all 8 patients. There were no significant complications especially those related to diaphragmatic function and cardiovascular stability. In contrast patients undergoing surgery under conventional general anaesthesia had complications related to endotracheal intubation, cardiac arrhythmias and hypotensionCONCLUSION: The technique of cervical epidural anaesthesia should be considered in thyroid patients where difficult endotracheal intubation is anticipated and in those in whom alterations in thyroid functional state make them vulnerable to cardiovascular complications under conventional general anaesthesia.

Thyroid. 2012 Jan;22(1):44-52. doi: 10.1089/thy.2011.0260. Epub 2011 Dec 5.Bilateral superficial cervical plexus block in combination with general anesthesia has a low efficacy in thyroid surgery: a meta-analysis of randomized controlled trials.Warschkow R, Tarantino I, Jensen K, Beutner U, Clerici T, Schmied BM, Steffen T.SourceDepartment of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland.AbstractBACKGROUND: A combination of bilateral superficial cervical plexus block (BSCPB) and general anesthesia is recommended for thyroid surgery. Proof of the efficacy of this combination remains weak. Furthermore, data on the safety of this regimen are lacking. Therefore, a meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy and safety of BSCPB as an adjunct to general anesthesia in patients receiving thyroid surgery was performed.METHODS: A meta-analysis of RCT was performed that included interventional groups evaluating the efficacy of BSCPB 6 and 24 hours after thyroid surgery.RESULTS: Eight RCT, including a total of 799 patients (463 who underwent BSCPB and 336 controls), were analyzed. A meta-analysis demonstrated a reduction in pain scores 6 hours (Hedges' g: -0.46 [95% CI: -0.74 to -0.19]; p=0.001) and 24 hours postoperatively (Hedges' g: -0.49 [95% CI: -0.71 to -0.27]; p<0.001) in patients who had undergone BSCPB. The relative risk for postoperative nausea and vomiting (PONV) was 0.80 (95% CI: 0.58 to 1.09, p=0.159) in patients receiving BSCPB. Procedure-related adverse events were reported in three of the 476 patients who had undergone BSCPB (0.6%; 95% CI: 0.1% to 2.0%). These three patients had transient paresis of the brachial plexus, combined with a diaphragmatic paresis in one case, and all spontaneously resolved.CONCLUSION: The combination of BSCPB and general anesthesia has a significant benefit in reducing pain 6 and 24 hours after thyroid surgery. However, the effect on pain reduction is too small to be of clinical relevance. Although it is a safe procedure, the existing evidence allows for no recommendation concerning the application of BSCPB in thyroid surgery. Further trials should evaluate a dose-response relationship and the incidence of PONV with this regimen.

Surgical Utility Anterior shoulder Acromioclavicular joint Clavicle Anterior neck (thyroid, carotid, etc.) Mastoid Auricular

Case 72 yo African male with symptomatic

hypercalcemia secondary to hyperparathyroidism

ROS: CAD with 2 vessel fixed stenosis, CHF EF 30-35%, Multiple CVAs (most recent 3 months ago)

Vitals: normal Surgery: Right parathyroidectomy

Case Pre-procedure – versed 1mg Procedure – Right intermediate cervical

plexus 10 ml Ropivicaine 0.75%, Right SCP 10 mL Ropivicaine 0.75%

Sugery: Propofol 25 mcg/kg/min Surgeon had to supplement twice (once

when he crossed the midline and the second at the posterior/inferior aspect of the thyroid)

Post-procedure – Pain 0/10

Questions?