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