Ultrasound-guided Intermediate Cervical Plexus Block Research Articles

The efficacy and safety of opioid-free anesthesia combined with ultrasound-guided intermediate cervical plexus block vs. opioid-based anesthesia in thyroid surgery—a randomized controlled trial

PurposeIn the context of the current comfort medicine and enhanced recovery after surgery, there is a demand for a new anesthesia method to reduce adverse reactions and accelerate recovery after surgery. This randomized controlled trial aimed to compare the efficacy and safety between opioid-free anesthesia (OFA) combined with ultrasound-guided intermediate cervical plexus block (ICPB) and opioid-based anesthesia in patients after thyroid surgery.MethodsIn this study, 75 patients scheduled for thyroid surgery under general anesthesia were randomly allocated into two groups. The primary outcome included the incidence of nausea within 24 h after surgery. The main secondary outcomes included the incidence of vomiting and the visual analog score (VAS) scores within 24 h after surgery as well as the quality of recovery 40 questionnaires (QoR-40) scores 24 h after surgery.ResultsIn the OFA group, the incidence of postoperative nausea was 6.1%, compared to 39.4% in the control group (p = 0.001). No patient presented with postoperative vomiting in the OFA group, while 15.2% of patients suffered from postoperative vomiting in the control group (p = 0.063). The VAS scores of patients in the postanesthetic care unit (PACU) and 2 h, 4 h, and 6 h after surgery were lower in the OFA group, and the difference is statistically significant. Besides, the VAS scores of patients at rest (p = 1.000) and during swallowing (p = 1.000) 24 h after surgery were comparable.ConclusionCompared with opioid-based anesthesia, the OFA combined with the ultrasound-guided ICPB can better improve patients' postoperative recovery, reduce nausea, and decrease pain scores.Trial registrationChinese Clinical Trial Regisrty, ChiCTR2200056344, https://www.chictr.org.cn

Comparison of Bilateral Ultrasound-Guided Intermediate Cervical Plexus Block vs Local Wound Infiltration for Postoperative Analgesia in Patients Undergoing Total Thyroidectomy

Abstract Background The thyroid gland surgery is a common and painful procedure demanding analgesia. Bilateral intermediate cervical plexus block (BSCPB) could be beneficial for analgesia in thyroid surgery. In this study we will evaluate the analgesic efficacy of ultrasound guided intermediate cervical plexus block vs local wound infiltration in patients undergoing elective thyroidectomy under general anaesthesia. Objective To evaluate the analgesic efficacy and possible side effects of ultrasound guided intermediate cervical plexus block vs local wound infiltration in patients undergoing elective thyroidectomy under general anaesthesia as a primary outcome. The secondary outcome is the assessment of the safety of ICPB and the total dose of meperidine used for 24 hours postoperatively. Patients and Methods 40 patients were divided into two equal groups: Group A: The patients received intermediate cervical plexus block with 10 ml of 0.25% bupivacaine. The same will be repeated on the contralateral side. Group B: Patient will receive local wound infiltration with 20 ml bupivacaine 0.25% under the skin immediately before extubation by the surgeon for pain control. Results ICPB group showed significant lower median score compared with LWI group at time 2 hrs, 4 hrs, 6 hrs, 12 hrs The time for first dose meperidine was significantly longer in ICPB group (17.2 ± 3.02 vs 10.15 ± 1.84) while Total 24 h meperidine consumption was significantly less in ICPB (26.25 ± 17.16 vs 36.25 ± 12.76) Conclusion Intermediate cervical plexus block provides another safe alternative analgesia compared to superficial blocks and local wound infiltration with better analgesic efficacy.

Effect of different modes of administration of dexmedetomidine on the quality of recovery in ambulatory thyroidectomy: a randomized, controlled trial

To compare the effects of two different administration methods of dexmedetomidine (DEX) used as an adjuvant to ropivacaine in ultrasound-guided bilateral intermediate cervical plexus block (CPB) in terms of efficacy and the duration of postoperative analgesia in patients undergoing ambulatory thyroidectomy. This double-blind, randomized study enrolled patients who underwent thyroidectomy with ultrasound-guided bilateral intermediate CPB. Patients were randomized to receive either perineural administration of dexmedetomidine (group DP) or intravenous pumping of dexmedetomidine (group DI). The 40-item Quality of Recovery (QoR-40) questionnaire was used to assess the primary endpoint, which was the global QoR-40 score 24 h after the operation. Sixty patients were randomized equally into the two groups. The total QoR-40 score 24 h postoperatively was significantly higher in group DP than group DI (160.6 ± 9.1 versus 152.8 ± 7.9, respectively). Dimensions of physical comfort and pain scores were significantly higher in group DP than group DI. The visual analogue scale pain score scores were significantly lower in group DP than group DI at 12 and 24 h postoperatively. DEX as an adjuvant to ropivacaine in ultrasound-guided intermediate CPB can improve the QoR-40 score and prolong postoperative analgesia.Trial registration number: ChiCTR2000031264 at www.chictr.org.cn on 26 March 2020.

Effect of adding dexmedetomidine to bupivacaine during superficial combined with ultrasound-guided intermediate cervical plexus block in total thyroidectomy

Effect of adding dexmedetomidine to bupivacaine during superficial combined with ultrasound-guided intermediate cervical plexus block in total thyroidectomy

Regional Anesthesia for Clavicle Fracture Surgery- What is the Current Evidence: A Systematic Review

Introduction: The sensory innervation of the clavicle remains controversial. It might come from both the cervical plexus and brachial plexus. Peripheral nerve blocks used to anesthetize the clavicle include cervical plexus blocks, brachial plexus blocks, and combined cervical and brachial plexus blocks. Objectives: The review was to determine whether there is a difference in pain scores and pain medication consumption intraoperatively and postoperatively among these blocks. Secondary endpoints were block success and serious adverse events. Methods: A comprehensive literature search of PubMed and Web of Science was performed. Only English-written randomized controlled studies were included. Results: Compared with patients with general anesthesia, patients with combined ultrasound-guided superficial cervical and interscalene brachial plexus block spent a shorter time in PACU (35.60 ± 5.59 min vs. 53.13 ± 6.95 min, P < 0.001), had a more extended pain-free period (324.67 ± 41.82 min vs. 185.27 ± 40.04 min, P < 0.001), and received less opioid consumption (Tramadol 213.33 ± 57.13 mg vs. 386.67 ± 34.57 mg, P < 0.001) in first 24 h postoperatively. Compared with patients with ultrasound-guided superficial cervical and interscalene brachial plexus block, patients with ultrasound-guided intermediate cervical and interscalene brachial plexus block had a higher success rate (100% vs. 80%) and longer duration of post-operative analgesia (7.5±0.8 h vs. 5.7± 0.4 h, P<0.001). Without ultrasound guidance, patients with combined superficial, deep cervical, and interscalene brachial plexus block had a higher success rate (96% vs. 60%), lower pain score at two h postoperatively (1.96±0.17 vs. 3.22±0.88, p=0.000), and a more extended pain-free period (1h vs 6h) compared to combined superficial cervical and interscalene brachial plexus block. There were no regional anesthesia-related complications reported in all studies. Conclusion: Patients with regional anesthesia have a more significant pain-free period and less intraoperative and postoperative opioid consumption than patients with general anesthesia. Combined intermediate or deep cervical plexus and Interscalene brachial plexus blocks provide better analgesia than combined superficial cervical plexus and Interscalene brachial plexus blocks. Ultrasound guidance improved the success rate of regional anesthesia. Combined cervical plexus and brachial plexus block can be used as sole anesthesia for clavicle fracture surgery.

Ultrasound-guided intermediate cervical plexus block for postoperative analgesia in patients undergoing carotid endarterectomy under general anesthesia: a case-control study

Aim: The aim of this study is to compare intravenous analgesia (IVA) and intermediate cervical plexus block (ICPB) in terms of acute pain scores and opioid consumption in patients undergoing carotid endarterectomy (CEA) under general anesthesia.
 Materials and methods: Following the induction of anesthesia, dexketoprofen trometamol 50 mg was administered before the surgical incision, and paracetamol 1 g was given at the end of the surgery and continued at 6 hour intervals for group IVA. Whereas, ultrasound-guided intermediate cervical plexus block was performed in ICPB group. VAS scores, morphine consumption, length of stay, and patient satisfaction status were compared.
 Results: A total of 109 patients (57 in the IVA group and 52 in the ICPB group) between January 2015 and June 2021 were enrolled. The mean VAS score after extubation was significantly lower in the ICPB group (4.1±1.4 vs 1.2±0.8, p = 0.005). Total morphine consumption was found to be significantly lower in the ICPB group (13.1±4.4 mg vs 3.9±2.4 mg, p < 0.001). The hospital stay was 3.1±1.3 days in the IVA group, while it was 2.2±0.9 days in the ICPB group (p = 0.0014). The patients in the ICPB group were found to be significantly more satisfied (3.4±1.4 vs 1.2±0.8, p < 0.001).
 Conclusion: Intermediate cervical plexus block provides lower acute pain scores and lower opioid consumption compared to intravenous analgesia in patients undergoing CEA under general anesthesia. In addition, this combined technique shortens the ICU and hospital length of stay and improves patient satisfaction.

Efficacy of Ultrasound-Guided Intermediate Cervical Plexus Block by Anterior Route for Perioperative Analgesia in Robotic Thyroidectomy by Retroauricular Approach: A Case Series.

Retroauricular or facelift approach for robotic thyroidectomy involves a long incision with extensive subcutaneous dissection causing severe pain and discomfort. Multimodal analgesic regimen with inclusion of intermediate cervical plexus block by anterior route provided excellent perioperative analgesia without affecting recurrent laryngeal nerve monitoring in 10 cases. All the patients were monitored with bispectral index (maintained 40-60) and extubated on table. Median numeric pain rating scale score in 24 hours postoperatively was 3. None of the cases had any significant complications on follow-up.

The effect of adding dexamethasone to the ultrasound-guided intermediate cervical plexus block in thyroidectomy: A double-blind randomized controlled study

Background: A bilateral superficial cervical plexus block provides good analgesia for neck surgery, including thyroidectomy. However, the duration of a single shot nerve block is usually short. Therefore, adjuvants are used in peripheral nerve blocks, especially with ambulatory surgery, where the analgesia duration is very important. Methods: Sixty patients scheduled for thyroidectomy were randomly assigned to one of two groups. Group C received general anesthesia and a bilateral intermediate cervical plexus block with isobaric 10 ml bupivacaine 2% + 2 ml NS deposited on each side. Group D received general anesthesia and bilateral intermediate cervical plexus block with 10 ml isobaric bupivacaine 2% + 4 mg (2 ml) dexamethasone deposited on each side. Primary outcome was postoperative analgesia evaluated by the VAS score. Secondary outcomes were perioperative IL6, blood glucose level, and postoperative nausea and vomiting. Results: Postoperative pain VAS scores were significantly lower in the dexamethasone group than control group; mean VAS score at 6 h postoperatively was 0.4 in Group D vs. 1.8 in Group C; P <0.001, at 8 h it was 0.4 vs. 2.6; P <0.001 in Group D and C, respectively, and in 24 h it was 3.5 in Group D vs. 5 in Group C; P 0.003. Analgesia duration was significantly longer in the dexamethasone group: 12 h versus 6 h in the control group; P<0.001. Postoperative IL-6 at 8 and 24 h postoperatively were significantly lower in the dexamethasone group than the control group (36.8 vs 21; P <0.001) and (18.9 vs 13; P<0.001), respectively. Non-significant changes could be detected between both groups in intraoperative bleeding and postoperative glycemic control. Conclusion: The addition of 8 mg dexamethasone to ultrasound-guided intermediate cervical plexus block can enhance analgesia duration and reduce postoperative opioid consumption and postoperative IL-6 levels with no significant effect on postoperative glycemic control in non-diabetic patients undergoing thyroidectomy under general anesthesia.

Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture

Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture

Ultrasound-Guided Intermediate Cervical Plexus Block for Transcarotid Transcatheter Aortic Valve Replacement

To report the authors' initial experience of transcarotid transcatheter aortic valve replacement (TAVR) managed with ultrasound-guided intermediate cervical plexus block. A single-center prospective study. A teaching hospital in Paris, France. All consecutive patients undergoing a transcarotid TAVR were included. The ultrasound-guided intermediate cervical plexus block was performed in 28 of 31 patients. In 3 patients, the procedure was scheduled under general anesthesia: 2 because of failure of previous transfemoral procedures under local anesthesia, and 1 for an emergency procedure in a pulmonary edema context. Anesthesia and all perioperative parameters were recorded, as well as any complications after the procedure. Twenty-eight patients were managed with intermediate cervical plexus block and light sedation without any anesthesia-related complication. No conversion to general anesthesia was required. The use of vasopressor was only required in 11% of the patients. In 2 patients, a loss of consciousness after the common carotid artery cross-clamping test occurred, leading to the use of a temporary femoral-carotid shunt; no other change in consciousness was recorded during the procedure. Ultrasound-guided intermediate cervical plexus block appeared to be an alternative anesthetic technique for carotid TAVR, providing adequate surgical conditions, continuous neurologic monitoring, and arterial pressure stability.

Intermediate Cervical Plexus Block in the Management of Persistent Postoperative Pain Post Carotid Endarterectomy: A Prospective, Randomized, Controlled, Clinical Trial

Background: The mechanisms of persistent postoperative pain (PPP) with neuropathic features after carotid endarterectomy (CEA) are multifaceted and are incompletely understood. Objectives: The aim of this research was to assess whether the ultrasound-guided (USG) intermediate cervical plexus block (ICPB) could provide better control of PPP and neuropathic disturbances (NPDs) after CEA than the USG superficial cervical plexus block (SCPB). Study Design: Prospective, randomized, controlled, clinical trial. Setting: This clinical trial was conducted at the SS Filippo and Nicola Academic Hospital of Avezzano (L’Aquila, Italy). Methods: Patients who were scheduled for primary CEA were chosen. In the experimental group, the USG-ICPB was performed unilaterally, at the level of the third cervical vertebra. The needle was inserted into the deep lamina of the deep fascia of the neck, between the posterior border of the middle scalene muscle and the anterior border of the posterior scalene muscle. Three milliliters saline solution was injected into the opening of the deep lamina, and 20 mL 0.375% levobupivacaine was injected. In the control group, the anesthetic target was located at the inferior border of the sternocleidomastoid muscle at the level of the third cervical vertebra. The needle was superficially inserted below the skin, and 2 to 3 mL saline solution was injected into the opening of the superficial lamina of the deep fascia of the neck. A total of 20 mL 0.375% isobaric levobupivacaine was subsequently injected. The primary outcome measure was the proportion of patients with PPP on movement and at rest 3 months after surgery. The secondary outcome measures were NPD assessment scores using the von Frey hair test and the Lindblom test, opioid and pregabalin consumption. Adverse effects were also recorded. Results: A total of 98 consecutive patients were enrolled and randomized to receive either a USGSCPB (control group, n = 49) or a USG-ICPB (experimental group, n = 49). The sensory blockade was longer in the experimental group. Three months after surgery, the proportions of patients with PPP on movement were significantly different between the experimental and control groups (33%, 95% confidence intervals [CI], 20%-47% vs. 71%, 95% CI, 57%-83%; P &lt; 0.001), whereas there were no differences in the proportions of patients with pain at rest between groups (31%, 95% CI, 18%-45% vs. 49%, 95% CI, 34%-64%; P = 0.063). The proportions of patients with NPDs were not different between the groups, whereas the sizes of the areas of interest (cm2 ) were significantly different. Limitations: A limitation of this study is that we assessed NPDs for only 3 months using the von Frey hair test and the Lindblom test without additional instrumental techniques. Additionally, there are many risk factors for NPDs after CEA. For this reason, another limitation of this research is that we neglected to consider the relationship between the choice of anesthetic block and the presence of these risk factors.Conclusions: The USG-ICPB provided long-lasting analgesia during the postoperative period and might mitigate the development of NPDs, thereby decreasing the analgesic drug requirement. Key words: Carotid endarterectomy, intermediate cervical plexus block, myofascial planes of neck, neuropathic disturbances, persistent postoperative pain, superficial cervical plexus blocks, ultrasound guidance, vascular disease

Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study.

An intermediate cervical plexus block (CPB) targets the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. The phrenic nerve descends obliquely on the surface of the anterior scalene muscle beneath the prevertebral fascia after originating from the C3-C5 ventral rami. Therefore, the phrenic nerve can be affected by a local anesthetic during an intermediate CPB, depending on the permeability characteristics of the prevertebral fascia. This study investigated whether an intermediate CPB affects the phrenic nerve, inducing hemidiaphragmatic paresis. In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2ml/kg) was performed at the C4-5 intervertebral level carefully, without penetrating the prevertebral fascia, before the patient emerged from general anesthesia. Diaphragmatic motions of the block side were measured by M-mode ultrasonography at three time points: before anesthesia (baseline) and at 30 and 60min after the intermediate CPB. Hemidiaphragmatic paresis was divided into three grades, depending on the percentage of diaphragm movement compared to the baseline: none (> 75%), partial paresis (25-75%), and complete paresis (< 25%). No patient showed any partial or complete ipsilateral hemidiaphragmatic paresis within 60min after the intermediate CPB. Intermediate CPB using 0.2ml/kg of 0.25% ropivacaine at the C4-5 intervertebral level did not cause ipsilateral hemidiaphragmatic paresis. This may imply that the effect of the intermediate CPB on the phrenic nerve is not significant.

Ultrasound-guided intermediate cervical plexus and additional peripheral facial nerve block for carotid endarterectomy : Aprospective pilot study.

Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus. An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group1: no perivascular infiltration, n = 14, group2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects. The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group2 significantly decreased the total amount of local anesthetic supplemented: group1 M = 4.2 ml (SD = ±3.1 ml), group2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups. This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Postoperative Analgesic Effect of Ultrasound-Guided Intermediate Cervical Plexus Block on Unipolar Sternocleidomastoid Release With Myectomy in Pediatric Patients With Congenital Muscular Torticollis: A Prospective, Randomized Controlled Trial.

Unipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM. Thirty-two patients (1-7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward. The FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1-7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 μg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups. Ultrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM. This study was registered at ClinicalTrials.gov, identifier NCT02651311.

Ultrasound-guided intermediate cervical plexus block and perivascular local anesthetic infiltration for carotid endarterectomy : Arandomized controlled trial.

Ultrasound-guided blocks of the cervical plexus are established anesthetic procedures for carotid endarterectomy. This randomized, double-blind, placebo-controlled study tested the hypothesis that an additional ultrasound-guided periarterial injection of local anesthetic leads to alower frequency of periarterial supplementation by the surgeon. Atotal of 40patients were randomly assigned to 1 of 2 groups. In both groups an ultrasound-guided intermediate cervical plexus block (20ml of 0.75 % ropivacaine) at the level of the fourth cervical vertebra was performed. In asecond step, the needle was inserted from posterolateral to anteromedial (in-plane technique) relative to the internal carotid artery and then, depending on the randomized group assignment, 5ml of 0.75 % ropivacaine (group2) or 5ml of 0.9 % saline (group1) was injected. The parameters investigated included the need for supplementation, patient comfort, the incidence of side effects and circulatory changes. The two groups did not significantly differ (p= 0.459) in terms of the need for intraoperative supplementation with 1 % prilocaine with a mean (range) in group2 of 4.9ml (0-20ml), in group1 of 3.7ml (0-16ml) and patient comfort (p= 0.144). In addition, atrend towards ahigher complication rate was observed in group2. For ultrasound-guided intermediate blocks of the cervical plexus, an additional periarterial infiltration showed no advantage. Abandoning this technique leads to arelevant simplification of the blocking technique and tends to reduce block-related side effects.

Ultrasound-Guided Intermediate Cervical Plexus Block. Anatomical Study

Ultrasound-Guided Intermediate Cervical Plexus Block. Anatomical Study

Safety and efficiency of ultrasound-guided intermediate cervical plexus block for carotid surgery

ObjectiveSince stroke and myocardial ischaemia are major causes of perioperative morbidity and mortality associated with carotid endarterectomy, monitoring the brain and ensuring the best haemodynamic stability are important goals of the management. As regional anaesthesia was reported to improve haemodynamic stability during carotid endarterectomy (CEA), we conducted a prospective observational study on the efficacy and safety of ultrasound-guided intermediate cervical plexus blocks (CPB), with early (immediate postoperative) and mid-term (day 30) outcomes in awake patients undergoing CEA. MethodsAfter the ethics committee approval, 50 patients undergoing a carotid endarterectomy with CPB from April 2011 to May 2013 were included. Anaesthesia and surgical dissection parameters, early complications and haemodynamic stability were recorded, as well as neurologic and cardiac outcomes initially and one month later. ResultsCervical space was easy to locate by ultrasound in 90% of the patients. The quality of anaesthesia and surgical dissection was good in 86 and 88% of patients, respectively. No conversion to GA was required, secondary to a lack of analgesia. Two patients (4%) had severe hypotension (<100mmHg). Three patients required a shunt after carotid clamping for loss of consciousness with a favourable neurological outcome. We observed one elevation of cTnI (0.95ng·ml−1) without ECG change and 1 death occurred after a postoperative haemorrhagic stroke. ConclusionsThe present work reports our first 50 cases of intermediate CPB using ultrasound guidance. The results underline that this technique is easy to perform, safe and reliable, provided good surgical conditions with continuous intraoperative neurologic monitoring and stable haemodynamics are respected.

Ultrasound-guided intermediate cervical plexus block for carotid endarterectomy using a new anterior approach: a two-centre prospective observational study.

The aim of this prospective, double-centre, observational study performed in 116 patients was to describe a new anterior approach of ultrasound-guided intermediate cervical plexus block for carotid endarterectomy. The median (IQR [range]) volume of ropivacaine 0.5% administered was 30 (25-30 [20-45])ml. Supplemental local anaesthesia (infiltration and topical) was needed in 66 (57%) patients. Overall, 41 (35%) patients needed additional sedation (18 midazolam; 23 remifentanil). There was no intra-operative complication or systemic toxicity of ropivacaine. One regional anaesthesia procedure was converted to general anaesthesia because of patient agitation. Adverse effects were of short duration and did not affect surgery. Satisfaction scores were high for 92 (79%) patients (63 satisfied; 29 very satisfied) and 104 (90%) surgeons (51 satisfied; 53 very satisfied). This study shows that the ultrasound-guided intermediate cervical plexus block using an anterior approach is feasible and provides similar results to other regional techniques during carotid endarterectomy.

Ultrasound-Guided Deep or Intermediate Cervical Plexus Block

To the Editor On the basis of 28 cadaver dissections and injections in 2 volunteers, Usui et al.1 described an ultrasound-guided technique for blocking the deep cervical plexus and cervical sympathetic chain. Although we agree with the authors that these 2 neural structures, which are under the prevertebral fascia, may be theoretically both blocked with a single injection, we offer the following comments. First, the local anesthetic solution was deliberately injected into the longus capitis muscle of both volunteers. Intramuscular (IM) injections of local anesthetics may result in reversible myonecrosis and clinically relevant myopathy after nerve blocks of the neck and eye.2 Because the cervical sympathetic trunk is located posterior and lateral to the prevertebral fascia on the upper part of the longus colli muscle,3 a direct IM injection should be avoided, and a subfascial injection is recommended. Second, anatomical description and ultrasound image interpretations in their Figures 1 and 2 are quite confusing. In the schematic drawings, only the prevertebral layer (fascia) is drawn by the authors. On ultrasound images, the colored parts markedly overlap muscles and cover the connective tissue of the superficial cervical fascia, which is not drawn. In the posterolateral portion of the neck, this connective tissue is defined as the posterior cervical space.4 This space, deep to the sternocleidomastoid and trapezius muscles, and superficial to the prevertebral fascia, can be seen in their Figure 5. The posterior cervical space corresponds to the superficial cervical space described by Pandit et al.5 The superficial divisions of the cervical plexus cross this space, then cutaneous branches emerge from the posterior border of the sternocleidomastoid muscle. We suggest the technique promoting the lowest incidence of adverse events. The deep cervical plexus block can be difficult and risky because the needle is advanced to the spinal canal and vertebral artery. Pandit et al.5 reported the accuracy and safety of the superficial/intermediate cervical plexus block when compared with any technique using a deep injection.6 The main conclusion of this review is that the deep block is more than twice as likely to yield a serious life-threatening complication as a result of block placement than is the superficial block. An original technique of ultrasound-guided intermediate cervical plexus block is currently being studied in our institution. In brief, the needle is advanced in plane at the C4 level between the anterior border of elevator scapulae muscle and posterior border of the sternocleidomastoid muscle to reach the posterior cervical space in which the local anesthetic solution is injected (Fig. 1). For carotid surgery, the local anesthetic solution spreads towards the carotid sheath. Figure 1: A, Transverse sonogram of the lateral cervical area at the C4 level: the posterior cervical space is located between the sternocleidomastoid (SCM), elevator scapulae (ES), longus colli (LC), and scalene (SM) muscles. B, Technique of ultrasound-guided intermediate cervical plexus block: the needle is located in the posterior cervical space; the local anesthetic (LA) solution spreads towards the carotid sheath (green dashed line).Olivier Choquet, MD Christophe Dadure MD, PhD Xavier Capdevila, MD, PhD Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital and Montpellier 1 University Montpellier, France [email protected]