Clavicle fractures are common injuries that often require surgical intervention. Effective pain management is crucial for patient comfort and successful recovery. Regional anesthesia has become a preferred method for managing pain in clavicle fracture surgeries due to its ability to provide targeted pain relief while minimizing systemic side effects. This blog explores the current practices in regional anesthesia for clavicle fracture surgery, with a focus on the advantages of combining intermediate or deep cervical plexus blocks with interscalene brachial plexus blocks under ultrasound guidance.
The Role of Regional Anesthesia in Clavicle Fracture Surgery
Regional anesthesia offers several benefits over general anesthesia, including reduced opioid consumption, lower risk of systemic complications, and improved postoperative pain control. For clavicle fracture surgeries, regional anesthesia techniques such as the interscalene brachial plexus block and cervical plexus block are commonly used. These techniques target the nerves supplying the shoulder and upper chest, providing effective analgesia for the surgical site.
Interscalene Brachial Plexus Block
The interscalene brachial plexus block is a well-established technique for providing anesthesia and analgesia for shoulder and upper arm surgeries. This block targets the roots of the brachial plexus as they pass between the anterior and middle scalene muscles. By anesthetizing these nerves, the interscalene block effectively covers the surgical area for clavicle fracture repairs.
Cervical Plexus Block
The cervical plexus block can be performed at different levels, including the superficial, intermediate, and deep cervical plexus blocks. The deep cervical plexus block targets the cervical nerves (C2-C4) as they emerge from the cervical spine, providing anesthesia to the skin and muscles of the neck and upper shoulder. The intermediate cervical plexus block, on the other hand, targets the nerves as they pass through the deep cervical fascia.
Combining Interscalene and Cervical Plexus Blocks
Recent studies and clinical practices have highlighted the benefits of combining interscalene brachial plexus blocks with intermediate or deep cervical plexus blocks for clavicle fracture surgeries. This combination provides more comprehensive coverage of the surgical area, ensuring effective pain relief for both the shoulder and the upper chest.
A recent article, “Regional Anesthesia for Clavicle Fracture Surgery- What is the Current Evidence: A Systematic Review” provides recent data. This comprehensive literature search was conducted using PubMed and Web of Science, including only English-written randomized controlled trials. The primary outcomes were intraoperative and postoperative pain scores and opioid consumption. Secondary outcomes included block success rates and serious adverse events.
Results Summary
Combined Ultrasound-Guided Superficial Cervical and Interscalene Brachial Plexus Block:
PACU Time: Shorter (35.60 ± 5.59 min vs. 53.13 ± 6.95 min, P < 0.001)
Pain-Free Period: Longer (324.67 ± 41.82 min vs. 185.27 ± 40.04 min, P < 0.001)
Opioid Consumption: Lower (Tramadol 213.33 ± 57.13 mg vs. 386.67 ± 34.57 mg, P < 0.001)
Ultrasound-Guided Intermediate Cervical and Interscalene Brachial Plexus Block:
Success Rate: Higher (100% vs. 80%)
Duration of Analgesia: Longer (7.5 ± 0.8 h vs. 5.7 ± 0.4 h, P < 0.001)
Without Ultrasound Guidance:
Success Rate: Higher (96% vs. 60%)
Pain Score at 2 Hours Postoperatively: Lower (1.96 ± 0.17 vs. 3.22 ± 0.88, P = 0.000)
Pain-Free Period: Longer (6 h vs. 1 h)
No regional anesthesia-related complications were reported in any of the studies.
This data review concludes that a combination of intermediate or deep cervical plexus and interscalene brachial plexus blocks offer superior analgesia compared to superficial blocks. Ultrasound guidance enhances the success rate of regional anesthesia. These techniques can be effectively used as the sole anesthesia for clavicle fracture surgery.
For detailed information you can review the article here.
Combining these procedures
The combination of cervical plexus and brachial plexus blocks is used to achieve effective anesthesia for clavicle fracture surgery. The most common combinations include:
Superficial Cervical Plexus Block (SCPB) and Interscalene Brachial Plexus Block (ISB): This combination targets the sensory innervation from both plexuses, providing comprehensive anesthesia.
Intermediate Cervical Plexus Block (ICPB) and ISB: This approach offers a higher success rate and longer duration of analgesia compared to SCPB and ISB.
Deep Cervical Plexus Block (dCPB) and ISB: This combination provides extensive coverage and is particularly effective for clavicle surgeries.
Method for Combining DCPB and ISB
Patient Preparation:
Position the patient supine with the head turned away from the side to be blocked.
Ensure standard monitoring and establish intravenous access.
Deep Cervical Plexus Block (dCPB):
Landmarks: Identify the transverse processes of C2-C4 vertebrae.
Technique: Using a high-frequency linear ultrasound probe, visualize the transverse processes and the deep cervical plexus. Insert the needle in-plane, targeting the space adjacent to the transverse processes. Inject 5-10 mL of local anesthetic at each level (C2, C3, and C4).
Interscalene Brachial Plexus Block (ISB):
Landmarks: Identify the interscalene groove between the anterior and middle scalene muscles at the level of the cricoid cartilage (C6).
Technique: Using ultrasound guidance, visualize the brachial plexus roots between the scalene muscles. Insert the needle in-plane, directing it towards the brachial plexus. Inject 10-20 mL of local anesthetic around the nerve roots.
Limitations
Complex Innervation: The clavicle's innervation is not fully understood, which can make achieving complete anesthesia challenging.
Technical Skill: Performing these blocks requires significant expertise, especially when using ultrasound guidance.
Variability in Response: Patients may respond differently to the blocks, and achieving consistent results can be difficult.
Potential Complications and Management
Hemidiaphragmatic Paresis: This can occur with ISB and may affect breathing. Management includes monitoring respiratory function and providing supportive care if needed.
Nerve Injury: Although rare, nerve injury can occur. Immediate cessation of the procedure and appropriate medical intervention are required.
Local Anesthetic Systemic Toxicity (LAST): This is a serious complication that requires prompt recognition and treatment with lipid emulsion therapy.
Advantages of Ultrasound Guidance
Increased Success Rates: Ultrasound guidance improves the accuracy of needle placement, leading to higher block success rates[1].
Reduced Complications: Visualization of anatomical structures helps avoid inadvertent injury to nerves and blood vessels[1].
Enhanced Patient Comfort: Ultrasound guidance can reduce the number of needle passes and associated discomfort[1].
Conclusion
Regional anesthesia for clavicle fracture surgery provides a longer pain-free period and reduces opioid consumption compared to general anesthesia. Combined intermediate or deep cervical plexus and interscalene brachial plexus blocks offer superior analgesia compared to superficial blocks. Ultrasound guidance enhances the success rate of regional anesthesia. These techniques can be effectively used as the sole anesthesia for clavicle fracture surgery.
For detailed information you can review the article here.
Valkyrie Simulators offers the offers the Interscalene simulator and Hands-on Skills workshops that include these features blocks
Sources
The Open Anesthesia Journal • 27 Sep 2022 • SYSTEMATIC REVIEW • DOI: 10.2174/25896458-v16-e2208010
Balaban O, Dülgeroğlu TC, Aydın T. Ultrasound-Guided Combined Interscalene-Cervical Plexus Block for Surgical Anesthesia in Clavicular Fractures: A Retrospective Observational Study. Anesthesiol Res Pract. 2018 Jun 3;2018:7842128. doi: 10.1155/2018/7842128. PMID: 29973954; PMCID: PMC6008659.
NYSORA - Ultrasound-Guided Cervical Plexus Nerve Block NYSORA – Cervical Plexus Block (YouTube NYSORA Education)
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