Chapter 80A: Cervical Plexus Block

INTRODUCTION

Cervical plexus anesthesia was developed early in the 20th century with two main approaches being used. In 1912, Kappis described a posterior approach to the cervical and brachial plexus, which attempted to block the nerves at their point of emergence from the vertebral column.¹ The posterior approach was advocated because the vertebral artery and vein lie anterior to the plexus.² However, the needle must pass through the extensor muscles of the neck which causes considerable discomfort, and the long path of the needle is more hazardous. Consequently, this technique is not recommended as a routine for cervical or brachial plexus block.

In 1914, Heidenhein described the lateral approach, which has formed the basis for subsequent techniques of anesthetizing the cervical plexus.⁶ Victor Pauchet also described a lateral approach to blocking the cervical plexus in 1920 and recommended it over the posterior approach.⁷ Winnie revisited the lateral approach to the cervical plexus block in 1975, and described a simplified, single-injection technique.⁸ The lateral approach is currently the more commonly used approach and will be described in this chapter.

INDICATIONS AND CONTRAINDICATIONS

Deep and superficial cervical plexus blocks can be used in a variety of surgical procedures, including superficial surgery on the neck and shoulders and thyroid surgery. Its use is most common in carotid endarterectomy, in which an awake patient self-monitors to ensure adequate cerebral blood flow during cross-clamping of the carotid artery (Figure 80A–1).^9,10 Since the description of the first carotid endarterectomy in 1954 by Eastcott, the number of these operations has been growing annually.¹¹ Regional anesthesia is a viable anesthetic choice for carotid surgery, although debate continues whether it improves patient outcomes.^12-25 The largest randomized trial to date on this topic (GALA trial) showed no difference in 30-day stroke or mortality rates, a conclusion that has been supported by a recent meta-analysis.^26,27

The superficial cervical plexus block can be used for many superficial surgeries in the neck area, including lymph node dissection, excision of thyroglossal or branchial cleft cysts, carotid endarterectomy, and vascular access surgery.²⁸

Comparisons of superficial vs deep cervical plexus blocks for carotid endarterectomy have either shown equivalence or favored the superficial block due to the lower risk of complications.^29,30,31 Although both the deep and superficial cervical plexus blocks can be performed separately, they have been used by some also in combination for anesthesia and postoperative analgesia for head and neck surgery.^32,33,34

Contraindications to performing a cervical plexus block include patient refusal, local infection, and previous surgery or radiation therapy ...