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The cervical paravertebral approach to the brachial plexus results in a volume-dependent blockade of the roots of the brachial plexus. Cervical paravertebral block is indicated for anesthesia and postoperative analgesia in all major surgery on the upper extremity, including surgery on the shoulder, elbow, and wrist.1 It is also suitable for patients in whom it is difficult to reach the brachial plexus trunks via the interscalene approach.2 Because both the loss-of-resistance technique and nerve stimulation can be used for placement of this block, it is well suited to postoperative placement or for other patients (eg, patients with fractures of the arm) in whom motor activity due to nerve stimulation may be poorly tolerated.1

The technique described in this chapter is a modification of the single-injection block, originally described by Kappis in the 1920s3 and modified by Pippa in 1990.4 The original technique never gained popularity, probably because it was uncomfortable to patients due to penetration of the paraspinal extensor muscles of the neck. A modified technique, which does not penetrate these muscles, was described recently.5,6 The modification is insertion of the needle in the V-shaped space between the levator scapulae and trapezius muscles at the level of the sixth cervical vertebra. By this method, penetration of the posterior paraspinal muscles is avoided, which minimizes the associated pain of this approach. Because all of the structures (eg, vertebral artery and vein, phrenic nerve, carotid and other major arteries, internal jugular vein, etc.) associated with complications from brachial plexus blockade are anterior to the nerve roots in the neck, where they exit the neuroforamina, Kappis' original argument that it is best to approach the roots from the posterior, where there are only muscles, remains valid. Furthermore, at the root level of the brachial plexus, which is the level at which this block is done,5,6 the nerve fibers are arranged with sensory fibers posterior and motor fibers anterior. This probably explains the predominantly sensory block when approached from the posterior aspect of the neck.


The brachial plexus is situated between the anterior and middle scalene muscles (Figure 24–1). The phrenic nerve lies in front of the anterior scalene muscle. The vertebral artery and vein are situated anterior to the pars intervertebralis, or articular column of the vertebrae. The approach described in this section1,2,5,6 avoids penetrating the extensor muscles of the neck by entering the neck through the “window” at the level of apex of the V formed by the trapezius and levator scapulae muscles (Figure 24–2).

Fig. 24-1

Anatomic considerations for cervical paravertebral block. 1 = Anterior scalene muscle; 2 = Middle scalene muscle; 3 = Brachial plexus; 4 = Phrenic nerve; 5 = Stellate ganglion; 6 = vertebral artery; 7 = Articular ...

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