Abstract
Purpose
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.
Methods
In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2 ml/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 60 min 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%).
Results
No patient showed any partial or complete ipsilateral hemidiaphragmatic paresis within 60 min after the intermediate CPB.
Conclusion
Intermediate CPB using 0.2 ml/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.
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References
Guidera AK, Dawes PJ, Fong A, Stringer MD. Head and neck fascia and compartments: no space for spaces. Head Neck. 2014;36:1058–68.
Choquet O, Dadure C, Capdevila X. Ultrasound-guided deep or intermediate cervical plexus block: the target should be the posterior cervical space. Anesth Analg. 2010;111:1563–4 (author reply 4–5).
Balaban O, Dulgeroglu TC, Aydin T. Ultrasound-guided combined interscalene-cervical plexus block for surgical anesthesia in clavicular fractures: a retrospective observational study. Anesthesiol Res Pract. 2018;2018:7842128.
Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg. 1991;72:498–503.
Castresana MR, Masters RD, Castresana EJ, Stefansson S, Shaker IJ, Newman WH. Incidence and clinical significance of hemidiaphragmatic paresis in patients undergoing carotid endarterectomy during cervical plexus block anesthesia. J Neurosurg Anesthesiol. 1994;6:21–3.
Emery G, Handley G, Davies MJ, Mooney PH. Incidence of phrenic nerve block and hypercapnia in patients undergoing carotid endarterectomy under cervical plexus block. Anaesth Intensive Care. 1998;26:377–81.
Standring S. Gray's anatomy. 41st ed. London: Churchill Livingstone; 2016. p. 464.
Canella C, Demondion X, Delebarre A, Moraux A, Cotten H, Cotten A. Anatomical study of phrenic nerve using ultrasound. Eur Radiol. 2010;20:659–65.
Pandit JJ, Dutta D, Morris JF. Spread of injectate with superficial cervical plexus block in humans: an anatomical study. Br J Anaesth. 2003;91:733–5.
Seidel R, Schulze M, Zukowski K, Wree A. Ultrasound-guided intermediate cervical plexus block. Anatomical study. Anaesthesist. 2015;64:446–50.
Barone M, Diemunsch P, Baldassarre E, Oben WE, Ciarlo M, Wolter J, Albani A. Carotid endarterectomy with intermediate cervical plexus block. Tex Heart Inst J. 2010;37:297–300.
Ramachandran SK, Picton P, Shanks A, Dorje P, Pandit JJ. Comparison of intermediate vs subcutaneous cervical plexus block for carotid endarterectomy. Br J Anaesth. 2011;107:157–63.
Merdad M, Crawford M, Gordon K, Papsin B. Unexplained fever after bilateral superficial cervical block in children undergoing cochlear implantation: an observational study. Can J Anaesth. 2012;59:28–33.
Kim JS, Lee J, Soh EY, Ahn H, Oh SE, Lee JD, Joe HB. Analgesic effects of ultrasound-guided serratus-intercostal plane block and ultrasound-guided intermediate cervical plexus block after single-incision transaxillary robotic thyroidectomy: a prospective, randomized. Control Trial Reg Anesth Pain Med. 2016;41:584–8.
Shin S, Chung WY, Jeong JJ, Kang SW, Oh YJ. Analgesic efficacy of bilateral superficial cervical plexus block in robot-assisted endoscopic thyroidectomy using a transaxillary approach. World J Surg. 2012;36:2831–7.
Matamis D, Soilemezi E, Tsagourias M, Akoumianaki E, Dimassi S, Boroli F, Richard JC, Brochard L. Sonographic evaluation of the diaphragm in critically ill patients Technique and clinical applications. Intensive Care Med. 2013;39:801–10.
Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD, McDonald C. Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med. 2001;20:597–604.
Kang RA, Chung YH, Ko JS, Yang MK, Choi DH. Reduced hemidiaphragmatic paresis with a "corner pocket" technique for supraclavicular brachial plexus block: single-center, observer-blinded, randomized controlled trial. Reg Anesth Pain Med. 2018;43:720–4.
Renes SH, Rettig HC, Gielen MJ, Wilder-Smith OH, van Geffen GJ. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2009;34:498–502.
El-Boghdadly K, Chin KJ, Chan VWS. Phrenic nerve palsy and regional anesthesia for shoulder surgery: anatomical, physiologic, and clinical considerations. Anesthesiology. 2017;127:173–91.
Hertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31:180–91.
Stoneham MD, Wakefield TW. Acute respiratory distress after deep cervical plexus block. J Cardiothorac Vasc Anesth. 1998;12:197–8.
Telford RJ, Stoneham MD. Correct nomenclature of superficial cervical plexus blocks. Br J Anaesth. 2004;92:775 (author reply-6).
Stoneham MD, Stamou D, Mason J. Regional anaesthesia for carotid endarterectomy. Br J Anaesth. 2015;114:372–83.
Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol. 2018;71:274–88.
Cornish PB. Applied anatomy of cervical plexus blockade. Anesthesiology. 1999;90:1790–1.
Barone M, Brigand C, Sonnek T, Ramlugun D, Calon B, Rottenberg D, Diemunsch P. Intermediate cervical plexus block for cervical esophagus diverticulectomy. Acta Anaesthesiol Belg. 2015;66:59–61.
Kim JS, Joe HB, Park MC, Ahn H, Lee SY, Chae YJ. 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. Reg Anesth Pain Med. 2018;43:634–40.
Thawale R, Alva S, Niraj G. Ultrasound-guided intermediate cervical plexus block with depot steroids in the management of refractory neck pain secondary to cervicothoracic myofascial pain syndrome: a case series. A A Pract. 2019;13:446–9.
Moore DC. Regional block: a handbook for use in the clinical practice of medicine and surgery. 4th ed. Springfield: Charles C. Thomas; 1979. p. 112–122.
Usui Y, Kobayashi T, Kakinuma H, Watanabe K, Kitajima T, Matsuno K. An anatomical basis for blocking of the deep cervical plexus and cervical sympathetic tract using an ultrasound-guided technique. Anesth Analg. 2010;110:964–8.
Tran DQ, Dugani S, Finlayson RJ. A randomized comparison between ultrasound-guided and landmark-based superficial cervical plexus block. Reg Anesth Pain Med. 2010;35:539–43.
Kang SS, Jang JS, Park JH, Hong SJ, Shin KM, Yun YJ. Unilateral phrenic nerve block guided by ultrasonography and nerve stimulator for the treatment of hiccup developed after tongue cancer operation: a case report. Korean J Anesthesiol. 2009;56:208–10.
Renes SH, van Geffen GJ, Rettig HC, Gielen MJ, Scheffer GJ. Ultrasound-guided continuous phrenic nerve block for persistent hiccups. Reg Anesth Pain Med. 2010;35:455–7.
Patella M, Saporito A, Mongelli F, Pini R, Inderbitzi R, Cafarotti S. Management of residual pleural space after lung resection: fully controllable paralysis of the diaphragm through continuous phrenic nerve block. J Thorac Dis. 2018;10:4883–900.
Alilet A, Petit P, Devaux B, Joly C, Samain E, Pili-Floury S, Besch G. Ultrasound-guided intermediate cervical block versus superficial cervical block for carotid artery endarterectomy: the randomized-controlled CERVECHO trial. Anaesth Crit Care Pain Med. 2017;36:91–5.
Madro P, Dabrowska A, Jarecki J, Garba P. Anaesthesia for carotid endarterectomy. Ultrasound-guided superficial/intermediate cervical plexus block combined with carotid sheath infiltration. Anaesthesiol Intensive Ther. 2016;48:234–8.
Martusevicius R, Swiatek F, Joergensen LG, Nielsen HB. Ultrasound-guided locoregional anaesthesia for carotid endarterectomy: a prospective observational study. Eur J Vasc Endovasc Surg. 2012;44:27–30.
Kikura M, Suzuki K, Itagaki T, Takada T, Sato S. Age and comorbidity as risk factors for vocal cord paralysis associated with tracheal intubation. Br J Anaesth. 2007;98:524–30.
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Kim, H.Y., Soh, E.Y., Lee, J. et al. Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study. J Anesth 34, 483–490 (2020). https://doi.org/10.1007/s00540-020-02770-2
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DOI: https://doi.org/10.1007/s00540-020-02770-2