Blocks for clavicular surgery

[excalibur]

Had a 27 y/o healthy patient with chronic shoulder pain and was diagnosed with shoulder impingement syndrome. Ortho surgeon opted to do an open distal claviculectomy for him.

I knew patient might not be covered with just ISB. I know there might be some contribution from the supraclavicular nerves from the cervical plexus. Figured this was distal claviculectomy and not midshaft, and ISB should be enough. I also did not want to needlessly give this guy possible hoarseness and dysphagia if ISB would cover.

The most recent edition of Regional Anesthesia and Pain Medicine Journal actually discusses innervation of clavicle and AC joint and discusses blocks that may help.

I opted for ISB only followed by LMA. Pt did wonderfully intraoperatively with no narcs. Postop patient c/o mild pain. His pain was not 0. On questioning the patient pointed at his mid shaft clavicle and said that was the only spot. Mind you pt would only display a mild grimace when he would move or reposition himself in bed. Just sitting up in bed he carried on a normal conversation wide awake without any signs of discomfort. I felt an USG superficial cervical plexus block would have fixed that mild pain, but I did not want to risk giving this guy hoarseness and dysphagia for 24 hrs for something that could easily be treated with oral pain meds. So I opted not to do the SCPB. If he were in intense pain and discomfort, then I would have done it. If this were a mid shaft clavicle fx repair, then I would have done it preop.

How about it? Anyone out there doing routine superficial cervical plexus block for clavicular fx repairs or distal claviculectomy/Mumford? If so are you doing it in combination with ISB? How frequently are you seeing hoarseness and/or dysphagia? Could a more dilute SCPB, like 0.25% of local, avoid the unwanted side effects?

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[Gas you down]

I do not believe that a superficial cervical plexus block causes any hoarseness or dysphagia. I never used an ultrasound for it either.

 

[Gas you down]

I certainly wouldn't perform a deep cervical plexus block. never saw one performed in private practice

 

[excalibur]

I do not believe that a superficial cervical plexus block causes any hoarseness or dysphagia. I never used an ultrasound for it either.

Do you do them for clavicular fx's?

 

[Oggg]

I'm looking to do both ISB and cervical plexus for them. I've had a drought of clavicles lately.

Previously I'd do the ISB and warn the pt about partial coverage.

I tried cervical plexus plus ISB for some shoulder scope/RCR based on ultrasoundblock.com strategy, and got the worst phrenic blocks of my life. Of course it could have been novice technique. For a clavicle, I feel bad about giving a dense arm block and then they still have pain. Definitely the cervical plexus should be 0.125-0.25% bupiv, or ropiv 0.2. ISB could be the same too. I want to do a couple more without dexamethasone before I start making the blocks denser.

 

[excalibur]

I'm looking to do both ISB and cervical plexus for them. I've had a drought of clavicles lately.

Previously I'd do the ISB and warn the pt about partial coverage.

I tried cervical plexus plus ISB for some shoulder scope/RCR based on ultrasoundblock.com strategy, and got the worst phrenic blocks of my life. Of course it could have been novice technique. For a clavicle, I feel bad about giving a dense arm block and then they still have pain. Definitely the cervical plexus should be 0.125-0.25% bupiv, or ropiv 0.2. ISB could be the same too. I want to do a couple more without dexamethasone before I start making the blocks denser.

Yeah, Oggg. I knew this case "might" call for a SCPB. I did feel somewhat bad that he had a dense block and mild pain. Again though it was minimal. We briefly discussed SCPB but Guy said he felt he would be fine with oral meds. It definitely though was not like the shoulder scopes I do where guy says he feels absolutely nothing. Afterward I thought I should have done it with just 0.25% Bupi. No decadron. 8 mLs. It actually is not often I do a clavicular fx repair, but that is one where I would go ahead and do both.

 

[Gas you down]

Do you do them for clavicular fx's?

no but I don't have clavicular fx's often at all.

 

[Arch Guillotti]

I have just done an interscalene and it seems to have worked well. I thought about doing a superficial cervical plexus block but didn't. I would not use ultrasound for a superficial cervical plexus block. Seems kind of silly.

 

[deleted9493]

I would opt for ISB w/ .5% bupivacaine + PSF dexamethasone, followed by a superficial cervical plexus block with whatever bupivacaine I have left. The Horner's or the dysphagia/hoarseness are just a reality of doing blocks in the neck. You can obliterate the pain of the procedure or have a patient with some temporary but pain-free side effects. Seems best to ask them which they'd prefer. If they don't strike you as being a patient of opinion, make the decision and tell them in advance what they may experience.

 

[deleted9493]

Agree. Using ultrasound for a superficial, landmark-based field block is not helpful.

 

[excalibur]

Agree. Using ultrasound for a superficial, landmark-based field block is not helpful.

It's a field block because without visualization you are using your knowledge of anatomy to dump local in a very reasonable area on where the target should be. The fanning technique is done on field blocks because your needle could be north or south of the target. Success rate is still high though because as you said the target is superficial.

But with US if you could literally see the target of the cervical plexus prior to injection, don't you think that would be better?

Why not use ultrasound? If I am going to do an USG ISB, why not withdraw the needle from IS, scan up and inject 5-10 mL right behind the SCM? I am already holding a probe and needle in my hand, so why not?

I know they are not considered field blocks, but there was a time when people thought US was a waste of time for interscalenes. It is a superficial, landmark based technique after all.

Not knocking anyone who does it one way or the other. If you have good success with your technique, it's safe, cost effective, and fast, then GO FOR IT!!

I rarely do SCPB. For our CEA's our CT surgeons infiltrate with local prior to incision and then some more a bit deeper. The whole operation in 50-60 mins with local they inject and minimal sedation from me. So of course anatomical based works. But I read and reviewed the USG SCPB technique, and if the only time I am going to do it is with and USG ISB, then why not? I could even fan 5 mLs north and south of my US target to pay respect.

 

[Oggg]

Part of the SCPB with landmarks is to inject 0.5-1cm deep into the SCM, at the midpoint of the neck, posterior border of SCM. Then you do the subcutaneous wheals up and down the posterior border of the SCM. It's the first part that I've never really understood -- does it work if you inject too deep or too shallow? What about super thin and super fat patients? The ultrasound gives you an objective target, and all with a single needle poke. That makes it superior in my mind. I can't seem to find the papers that show that the ultrasound technique actually gives complete block with a high success rate.

Also, I remember a study showing that ISB was great for distal clavicle fx, ok for middle third of clavicle, and sucky for medial third. And I believe it is the subclavian nerve that is supposed to innervate the clavicle, though it is controversial.

 

[Gaseous Clay]

I do ISB with ultrasound and SCPB using landmarks along post border SCM. This has never failed me. I have done a few blocks in PACU and usually an ISB brings immediate relief but I still like to add the SCPB if I am blocking pre op. I used to not always block clavicles but now I do since most end up in a great deal of pain.

 

[excalibur]

I do ISB with ultrasound and SCPB using landmarks along post border SCM. This has never failed me. I have done a few blocks in PACU and usually an ISB brings immediate relief but I still like to add the SCPB if I am blocking pre op. I used to not always block clavicles but now I do since most end up in a great deal of pain.

What do you use in your SCPB and how much? And you say you don't have problems with hoarseness or dysphagia?

 

[Gaseous Clay]

What do you use in your SCPB and how much? And you say you don't have problems with hoarseness or dysphagia?

10 ml syringe with 0.25% marcaine, usually use 5-8 ml total. Fortunately I haven't seen any hoarseness, dysphagia, or horners but I've done these blocks maybe 5-10 times total. The last clavicle I did was probably 6-8 months ago.

 

[excalibur]

10 ml syringe with 0.25% marcaine, usually use 5-8 ml total. Fortunately I haven't seen any hoarseness, dysphagia, or horners but I've done these blocks maybe 5-10 times total. The last clavicle I did was probably 6-8 months ago.

Cool. Yeah. I thought I should have just used 0.25% Bupi on my patient. I also do not do clavicular fx's often. Will keep this in mind for next time

 

[Gaseous Clay]

Cool. Yeah. I thought I should have just used 0.25% Bupi on my patient. I also do not do clavicular fx's often. Will keep this in mind for next time

You don't need a large volume for this. I go mid point along SCM around level of cricoid, only need to really infiltrate 2 levels above and 2 below. Also the fact I've essentially eliminated pain in pacu with just an ISB leads me to believe that block alone is likely adequate for post op pain control.

 

[tracheatoedoc]

I did 2 clavicle fractures yesterday. I performed an ultrasound guided block of the supraclavicular nerve and an ISB on both patients. They were both pain free. Find the SCM on ultrasound slightly caudal to the midpoint of the muscle. Move the probe a little, until you see the streak of nerves deep and dorsal to the muscle belly.

 

[Planktonmd]

I did 2 clavicle fractures yesterday. I performed an ultrasound guided block of the supraclavicular nerve and an ISB on both patients. They were both pain free. Find the SCM on ultrasound slightly caudal to the midpoint of the muscle. Move the probe a little, until you see the streak of nerves deep and dorsal to the muscle belly.

This is basically a superficial cervical block... it does help if your fracture is in the distal clavicle but for more proximal fractures an ISB alone is good enough.
That said, I do superficial cervical blocks + ISB on all clavicular fractures with 100% success.

 

[stonemd]

I do US guided ISB +sup cx plexus block for all shoulders and clavicles
If block alone bup 0.5% 20-30ml
If GA + block bup 0.25% 20-30ml
add 2-4mg of dexamethasone PF
I don't think sup cx plexus adds to incidence of phrenic, stellate gang or rec laryngeal block
It is just a few mls deep to the sternocleidomastoid at ~C6 level
between superficial and deep layer of cervical fascia
sometimes I can identify clavicular nerves but usually not
I don't see a reason NOT to use US if you are already using it for an ISB

 

[dhb]

I just do a superficial cervical block which works great.

 

[BLADEMDA]

 

[BLADEMDA]