Awake Single-Stage Bilateral Clavicle Surgeries Under a Bilateral Clavipectoral Fascial Plane Block: A Case Report and Review of Literature

Abstract

The clavicle is a frequently fractured bone with an infrequent bilateral occurrence. Regional anesthesia (RA) for clavicle surgeries is always challenging due to its complex innervation arising from the two plexuses (cervical and brachial). Various RA techniques described for clavicle surgeries include plexus blocks, fascial plane blocks, and truncal blocks. Plexus blocks are associated with undesirable effects, such as phrenic nerve blockade and paralysis of the entire upper limb, limiting their application for bilateral regional clavicle surgeries. The clavipectoral fascial plane block (CPB) is a novel, procedure-specific, phrenic-sparing, and motor-sparing RA technique that can provide anesthesia or analgesia for clavicle surgeries. The decision to use the CPB and/or other RA techniques may depend on the site of clavicle injury or variations in clavicular innervation.We report a case of single-stage bilateral clavicle surgery successfully managed with a bilateral CPB alone using ultrasound guidance and landmark guidance separately. The patient was kept awake and comfortable throughout the surgery.In conclusion, CPB can be an effective alternate RA technique in avoiding undesired side effects of more proximal techniques such as phrenic nerve involvement and motor blockade of upper limbs. Landmarkguided CPB can be an alternative with equianalgesic efficacy as of ultrasound-guided CPB in resource-poor or emergency settings.

In Response

“…Several case reports even illustrated that CPB could be considered as a sole and effective alternate regional anesthesia technique for midshaft clavicle surgery. 5,6 The anatomical results by Labandeyra et al 1 show us the right way, following which we could explain our clinical findings, but there is still a gap between clinical "hyperreality" and anatomical reality. We wonder whether the different tissue elasticity between cadaver and living patient and the effect of spontaneous breathing or intrathoracic pressure on the spread of local anesthetic would contribute to these discrepant realities.…”

Clavipectoral Fascia Plane Block Combined With Superficial Cervical Plexus Block for the Removal of Osteosynthesis Material From Clavicle Fracture

“…The main complications associated with interscalene brachial plexus block are phrenic nerve block which can lead to respiratory function decline, particularly in patients with pulmonary conditions; Horner syndrome characterized by ptosis, myosis, and anhydrosis; and recurrent laryngeal nerve block resulting in dysphonia. The main complications inherent to supraclavicular brachial plexus block are also phrenic nerve block, Horner's syndrome (although less frequently than in interscalene block), and pneumothorax [ 8 , 9 , 11 ]. The authors chose to perform a clavipectoral fascial plane block, combined with a superficial cervical plexus block, to prevent the aforementioned complications.…”

The Anesthetic Technique for Clavicle Surgery in Remote Areas: Clavicopectoral Plane Block With Landmark Technique

“…The regional anesthetic technique chosen should be effectively tailored to the expected surgical approach and include the necessary innervation of the muscles, skin and bones of the clavicle. Therefore, depositing local anesthesia between periosteum and the clavipectoral fascia may block the complete innervation [8,14,15,16,19].…”