Ultrasound-Guided Clavipectoral Fascial Plane Block With Intermediate Cervical Plexus Block for Midshaft Clavicular Surgery: A Prospective Randomized Controlled Trial

Abstract

BACKGROUND: Regional anesthesia such as interscalene brachial plexus block (ISBPB) with intermediate cervical plexus block (ICPB) is generally a preferred choice for clavicular surgery. However, various studies have shown that these blocks, especially ISBPB, could cause phrenic nerve paralysis and decrease diaphragmatic motion. The study aimed to evaluate the efficacy of clavipectoral fascial plane block (CPB), an alternative technique to ISBPB, with ICPB, in reducing hemidiaphragmatic paralysis during midshaft clavicular surgery. METHODS: Forty patients scheduled for right midshaft clavicular surgery were randomized (1:1) into an ultrasound-guided ISBPB with ICPB (BC) group or ultrasound-guided CPB with ICPB (CC) group. Five milliliter of 0.375% ropivacaine was used for ICPB, another 20 mL for ISBPB or CPB, and no administration of additional sedative or general anesthetic was planned. Primary outcome was measured by the incidence of hemidiaphragmatic paralysis using M-mode ultrasonography, while secondary outcomes were measured by bedside pulmonary function test, the success rate of block, the time required for the block procedure and onset of block, and motor block score in right upper extremity. RESULTS: In comparison with BC group, the incidence of hemidiaphragmatic paralysis postblock was decreased in CC group (50% vs 0%; P < .001), and measurement of bedside pulmonary function was significantly improved. There was a 100% success rate for anesthetic block in both BC and CC groups, and CC group showed lower motor block score in upper extremity and less block procedure time than BC group (7.1 ± 1.2 vs 3.2 ± 0.6 minutes; P < .001). Moreover, no significant differences were found between time of onset of block and other anesthetic complications in the 2 groups. CONCLUSIONS: Ultrasound-guided CPB with ICPB could significantly reduce hemidiaphragmatic paralysis and provide an adequate surgical anesthesia with fewer complications such as motor block in upper extremity during right midshaft clavicular surgery. (Anesth Analg 2022;135:633-40) KEY POINTS • Question: Can ultrasound-guided clavipectoral fascial plane block with intermediate cervical plexus block reduce hemidiaphragmatic paralysis during clavicular surgery? • Findings: Ultrasound-guided clavipectoral fascial plane block with intermediate cervical plexus block decreased the incidence of hemidiaphragmatic paralysis while providing an adequate surgical anesthesia for midshaft clavicular surgery with minimal motor block in upper extremity. • Meaning: Ultrasound-guided clavipectoral fascial plane block with intermediate cervical plexus block appears to be a promising anesthetic technique for midshaft clavicular surgery.GLOSSARY ANOVA = analysis of variance; ASA = American Society of Anesthesiologists; BMI = body mass index; CI = confidence interval; CL = clavicle; CONSORT = Consolidated Standards of Reporting Trials; CPB = clavipectoral fascial plane block; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; HR = heart rate; ICPB = i...

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 1—A Scoping Review

“…Most studies purportedly, in-text, included a SCPB (28 articles). However, considering the nomenclature differences above, we contend that at least 14 of these studies described an ICPB, while 5 studies performed a SCPB ( Table 3 ) [ 7 , 8 , 13 , 15 , 21 , 23 , 25 , 28 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 42 , 43 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 59 , 60 ]. Taking the in-text description at face value, two articles seemed to describe a deep cervical plexus block with deposition of LA below the prevertebral fascia, while the remaining eight studies did not provide sufficient detail to classify the block [ 8 , 15 , 28 , 33 , 34 , 36 , 37 , 48 , 60 ].…”

“…Cervical plexus blockade was also commonly used in combination with another nerve or fascial plane block. The most common combined technique utilized cervical plexus blockade with an ISB, as reported in 18 studies [ 7 , 8 , 13 , 21 , 23 , 25 , 32 , 36 , 37 , 38 , 39 , 43 , 45 , 46 , 48 , 51 , 52 , 53 ]. Of these, five studies utilized a SCPB, and nine studies described an ICPB [ 7 , 13 , 21 , 23 , 25 , 32 , 38 , 39 , 45 , 46 , 48 , 51 , 52 , 53 ].…”

“…The most common combined technique utilized cervical plexus blockade with an ISB, as reported in 18 studies [ 7 , 8 , 13 , 21 , 23 , 25 , 32 , 36 , 37 , 38 , 39 , 43 , 45 , 46 , 48 , 51 , 52 , 53 ]. Of these, five studies utilized a SCPB, and nine studies described an ICPB [ 7 , 13 , 21 , 23 , 25 , 32 , 38 , 39 , 45 , 46 , 48 , 51 , 52 , 53 ]. A single case report described a deep cervical plexus block [ 60 ]; however, based on our standardized nomenclature, two other studies had in-text descriptions suggestive of a deep cervical plexus block [ 8 , 51 ].…”

“…Given the breadth of techniques reported in the literature, stronger evidence to determine the most appropriate regional technique for emergency department and perioperative (surgical fixation) settings is required [ 11 ]. Furthermore, with the widespread availability of ultrasound platforms and the adoption of real-time ultrasound guidance as the de facto gold standard, sonography has contributed to the safety of RA, improved the efficacy of existing techniques, and paved the emergence of novel fascial plane blocks, such as the clavipectoral fascial plane (CPB) block and pectoral nerve block (PECS) [ 12 , 13 , 14 , 15 , 16 ]. Presently, many centers prefer GA with or without RA due to the region’s complex sensory innervation, and limited experience with RA as the main technique in this patient population.…”

“…Nonetheless, despite the attractiveness of RA, the preferred RA technique at present involves a superficial cervical plexus block (SCPB) and interscalene brachial plexus block (ISB) if complete anesthetic or analgesic cover is required [ 13 ]. Due to its close anatomical proximity, the latter is associated with motor blockade of the phrenic nerve—leading to hemidiaphragmatic paresis and the potential for respiratory compromise in susceptible patients.…”