peripheral nerve blocks

1. PERIPHERAL NERVE BLOCKS
Dr.sarmistha

2. Cervical Plexus
The cervical plexus represents nerves from
the anterior rami of C1 – C4
Superficial (4 primary braches)
• Lesser occipital n.
• Greater auricular n.
• Supraclavicular n.
• Transverse cervical n.
Deep (primarily muscular innervation)
• C1 innervates thyrohyoid, geniohyoid
• Ansa cervicalis (C1 – C3 loop) innervates
sternohyoid, omohyoid, sternothyroid
• Segmental branches innervate scalene
muscles
• Phrenic (C3 – C5) innervates the
diaphragm and pericardium
 http://www.studyblue.com/notes/note/n/neck/deck/4588539

3. Lesser Occipital Nerve
 Arises primarily from C2
with some C3 braches
 Innervates the
posterior/lateral aspect of
the scalp and along with
the greater auricular
provides sensation to the
posterior aspect of the ear
 http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

4. Greater Auricular Nerve
 Arises from C2 – C3
 Anterior branch –
innervates the skin
supplying the anterior
surface of the ear, and the
skin overlying the parotid
gland
 Posterior branch –
innervates the skin
overlying the mastoid
process and posterior
aspect of the ear
 http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

5. Supraclavicular Nerve
 Arises from C3 – C4
 Medial branch – Innervates
the skin and clavicle from
sternoclavicular joint to mid
clavicle.
 Intermediate branch –
Innervates clavicle and skin
from superior aspect of
pectoralis major out to
anterior deltoid
 Lateral branch – Innervates
distal clavical and skin
supplying the superior and
posterior aspect of the
deltoid
 http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

6. Transverse Cervical Nerve
 Arises from C2 – C3
 Provides cutaneous and
deep innervation to the
anterior/medial and
posterior/lateral aspects of
the neck
 http://quizlet.com/2618249/unit-11-posterior-triangle-of-neck-flash-cards/

7. Superficial Cervical Plexus Block
 Equipment
 A standard regional anesthesia tray is prepared with the
following equipment:
 Sterile towels and gauze packs
 A 20-mL syringe with local anesthetic, 25-gauge needle
 Sterile gloves, marking pen

8.  Landmarks and Patient Positioning
 The patient is in a supine or semi-sitting position with the
head facing away from the side to be blocked
 Surface landmarks for superficial cervical plexus block
 Mastoid process.
 Transverse process of C6 vertebrate
 Needle insertion site at the midpoint between C6 and
mastoid process behind the posterior border of the
sternocleidomastoid muscle.

9.  Technique
 After cleaning the skin with an antiseptic solution, the
needle is inserted along the posterior border of the
sternocleidomastoid, and three injections of 5 mL of
local anesthetic are injected behind the posterior border
of the sternocleidomastoid muscle subcutaneously,
perpendicularly, cephalad, and caudad in a “fan” fashion

10. Superficial Cervical Plexus Block
 www.nysora.com  Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders

12. Deep Cervical Plexus Block
 Position: Supine/sitting
 Landmarks: Mastoid process, Chassaignae tubercle
 Local: 3-4 ml injected each at C2, C3, C4
 Classically the block is performed using a paresthesia
eliciting technique to obtain a paravertebral block of C2 –
C4.

13. Landmarks and Patient
Positioning
 The patient is in the same position as for the superficial
cervical plexus block
 The three landmarks for a deep cervical plexus block are
similar to those for the superficial cervical plexus block
 To estimate the line of needle insertion overlying the
transverse processes, the mastoid process and the
transverse process of C6 are identified and marked
 The latter is easily palpated behind the clavicular head of
the sternocleidomastoid muscle just below the level of
the cricoid cartilage

14.  Next, a line is drawn connecting the mastoid process to the
C6 transverse process
 The palpating hand is best positioned just behind the
posterior border of the sternocleidomastoid muscle
 Once this line is drawn, the insertion sites over C2 through
C4 are labeled as follows: C2: 2 cm caudad to the mastoid
process, C3: 4 cm caudad to the mastoid process, and C4: 6
cm caudad to the mastoid process

15. Deep Cervical Plexus Block
 www.nysora.com
 EllisH, FeldmanS. Anatomy for Anaesthetists, 4th edn, 1983

16. Clinical Applications
 Carotid endarterectomy
 Lymph node dissections and plastic repairs(Neck)
 Thyroid surgeries

17. Stellate ganglion block
 ANATOMY
 The stellate ganglion is a sympathetic ganglion situated
on either side of the root of the neck
 It is formed on each side of the neck by the fusion of the
inferior cervical ganglion with the first, and occasionally
second, thoracic ganglion
 The stellate ganglion is only supplied by efferent
sympathetic fibres from the ipsilateral sympathetic chain
(which lies inferiorly), along with the first and second
thoracic segmental anterior rami.

19. The anatomical relations are:
 anteriorly:
§ subcutaneous tissue
§ sternocleidomastoid muscle
§ subclavian artery
§ carotid sheath
 posteriorly:
§ anterior scalene muscle
§ sheath of the brachial plexus
§ neck of first rib
§ transverse process of C7
§ vertebral artery
§ longus colli muscle

20.  laterally:
§ superior intercostal vein
§ superior intercostal artery
§ ventral ramus of first thoracic nerve
 medially:
§ prevertebral fascia
§ vertebral body of C7
§ oesophagus
§ thoracic duct

21.  inferiorly:
§ pleural dome over the lung apex
INDICATIONS
Chronic Pain conditions
§ CRPS 1 and 2
§ Herpes zoster affecting the face and neck
§ Refractory chest pain or Angina
§ Phantom limb pain

22.  Vascular Disorders of upper limb
 § Raynaud's phenomenon
 § Obliterative vascular disease
 § Vasospasm
 § Scleroderma
 § Trauma
 § Embolic phenomenon
 § Frost bites

23. CONTRAINDICATIONS
 § Recent myocardial infarction
 § Anti-coagulated patients or those with coagulopathy
 § Glaucoma
 § Pre-existing contralateral phrenic nerve palsy ( may
precipitate respiratory distress)

24. TECHNIQUES
 1) Landmark technique
 The patient is in a supine position with slight extension of
the neck
 The head is turned to the opposite side.The needle is
introduced between the trachea and the carotid sheath
at the level of the cricoid cartilage and Chassaignac's
tubercle (C6) to avoid any potential injury to the pleura
 The sternocleidomastoid muscle and carotid artery are
pushed laterally while simultaneously palpating the
Chassaignae's tubercle

25.  The skin and subcutaneous tissue are pressed firmly onto the
tubercle, the needle is directed medially and inferiorly
towards the body of C6, to hit it and then withdrawn by 1-2
mm to rest outside the longus colli muscle
 We inject 10 mls of 0.25% L-Bupivacaine after a small test
dose of 0.5 mls and repeated negative aspiration for blood to
rule out intravascular placement of the needle.
 Pain specialists use Bupivacaine (0.125-0.5%) or Ropivacaine,
0.2% in a volume ranging from 5-15mls depending upon
their approach for the block, local guidelines and protocols
and clinical judgement.

28. 2) Fluoroscopy assisted
 The anatomical landmarks are used to guide the
approach and direction of the needle and then
fluoroscopy is used to confirm its position
 Radioopaque contrast is injected and the spread is
visualised using anteroposterior and lateral views.

29.  3) CT guided
 The patient is supine with chin turned away from the
injection site.
 The head of the first rib, adjacent vertebral artery and
vein are identified and 25-gauge spinal needle is directed
onto the head of the first rib, as close to the vertebral
body as possible.

30. 4) Ultrasound guided
 The patient is in a supine position with slight extension of the neck.
 After cleaning and draping the site, the transducer is placed on the
neck at the level of C6 to enable cross sectional visualization of
anatomical structures
 At this level, the carotid artery, internal jugular vein, thyroid gland,
trachea, longus colli muscle, root of C6, and transverse process of C6
are identified
 To retract the carotid artery laterally and to position the transducer
close to the longus colli, the transducer is then gently pressed
between the carotid artery and trachea
 Using an in-plane approach, a 1.0-inch, 25-gauge long-bevel
needle is inserted paratracheally toward the middle of the longus
colli,
 Following a negative aspiration test for blood or CSF, local
anaesthetic is injected and visualised spreading in real time.

32. COMPLICATIONS
 1) Horners syndrome :Is caused by sympathetic
blockade and produces the following features on the
ipsilateral side of the face :
 § drooping of the eyelid (ptosis)
 § constriction of the pupil (miosis)
 § decreased sweating of the face on the same side
(anhydrosis)
 § redness of the conjunctiva of the eye
 § impression of an apparently sunken eyeball
(enophthalmos)

33.  Although it may be considered a complication, the presence
of Horner’s syndrome is a confirmatory sign of successful
stellate ganglion blockade.
 2) Misplaced needle puncturing important adjacent
structures
 § Vascular (which may lead to local haematoma or
haemothorax)
 § Carotid artery puncture
 § Internal jugular vein puncture
 § Inferior thyroid artery (serpentine artery) puncture during
ultrasound guided approach

34.  § Neurological
 § Vagus nerve injury
 § Brachial plexus root injury
 § Others
 § Pulmonary injury, pneumothorax
 § Chylothorax (thoracic duct injury)
 § Oesophageal perforation

35.  3) Inadvertent spread of local anaesthetic
 § Intravascular injection into Carotid artery,Vertebral
artery, Internal jugular vein or
 Inferior thyroid artery
 § Neuraxial/brachial plexus spread
 § Localised spread
 § Hoarseness due to recurrent laryngeal nerve injury
 § Elevated hemidiaphragm from phrenic nerve blockade

36.  4) Local anaesthetic toxicity
 5) Infection
 § Soft tissue abscess
 § Meningitis
 § Osteitis

37. Coeliac plexus block
 Anatomy
 The coeliac plexus is also known as the solar plexus.
 It is the main junction for autonomic nerves supplying
the upper abdominal organs (liver, gall bladder, spleen,
stomach, pancreas, kidneys, small bowel, and 2/3 of the
large bowel).
 The celiac plexus proper consists of the celiac ganglia
with a network of interconnecting fibers.
 The ganglia lie on each side of L1 (aorta lying posteriorly,
pancreas anteriorly and inferior vena cava laterally).

38.  Sympathetic supply:
 Greater splanchnic nerve (T5/6 toT9/10)
Lesser splanchnic nerve (T10/11)
 The upper abdominal organs receive their parasympathetic
supply from the left and right vagal trunks, which pass
through the coeliac plexus but do not connect there.
 Technique
 The block is performed using X-ray screening, intravenous
sedation, local anaesthetic infiltration of the superficial
layers, with the patient in the prone position.

39.  Intravenous fluids are required pre-block to reduce the
risk of hypotension after the procedure.
 It normally takes two needle insertions, one on each side
to block both of the coeliac ganglia, but on some
occasions good spread to both sides is achieved just
using one needle.
 The needle entry point is just below the tip of the 12th
rib, and using X-ray screening in two planes, the needle is
advanced until it hits the side of the L1 vertebra.

40. Figure of coeliac plexus block
technique

41.  The needle is withdrawn slightly and then redirected
forwards until it is in the area of the coeliac plexus, avoiding
the aorta and inferior vena cava.
 Radioopaque dye is injected to confirm the correct
placement of the needle, and then the appropriate mixture is
injected
 For nonmalignant
pain: 10 ml 0.5% chirocaine on each side
 For malignant pain: 5 ml 6% aqueous phenol + 5 ml 0.5%
chirocaine on each side

42.  As the block causes dilatation of the upper abdominal vessels,
venous pooling can occur, leading to hypotension
 This can be excacerbated by preexisting dehydration, hence
the need for IV hydration before performing the block.
 Complications
 Severe hypotension may result, even after unilateral block.
 Bleeding due to aorta or inferior vena cava injury by the
needle.
 Intravascular injection
 Upper abdominal organ puncture with abscess/cyst formation.

43.  Paraplegia from injecting phenol into the arteries that
supply the spinal cord
 Sexual dysfunction
 Lumbar nerve root irritation (injected solution tracks
backwards towards the lumbar plexus).

44. THANK YOU