A brief description of techniques which can be used for regional anaesthesia during neck surgeries.

2. Regional anaesthesia
Regional anaesthesia is anaesthesia affecting only a large part of
the body, such as a limb or the lower half of the body. Regional
anaesthetic techniques can be divided into central and peripheral
techniques.
The central techniques include so called neuraxial blockade
(epidural anaesthesia, spinal anaesthesia). The peripheral techniques
can be further divided into plexus blocks such as brachial plexus
blocks, and single nerve blocks.
Regional anaesthesia may be performed as a single shot or with a
continuous catheter through which medication is given over a
prolonged period, e.g. continuous peripheral nerve block.
Regional anaesthesia can be provided by injecting local anaesthetics
directly into the veins of an arm, i.e. intravenous regional
techniques

3. Regional anaesthesia...
Neck Surgeries, which can be performed under regional anaesthesia…
-Carotid Artery Surgeries, including endarterectomy
-Percutenous Carotid Baloon Angioplasty
-Thyroidectomy
-Parathyroidectomy
-Excision of thyroglossal and branchial cysts and thyroglossal fistula
-Radical Neck Dissection
-Cervical Node Biopsy
-Stenomastoid release for torticolis
-Chemodectoma
-Tracheostomy and repair
-Laryngectomy
-Superficial Neck Procedures
-Plastic repairs on the neck
-Plastic procedure like liposuction, platysmoplasty etc.

4. Interesting Fact
Tait and Caglieri suggested the use of cervical intrathecal
injections for operating on the upper extremities and neck.
A. W. Morton reported success with total spinal anesthesia
after lumbar puncture for operations on all parts of the body.
Thomas Jonnesco reported no adverse effects from 398
spinal anesthetics administered between vertebrae at the
thoracic and lumbar levels with a novocaine and strychnine
mixture. Jonnesco called the method General Spinal
Anesthesia.

5. Introduction
Uses Of Regional Anaesthesia in Neck Surgeries...
-Post operative analgesia
-Operative analgesia with GA
-Operative anaesthesia.

6. Advantages Of Regional Anaesthesia Over GA
- Patient remains conscious
- Maintain airway
- Aspiration unlikely
- Earlier recovery of bowel function
- Reduction in surgical stress because of better intraop
analgesia
- Reduced opioid requirements, so low incidence of PONV
- Smooth recovery requiring less skilled nursing care
- Postoperative analgesia
- Earlier discharge for outpatients
Introduction...

7. - Less expensive
- Patients unfit for GA can be operated if emergency is expected.
- Reduced intra-operative blood loss.
- Decreased chances DVT
- Decreased metabolic changes, ie. for severe respiratory impairment.
- Excellent muscle relaxation.
- Avoidance of rare complications like malignant hyperthermia
Introduction...

8. Introduction...
Disadvantages of RA compared to GA
- Patient may prefer to be asleep
- Practice and skill is required for the best results
- Some blocks require up to 30 minutes or more to be fully
effective
- Analgesia may not always be totally effective - patient may
require additional analgesics, IV sedation, or a light general
anesthetic( this will blunten the advantages of RA)
- Toxicity may occur if the local anesthetic is given
intravenously or if an overdose is injected
- Patient discomfort from long operation
- Patient discomfort during eliciting paresthesia
- Contraindicated in confused patients.
- Potential for nerve damage(although rare)
- Some operations are unsuitable for regional anesthetics.

9. Advantages of GA over Regional
- A patent airway may be assured.
- Adequate oxygenation possible.
-Cardiovascular effects are usually titrable.
-Familiarity for most anaesthesists.
-Patient preference.
Disadvantages of GA compared to RA
- Higher prevalence of cardiovascular depression.
- Depressed protective reflexes
- Prolonged psychomotor impairment
- Possibility of inadvertent awareness during the surgery
- PONV, headache etc.
Introduction...

10. Introduction...
Specific advantages of Regional Anesthesia of Neck..
-Identification of intra-operative laryngeal nerve injury
Specific disadvantages of Regional Anesthesia of Neck..
- Intraoperatively Airway manipulation if required may be more
difficult than Preoperative manipulation.
- Incase of tracheal injury, aspiration of the blood and secretions
- Inadvertent Stellate Ganglion Block
- Injury to important surrounding structures, like vessels and
nerves.
- Effects on heart rate and hemodynamic stability- Cardiac
sympathectomy, which in turn depresses phasic and tonic dynamic
modulation of the cardiac cycle. Therefore, causing hypotension
and bradycardia

11. Relevant Anatomy
The Cervical Plexus..
The anterior rami of the upper four cervical nerves unite by
a series of loops to form the cervical plexus, whose
function is the supply of the skin and muscles of the neck
and the innervation of the diaphragm.
Formation of the plexus
The loops are three in number,
C1–2, C2–3 and C3–4,
with a further loop (C4–5) often
present to connect the cervical
plexus with the brachial plexus.
They lie on the scalenus medius
and legato scapulae muscles under
the cover of the sternocleidomastoid
muscle.

14. Branches
The branches of the cervical plexus can be divided into four
groups.
1 Communicating branches, which pass to the hypoglossal
nerve, to the vagus and to the cervical sympathetic chain.
2 Superficial branches, which supply cutaneous fibres to the
neck.
3 Deep branches, to the neck muscles.
4 The phrenic nerve.
Relevant Anatomy...

15. Relevant Anatomy...
The superficial cervical plexus
Innervates the skin of the anterolateral neck through
anterior primary rami of C2 through C4.
Individual nerves emerge as four distinct nerves from the
posterior border of the sternocleidomastoid muscle.
The lesser occipital nerve usually is a direct branch from
the main stem of the second cervical nerve. The larger
remaining part of this stem then unites with a part of the
third cervical nerve to form a trunk that arises as the greater
auricular and the transverse cervical nerves.

16. Superficial Cervical Plexus Banches
Ascending Branches
Occipitalis major
Auricularis magnus
Superficialis colli
Phrenic
Suprasternal
Descending
Branches
Supraclavicular
Supra-acromial
Relevant Anatomy...
Another part of the third cervical nerve runs downward to unite
with a major part of the fourth to form a supraclavicular
trunk, which then divides into the three groups of supraclavicular
nerves.
The supraclavicular nerves (C3, 4),
on careful palpation, can be rolled
over the subcutaneous anterior
border of the clavicle.

17. Relevant Anatomy...
The deep cervical plexus
This supplies the anterior vertebral muscles, i.e. the recti
capitis, longus capitis and longus cervicis, as well as giving
contributions to scalenus medius (main innervation from roots
of branchial plexus).
In addition, branches pass to levator scapulae (C3, 4) and to
two muscles whose principal innervation is from the spinal
accessory nerve: sternocleidomastoid (C2, 3) and trapezius
(C3, 4).
The fourth cervical nerve may send a branch downward to
join the fifth cervical nerve and participate in the formation of
the brachial plexus.

18. The superficial cervical plexus block.
Distribution Of Anaesthesia..
Skin of anterolateral neck.
Position Of the Patient..
The patient is in the supine or
semi-sitting position with the
head facing away from the side
to be blocked.
Equipments required
- Sterile towels and 4"x4" gauze packs
- 20 mL syringe(s) with local anesthetic
- Sterile gloves and marking pen
- 1½ cm-long, 22-gauge, short bevel needle

19. The superficial cervical plexus block...
Anatomic landmarks
A line extending from the mastoid to C6 is drawn.
The site of needle insertion is marked at the midpoint of the line
connecting the mastoid process with Chassaignac's tubercle of C6
transverse process.
This is the location of the
branches of the superficial
cervical plexus as they
emerge behind the posterior
border of the
sternocleidomastoid muscle.

20. The superficial cervical plexus block...
After skin cleansing with an antiseptic solution, a skin wheel is
raised at the site of needle insertion using a 25-gauge needle.
The needle is inserted perpendicularly just behind the posterior
border of sternocleidomastoid. The needle depth be subcutenous
and superficial to the deep cervical fascia.
After negative blood aspiration, 5 mL of anaesthetic is injected.
Two additional injections are made as the needle is directed
superiorly and inferiorly at 30-45
o
.
The most caudal injection usually blocks the supraclavicular
nerves, while the most cephalic blocks greater auricular.
This injection technique should be adequate to achieve blockade
of all four major branches of the superficial cervical plexus.

21. The superficial cervical plexus block...
The goal of the injection is to infiltrate the local anesthetic
subcutaneously and behind the sternocleido-mastoid muscle.
Attention should be paid to avoid deep needle insertion.
Paresthesia is occasionally elicited during needle insertion.
However, paresthesia is nonspecific and should not be routinely
sought.

22. The deep cervical plexus block
A deep cervical plexus block is essentially a paravertebral block
of the C2, C3, and C4 spinal nerves as they emerge from the
foramina of the respective vertebrae.
Blockade of the deep cervical plexus also results in the blockade
of the superficial cervical plexus.
A deep cervical block is often accidentally accomplished when a
larger volume of local anesthetic is used in the interscalene
brachial plexus block.
 The most common clinical use for this block includes a carotid
endarterectomy and removal of cervical lymph nodes.

23. The deep cervical plexus block...
Distribution Of Anaesthesia..
The cutaneous innervation of both the deep and
superficial cervical plexus blocks includes skin of the
anterolateral neck and the ante- and
retro-auricular areas.
Positioning..
The patient is in the supine or semi-sitting position
with the head facing away from the side to be blocked.
Materials required..
• Sterile towels and 4"x4" gauze packs
• 20-mL syringe with local anesthetic
• Sterile gloves and marking pen
• 1½" 25-gauge needle for skin infiltration
• 1½ cm-long, 22-gauge, short bevel needle

24. The deep cervical plexus block...
Anatomic Landmarks
The following three landmarks for a deep cervical plexus block are
identified and marked:
1. Mastoid process
2. Chassaignac's tubercle of C6
3. Posterior border of the
sternocleidomastoid muscle
The anatomic landmarks for this block can be accentuated by asking
the patient to:
- Lift the head up (tenses the sternocleidomastoid muscles)
- Reach the knee with the hand on the ipsilateral side

25. The deep cervical plexus block...
-A line is drawn connecting the mastoid process (MP) to
Chassaignac's tubercle of C6 transverse process.
- Once this line is drawn, the insertion sites over the C2, C3, and C4
are labeled some 2-cm, 4-cm, and 6-cm caudal from the mastoid
process, respectively.
-After cleaning the skin with an antiseptic solution, local anesthetic is
infiltrated subcutaneously alongside the line estimating the position
of the transverse processes

26. The deep cervical plexus block...
-A needle connected to the syringe with local anesthetic is inserted
between the palpating fingers and advanced at an angle perpendicular
to the skin plane.
The needle should never be oriented cephalad.
A slight caudal orientation of the needle is the
single best method to prevent the inadvertent
insertion of the needle toward the cervical
spinal cord.
-The needle is advanced slowly until the
transverse process is contacted. At this point,
the needle is withdrawn 1-2 mm, firmly
stabilized, and 4 mL of local anesthetic is injected,
after a negative aspiration test for blood. The needle is then removed
and the entire procedure is repeated at the consecutive levels

27. The deep cervical plexus block...
- Goal is contact with the posterior tubercle of the transverse process.
The spinal nerves at the individual levels are located just in front of
the transverse process.
Failure to contact the transverse process on the first needle pass
- Withdraw the needle to the skin, redirect it 15o inferiorly, and repeat
the procedure.
- Withdraw the needle to the skin, reinsert the needle 1cm caudal, and
repeat the above procedure.

28. The cervical plexus blocks...
- The onset time for these blocks is 10-15 minutes. The first sign of
the blockade is the decreased sensation in the area of the distribution
of the respective components of the cervical plexus.
- It should be noted that due to the complex arrangement of the
neuronal coverage of the various layers in the neck area as well as the
cross-coverage from the contralateral side, the anesthesia achieved
with cervical plexus block is rarely complete.
- While this should not be discouraging from the use of cervical
plexus block, its use does require an understanding surgeon who is
willing to supplement the block with the local anesthetic as
necessary.
- Carotid surgery also requires blockade of the glossopharyngeal
nerve branches. This is easily accomplished intraoperatively by
injecting the local anesthetic inside the carotid artery sheath

29. The cervical plexus blocks...
- Although the placement of deep cervical block may be associated
with moderate patient discomfort, excessive sedation should be
avoided.
- During neck surgery the airway management may be difficult due
to the shared access to the head and neck with the surgeon.
-
-Surgeries like carotid endarterectomy require that the patient be
fully conscious, oriented and cooperative during the entire surgical
procedure.
- A subcutaneous midline injection of the local anesthetic extending
from the thyroid cartilage distally to the suprasternal notch will block
the branches crossing from the opposite side. This injection can be
considered as a "field" block.

30. Local Analgesics
Onset (min) Anesthesia (hrs) Analgesia (hrs)
2% Lidocaine
(+HCO3; +
epinephrene)
10-15 2-3 3-6
0.5% Ropivacaine 10-20 3-4 4-10
0.25% Bupivacaine
(+ epinephrene)
10-20 3-4 4-10
- A superficial cervical plexus block requires 10-15 mL of local
anesthetic (3-5 mL per each redirection/ injection). Most patients
benefit from the use of a long-acting local anesthetic.
- A deep cervical plexus block requires 3-5 mL of local anesthetic
per level to ensure reliable blockade. Except perhaps with patients
with significant respiratory disease (blockade of the phrenic nerve),
most patients benefit from the use of a long-acting local anesthetic

31. Infection
Low risk
A strict aseptic technique is used
Hematoma
Avoid multiple needle insertions, particularly in anticoagulated patients
Keep a 5 minute steady pressure on the site when the carotid artery is inadvertenly
punctured
Phrenic Nerve Blockade
Phrenic nerve blockade (diaphragmatic paresis) invariably occurs with a deep cervical
plexus block
A deep cervical plexus block should be carefully considered in patients with significant
respiratory disease
Bilateral deep cervical block in such patients may be considered contraindicated
Blockade of the phrenic nerve does not occur after superficial cervical plexus block
Local anesthetic toxicity
Central nervous system toxicity is the most serious consequence of the cervical plexus
block. This complication occurs because of the rich vascularity of the neck, including
vertebral and carotid artery vessels; it is usually caused by an inadvertent intravscular
injection of local anesthetic rather then absorbtion
Careful and frequent aspiration should be performed during the injection
Nerve injury
Local anesthetic should never be injected against resistance or when the patient complains
of severe pain on injection
Spinal anesthesia
This complication may occur with injection of a larger volume of local anesthetic inside
the dural sleeve that accompanies the nerves of the cervical plexus
It should be noted that a negative aspiration test for CSF does not rule out the possibility
of intrathecal spread of local anesthetic
Avoidance of high volume and pressure during injection are the best measures to avoid
this complication

32. Cervical Epidural Anaesthesia
-Epidural anesthesia has been traditionally limited to procedures
involving the lower limbs, pelvis, perineum, and lower abdomen.
-As clinicians have become more experienced with its
application, epidural anesthesia with or without sedation has been
used as the sole anesthetic or in combination with general anesthesia
for a larger variety of cases.
- Dogliotti in 1933 was the first to describe cervical epidural
anesthesia. #
- Bonica et al described a series of cases in which cervical epidural
anesthesia was used for surgery of the upper extremities.##
#Dogliotti AM: A new method of block anesthesia, regimental procedural anesthesia. Amer J Surg (1933); 20 : 107
## Bonica JJ, Backup PH, Anderson CE, Hadfield D, Crepps WR, Monk BF: Peridural block: Analysis of 3, 637 cases
and a review. Anaesthesiology (1957) 18:719

33. Cervical Epidural Anaesthesia...
-Ciocatto discussed the technique of continuous epidural block for
the control of severe pain due to metastatic carcinoma of the
cervical spine or disc extrusion.#
-Michalek reported the use of cervical epidural anesthesia at the C6–
7 level for a total parathyroidectomy with parathyroid gland
implantation into the forearm. He concluded that combined
procedures involving the neck and upper limbs could be safely
conducted under cervical epidural blockade. ##
-Several studies have described the use of high thoracic epidural
anesthesia for off-pump coronary revascularization and even for
minimally invasive aortic valve replacement.
#Ciocatto E: The management of pain, Int. Anesth. Clin. (1964); 2:3
##Anesth Analg. 2004 Dec;99(6):1833-6, table of contents.

34. Cervical Epidural Anaesthesia...
- In patients in whom general anesthesia could lead to prolonged
ventilatory care, such as those with diffuse interstitial lung
disease, thoracic epidural anesthesia as the sole anesthetic has been
described as a successful alternative.
- Although it is intriguing to realize that epidural blockade can be
performed for procedures that in the past were limited to general
anesthesia, the decision about whether to use this form of neuraxial
blockade should be determined by the needs of the patient.
- Physiologically, blocks above T5 have a far greater effect on
patient hemodynamics than blocks at T10 or lower. However, if
the benefits of epidural blockade outweigh the risks to the
patient, and the sensory blockade needed for the particular procedure
can be obtained, then it is indicated.

35. Cervical Epidural Anaesthesia...
- The epidural space is smaller than the subarachnoid space, extends
from the base of the skull to the sacral hiatus, and surrounds the dura
mater anteriorly, laterally, and posteriorly. The epidural space is
bound posteriorly by the ligamentum flavum and laterally by the
pedicles and the intervertebral foramina. It is a space filled with the
fat, areolar tissue, lymphatics, veins, and nerve roots that traverse
it, but no free fluid. The volume of fat is greater in obese individuals
and less in the elderly.
1. Anterior epidural space,
2. Posterior epidural space,
3. Ligamentum flavum,
4. Blood vessels in the epidural space,
5. Pedicles, 6. Nerve roots,
7. Transverse process,
8. Vertebral body, 9. Spinal cord

36. Cervical Epidural Anaesthesia...
-The interlaminal space at C6 and C7 is slit-like but easily accesible
when the neck is flexed.
The ligamenta flavum in the cervical spine is thinner than at other
levels, the epidural space is more concentric with the laminae and
dura with a distance varying from 3-4 mm at the mid-sagittal point.
This interval can be increased to about 5-6 mm with forward neck
flexion.
-Epidural puncture in the cervical region is therefore technically
simpler than THORACIC ENTRY because of the prominence of the
6th and 7th spinous processes and the amount of widening that
occurs in the interlaminal spaces with flexion as opposed to the
interlaminal spaces in the thoracic region where there is practically
no increase in size with anteroposterior movement.

37. Cervical Epidural Anaesthesia...
-Because of the increased negative pressure in the thoracic
region, cephalad movement of any injected fluid will be impeded by
the natural tendency for it to move towards the area of greater
negativity. Placing the patient in a steep Trendelenburg position will
facilitate cephalad movement of the local anesthetic.
-The subatmospheric pressure in the cervical epidural space is
exaggerated by forward flexion, particularly when the patient is
sitting.
-Either a median or a paramedian approach may be used. Advantages
of the paramedian approach over the midline approach are
-much greater ease with which it is possible to insert an epidural
catheter, and
-the lowered risk of accidental dural puncture.

38. Cervical Epidural Anaesthesia...
Choice of Anesthetic Agent
The choice of anesthetic will depend on the duration required. In
cervical regions, duration of epidural anesthesia is approximately 15
% shorter than expected from an equivalent dose in the lumbar
region.
The volume of local anesthetic required to block all the cervical and
upper 4-5 dermatomes is 8-12 ml. An initial dose of 8 ml is
recommended. If this is inadequate, then an additional 12 ml should
be administered after waiting 30 minutes.
The concentration of local anesthetic will depend on whether a full
motor block, sensory analgesia or sympathetic block is required.

39. Cervical Epidural Anaesthesia...
Complications
-Because of the size of needle, accidental dural puncture will almost
invariably result in a severe spinal headache.
- Accidental puncture of an epidural vein will be revealed by a test
dose containing 1:200,000 (5 mcg/ml) of adrenaline.
- Neural injury from either catheter or needle is possible.
- Epidural hematoma, although extremely rare, is always a possibility
and while it is known to occur spontaneously.
-Epidural abscess may be associated with an in-dwelling epidural
catheter but can occur after installation of steroid.
-Although frequently anticipated, diaphragmatic paralysis is rarely
seen with cervical epidural anesthesia.
It does seem however that the phrenic nerves are more resistant than
other segmental nerves to the Cm of local anesthetic agents.

40. Cervical Epidural Anaesthesia...
Physiological effects block Above T4
The cardiovascular effects of a block above T4 are the result of a
high sympathetic block. The cardiac sympathetic fibers arise from T1
to T4, and when blocked, profound hypotension and bradycardia can
occur.
In addition to the cardiac effects, a high level of sympathetic
blockade causes:
Increased central venous pressure without an increase in stroke
volume
Vasoconstriction in the head, neck, and upper limbs
Splanchnic nerve blockade with blockade of medullary secretion
of catecholamines
Blockade of vasoconstrictive effect on the capacitance vessels of
the lower limbs

41. Cervical Epidural Anaesthesia...
-When a sympathetic block occurs at such a high level, the
cardiovascular system may be left without its mechanisms for
responding to low cardiac output states. This can be detrimental to a
patient with limited cardiac reserve because profound hypotension
with bradycardia and decreased contractility can result.
The anesthesiologist must be prepared to take over the control of the
circulatory system until the block subsides and the patient stabilizes.
- Rarely, respiratory arrest during high epidural blockade has been
reported. The reported causes of rare instances of respiratory arrest is
from the sympathetic block, leading to decreased cardiac output with
subsequent reduced blood flow to the brain.