Intermediate Cervical Plexus Nerve Block

The performance of an ultrasound guided intermediate cervical plexus nerve block in a pediatric patient under general anesthesia is demonstrated in this video. A cervical plexus nerve block is commonly used for procedures of the anterolateral neck, ear, clavicle, and acromioclavicular joint (Ref 1, 2). It is commonly used for procedures in the superficial neck and upper chest, carotid surgery, thyroid surgery and clavicle surgeries. Ultrasound technology is used to assist in visualization of the spread of local anesthetic and guidance of proper needle placement. Cervical plexus nerve blocks provide a strategy for postoperative pain management and reduce the need for analgesics (Ref 1, 2). Superficial/intermediate cervical plexus nerve blocks have been reported to be safer and provide similar analgesia compared to the deep cervical nerve blocks (Ref 3).

Cervical plexus nerve blocks are performed in the pediatric population for intraoperative and postoperative pain control. Anatomically, the cervical plexus is a network of nerves formed by the anterior rami of the first four cervical spinal nerves (C1-C4) and provides sensory and motor innervation to parts of the neck and upper shoulders. The true superficial cervical plexus emerges in the subcutaneous plane at the midpoint of the sternocleidomastoid muscle at the level of the upper margin of the thyroid cartilage. The intermediate cervical plexus lies between the investing layer and the prevertebral layer of deep cervical fascia (Ref 4). Reports have shown that the more superficial cervical plexus nerve block types are favored over the deep cervical plexus nerve block due to a lower risk of complications and preservation of analgesia coverage (Ref 3). The use of ultrasound-guidance to perform nerve blocks has enhanced visualization of internal structures and decreased the rate of unintentional punctures of nearby structures.  

Materials

Personal protective equipment (sterile gloves, face mask, cap)  

Skin cleaning solution (chlorhexidine, alcohol, or iodine)  

Sterile drapes, towels, gauze   

6-13 MHz linear transducer and ultrasound machine   

Sterile ultrasound probe cover  

Sterile ultrasound gel  40 -50 mm

22-gauge echogenic blunt needle  

Low volume extension tubing   

3-way stopcock attached to saline syringe and syringe with local anesthetic  

Local anesthetic for injection (ropivacaine 0.2%, bupivacaine 0.25%, or lidocaine 2%)   

Bandage     

 

Procedure  

Review patient history, examine the patient, and obtain informed consent.

 Review general contraindications and indications for a cervical plexus nerve block.   

During time out, identify the correct patient, scheduled procedure, and location of the procedure.   

Monitor vital signs continuously (ECG, BP, pulse oximetry at minimum) during block placement.  

Induce general anesthesia in pediatric patients and obtain PIV if not already present.  

Ensure all necessary equipment to perform a cervical plexus nerve block is available, including emergent rescue equipment and available 20% lipid emulsion for treatment of local anesthetic systemic toxicity (LAST).

Position the patient in lateral recumbent position or supine position with the head turned slightly away to optimize access. Semi-sitting or lateral decubitus positions can also be used. In infants and children, lateral decubitus provides more working area and allows to approach from the posterior aspect.  

For patients who can tolerate this procedure awake, prior to the block, infiltrate the superficial skin with lidocaine 1-2% using a 25-gauge needle.   

Follow aseptic procedure and maintain a sterile field.   Clean the skin at the site of the procedure with sterilizing solution. Cover to the US probe with a sterile sleeve.  

Verify that the ultrasound probe and screen are in the same orientation.   Apply ultrasound sterile US gel to the site.   

Place the US transducer transversely at the midpoint of the mastoid process and the clavicle, on the sternocleidomastoid muscle (SCM) of the neck. Note where the external jugular vein crosses the SCM, to avoid puncturing it.  Scan the site and identify relevant structures: carotid artery (CA), internal jugular vein (IJV), SCM muscle, anterior and middle scalene muscles, interscalene groove.  Move posteriorly until the SCM is located in the middle of the screen. 

The block is usually performed at the C4-5 level (C4 can be identified by level at which carotid artery splits).  Superficial to the interscalene groove, identify the cervical plexus as a collection of hypoechoic nodules. Nerves are usually not clearly identified as it has similar echogenicity as the surrounding fascia. The plane is deep to the sternocleidomastoid and above the scalene muscles.  

Insert an echogenic, blunt needle in-plane from the lateral border of the SCM. Advance the needle from the posterolateral to the anteromedial direction into the space adjacent to the cervical plexus.   

Aspirate to ensure intravascular placement of the needle has not occurred.   Following negative aspiration, inject 1-2 ml of saline to confirm spread, and if appropriate, switch to local anesthetic solution and visualize the deposit of the local anesthetic on the screen.  Confirm proper injection site.  Inject the remainder of the local anesthetic in 2 mL aliquots to ensure spread of local anesthetic underneath the SCM.  

 Remove the needle once all the solution has been administered. Place a sterile bandage on the entry site.

With the use of ultrasound guidance, the cervical plexus nerve block was successful on the first attempt, and no complications were observed. Analgesia from this block was successful and consistent with the intraoperative and postoperative course.

A cervical plexus nerve block is indicated when a patient presents for surgeries of the head and neck regions. Common procedures that require cervical plexus nerve blocks involve procedures of the anterolateral neck, mastoid, clavicle, and acromioclavicular joint, carotid endarterectomies, lymph node dissections, ear and neck surgeries. Reports have shown that the use of a cervical plexus nerve block has been valuable for pain control following central venous cannulation (Ref 5). It can also be used to supplement interscalene brachial plexus for shoulder surgeries to cover the cape of shoulder.  Choice of anesthetic and volume:   Commonly used local anesthetic for cervical plexus nerve block includes ropivacaine 0.2-0.5%, bupivacaine 0.25%, 1.5% mepivacaine or lidocaine 2% (Ref 1, 2). Dosing is between 0.1 ml/kg to 0.3 ml/kg (Ref 2). Since the cervical plexus is composed mainly of sensory nerves, high concentrations of local anesthetic are not required (Ref 1). Typically, the onset time for the block is approximately 5-10 minutes depending on the choice of local anesthetic  The use of ultrasound technology to guide needle placement improves the success rate of this nerve block, provides real-time visualization of vascular and nervous structures and local anesthetic dispersion, and decreases the chances of deep needle insertions that puncture nearby structures (Ref 1, 5).   To avoid complications, clinicians who perform cervical plexus nerve blocks should have an understanding of the fascial planes of the neck and have the skills to properly perform the procedure (Ref 1, 5). When performing an intermediate cervical plexus nerve block, the needle tip should be placed in the fascial layer underneath the sternocleidomastoid muscle in the neck and adjacent to the cervical plexus (Ref 1).  Potential complications for cervical plexus nerve blocks are intravascular injection, hematoma, local infection, and local anesthetic toxicity (Ref 5). Accidental puncture of the internal jugular vein or carotid artery can lead to hematoma formation. Block of the laryngeal nerve, phrenic nerve, deep cervical plexus, and brachial plexus can result from accidental deep injection or excessive local anesthetic volume (Ref 5). Caution is advised in patients with contralateral phrenic nerve palsy or severe respiratory compromise. In such situations, a strict true superficial cervical plexus block with careful attention to volume of local anesthetic is advised. Inadvertent epidural and intrathecal injections can also occur. Complications can be decreased by understanding the physiology and local anesthetic toxicity (Ref 5). Contraindications to this procedure include patient or guardian refusal, infection, contralateral phrenic nerve paralysis, allergy to local anesthetic agents, neck radiation, or previous neck surgery (Ref 5). For patients who have severe chronic obstructive pulmonary disease or untreated contralateral pneumothorax, extra caution should be taken as the block could cause accidental phrenic nerve dysfunction (Ref 3).

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2. Stoeter D. Superficial cervical plexus block. European Society for Paediatric Anaesthesiology. (2024, July 19). https://www.euroespa.com/science-education/specialized-sections/espa-pain-committee/us-regional-anaesthesia/head-and-neck/superficial-cervical-plexusblock/.

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4. Saranteas T, Kostroglou A, Efstathiou G, et al. Peripheral nerve blocks in the cervical region: from anatomy to ultrasound-guided techniques. Dentomaxillofac Radiol. 2020;49(8):20190400. doi:10.1259/dmfr.20190400 

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6. Bilateral superficial cervical plexus block as sole anesthesia for parathyroid surgeries in chronic kidney disease patients - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Anatomical-landmarks-for-superficial-cervical-plexus-block_fig1_381104338 [accessed 19 Jul 2024] 

7. Peksöz U, Öner F, Ahıskalıoğlu A. Superficial Cervical Plexus Block for Retroauricular Mass Excision in a Patient with High Risk of General Anaesthesia: A Case Report. Turk J Anaesthesiol Reanim. 2022 Apr;50(2):148-150. doi: 10.5152/TJAR.2021.21070. PMID: 35544256; PMCID: PMC9361340.