Ultrasound-guided combined interscalene and superficial cervical plexus blocks for anesthesia management during clavicle fracture surgery

To the Editor,

Fractures of the clavicle constitute 2.6–4% of all fractures in adult patients. The most frequent injury mechanism is a direct trauma on the shoulder. These fractures are mainly treated surgically (Kihlstrom et al. 2017). The cervical and brachial plexus innervate the clavicular region (Tran et al. 2013). Thus, interscalene brachial plexus block (IBPB) and superficial cervical plexus block (SCPB) may be used for pain management following clavicular surgery. Herein, we aimed to report our ultrasound (US)-guided IBPB and SCPB combination experiences for anesthetic management during clavicular surgery.

Sixteen patients who underwent clavicular surgery were analyzed retrospectively. US-guided combined IBPB and SCPB were performed to the patients. 7.5 ml of 2% lidocaine and 7.5 ml of 0.5% bupivacaine for IBPB and 5 ml of 2% lidocaine and 5 ml of 0.5% bupivacaine for SCPB were injected using a 7–12-MHz linear probe via in-plane technique (Fig. 1). Age, sex, additional sedation requirement, recovery time of motor block, VAS scores, postoperative analgesic use, adverse events, complications, and the patients who needed general anesthesia were recorded from the routine form of operation. The patients’ characteristics and operational data are shown in Table 1. Fracture localization was lateral in six cases, midshaft in eight cases, and medial in two cases. General anesthesia was performed in one patient. Additional sedoanalgesia was performed for four patients. No additional sedoanalgesia was performed in six cases with lateral fracture. Sedoanalgesia was performed in three patients with midshaft fracture. One case with medial fracture underwent general anesthesia, and the other one was performed under sedoanalgesia.

Fig. 1

Patient, probe, and ultrasound setup for block with sonographic anatomy of interscalene-superficial cervical block area. SCM sternocleidomastoid muscle, ASM anterior scalene muscle, MSM middle scalene muscle, IJV internal jugular vein, CA carotid artery

Table 1 The demographic and operational characteristics of the patients and adverse events

Discussion

The sensorineural innervation of the clavicle is a complex issue. The osseous part is mainly innervated by long thoracic, subclavian, supraclavicular, and suprascapular nerves that originated from C3–5 roots. Since these nerves are originated from the brachial plexus, they may be blocked between the scalene muscles. The skin is innervated from SCP which originated from anterior ramii of C1–4 nerve root. The SCP leaves from the lateral part of the upper 1/3 sternocleidomastoid muscle (Tran et al. 2013; Shanthanna 2014). IBPB and SCPB may be used for pain management following clavicular surgery. In the literature, IBPB and SCPB were reported for anesthesia management in a few number of cases and retrospective studies (Vandepitte et al. 2014; Dillane et al. 2014; Reverdy 2015).

IBPB and SCPB may cause complications such as phrenic nerve palsy, vocal cord paralysis, pneumothorax, and spinal cord injury. There were no block-related complications in our cases.

The patient who was administrated general anesthesia had medial clavicular fracture case. One of the patients who received additional sedation had medial fracture case, and the other three had midshaft fracture. These results support that IBPB provides analgesia in proximal humerus, shoulder joint, and 2/3 lateral part of the clavicle. The adverse events such as nausea, vomiting, and itching occurred in those who were administrated additional sedation/sedoanalgesia via opioid agents.

The combination of US-guided IBPB and SCPB may be used for anesthesia during clavicular fracture surgery for patients having high risk rate for general anesthesia. Further studies may be needed in terms of this.