Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study

Comparing C3, 4, and 5 nerve root block and interscalene with intermediate cervical plexus block in diaphragmatic motion for clavicle surgery

Regional anesthesia is a popular method for surgical anesthesia in clavicular surgery. Selective blocking of the cervical 3, 4, and 5 nerve roots shows promise in clavicle surgery, with its fast onset, good anesthesia and less complications, necessitating evaluation of its impact on diaphragmatic function. The purpose of this study is to examine the safety of C3, 4, and 5 nerve root block for its application in clavicle surgery. We conducted a pragmatic, randomized trial to evaluate the effect of C3, 4, and 5 nerve root block as compared with interscalene with intermediate cervical plexus block in diaphragmatic motion. This study involved forty patients undergoing right clavicle surgery. Patients were assigned in a 1:1 ratio to either a C345 nerve root block (administered with 2, 3, and 5 ml of 0.5% ropivacaine) or an interscalene with intermediate cervical plexus block (ISB + ICPB, each receiving 10 ml of 0.5% ropivacaine). Diaphragmatic kinetics were quantitatively assessed using sonographic techniques. The primary outcome was the incidence of complete hemi-diaphragmatic paralysis, observed at 30 min post-blockade. Secondary outcomes included the rate of complete hemi-diaphragmatic paralysis at 15 min and the degree of diaphragmatic motion restoration at 2, 4, 6, and 8 h post-blockade, onset time of block, motor block score in upper extremity, and adverse events. Results showed that only one patient (5%) in the C345 group vs. fifteen (75%) in the ISB + ICPB group experienced complete hemi-diaphragmatic paralysis at 30 min during deep breathing (P = 0.001). No patients in the C345 group, compared to five (25%) in the ISB + ICPB group exhibited paradoxical movement at 30 min during voluntary sniffing (P = 0.0471). Additionally, the C345 group demonstrated significantly greater diaphragmatic motion and upper limb strength restoration at all measured intervals post-blockade. Moreover, faster onset time and less adverse events were observed in the C345 group vs. in the ISB + ICPB group. Benefit from low volume of local anesthetics, the C345 nerve root block not only significantly reduces the incidence of complete hemi-diaphragmatic paralysis but also facilitates better recovery from diaphragmatic paralysis compared to the ISB + ICPB. It can be inferred that C345 is a more beneficial anesthesia method for early recovery of clavicular patients.Trial registration number: ChiCTR2300078283 04/12/2023.

Determination of the Optimal Volume of 0.5% Ropivacaine in Single-injection Retroclavicular Brachial Plexus Block for Arthroscopic Shoulder Surgery: A Phase I/II Trial

BACKGROUND

A brachial plexus block plays an important role in providing perioperative analgesia for shoulder surgery; however, the inherent risk of phrenic nerve block and resulting hemidiaphragmatic paralysis may limit its use in patients with compromised pulmonary function. This study aimed to evaluate the safety, efficacy, maximum tolerated volume, and optimal biologic volume of 0.5% ropivacaine used in a single-injection retroclavicular brachial plexus block for arthroscopic shoulder surgery.

METHODS

In this seamless single-arm exploratory phase I/II trial, a novel Bayesian optimal interval design was used to guide volume escalation for determination of the maximum tolerated volume, followed by sequential volume expansion using Bayesian optimal phase 2 design to establish the optimal biologic volume. Fifty-four patients who underwent arthroscopic shoulder surgery received a single-injection retroclavicular brachial plexus block with 0.5% ropivacaine ranging from 15 to 40 ml. The primary outcomes were complete or partial hemidiaphragmatic paralysis in phase I, measured using ultrasound 30 min after block completion, and the block success in phase II, defined as achieving a total sensorimotor score 12 points or greater and the total sensory score 3 points or greater, measured through manual sensorimotor testing.

RESULTS

The maximum tolerated volume for the single-injection retroclavicular brachial plexus block was determined to be 35 ml of 0.5% ropivacaine, with a hemidiaphragmatic paralysis rate of 0.09 (95% credible interval, 0 to 0.29). The optimal biologic volume was found to be 25 ml, with a block success rate of 1.0 (95% credible interval, 0.95 to 1.0) and a negligible hemidiaphragmatic paralysis rate of 0.01 (95% credible interval, 0 to 0.06).

CONCLUSIONS

A single-injection retroclavicular brachial plexus block using 25 ml of 0.5% ropivacaine produced consistent block success with a minimal hemidiaphragmatic paralysis rate, suggesting the need for further studies to confirm this result in arthroscopic shoulder surgery.

EDITOR’S PERSPECTIVE

Evaluating Anesthesia Guidance for Rescue Analgesia in Awake Patients Undergoing Carotid Endarterectomy with Cervical Plexus Blocks: Preliminary Findings from a Randomized Controlled Trial

Background/Objectives: Eversion carotid endarterectomy (CEA) in awake patients is performed using cervical plexus blocks (CPBs) with or without carotid artery sheath infiltration (CASI) under ultrasound guidance. Although adequacy of anesthesia (AoA) guidance monitors nociception/antinociception balance, its impact on intraoperative analgesia quality and perioperative outcomes in awake CEA remains unexplored. Existing literature lacks evidence on whether AoA-guided anesthesia enhances clinical outcomes over standard techniques. This study aimed to assess the role of AoA guidance in improving intraoperative analgesia and perioperative outcomes in patients undergoing CEA with CPBs alone or with CASI compared to standard practice. Methods: A randomized controlled trial included 184 patients divided into three groups: CPBs with intravenous rescue fentanyl (IRF) and lidocaine (LID) guided by hemodynamic observation (C group), AoA-guided IRF and LID (AoA group), and AoA-guided IRF, LID, and CASI (AoA-CASI group). Primary outcomes included perioperative adverse events, and secondary outcomes assessed rescue medication demand and hemodynamic stability. Results: Analysis of 172 patients revealed no significant differences between groups in perioperative adverse events or hemodynamic parameters (p > 0.05). However, the AoA-CASI group demonstrated significantly reduced IRF and LID usage compared to the C and AoA groups (p < 0.001). No significant advantage was observed between the AoA and C groups regarding adverse events (p = 0.1). Conclusions: AoA-guided anesthesia with or without CASI does not significantly reduce perioperative adverse events or improve hemodynamic stability in awake CEA. Clinical implications suggest that focusing on surgical technique optimization may yield greater benefits in reducing adverse events compared to advanced anesthetic monitoring. Further studies are warranted to explore alternative approaches to enhance clinical outcomes.

Perioperative Diaphragm Dysfunction

Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the former is more common. Increasing research has recently delved into perioperative diaphragm protection. It has been established that DD promotes atelectasis development by affecting lung and chest wall mechanics. Diaphragm function must be specifically assessed for clinicians to optimally select an anesthetic approach, prepare for adequate monitoring, and implement the perioperative plan. Recent technological advancements, including dynamic MRI, ultrasound, and esophageal manometry, have critically aided disease diagnosis and management. In this context, it is noteworthy that therapeutic approaches for DD vary depending on its etiology and include various interventions, either noninvasive or invasive, aimed at promoting diaphragm recruitment. This review aims to unravel alternative anesthetic and operative strategies that minimize postoperative dysfunction by elucidating the identification of patients at a higher risk of DD and procedures that could cause postoperative DD, facilitating the recognition and avoidance of anesthetic and surgical interventions likely to impair diaphragmatic function.

Combined Intermediate Cervical Plexus and Costoclavicular Block for Arthroscopic Shoulder Surgery: A Prospective Feasibility Study

A combined cervical plexus and costoclavicular block provides effective shoulder analgesia without the risk of hemidiaphragmatic paralysis. However, whether this technique can also provide effective anesthesia for shoulder surgery remains unknown. Therefore, this study aimed to assess the feasibility and adverse effects of combined blocks in arthroscopic shoulder surgery. Fifty patients scheduled for arthroscopic shoulder surgery were prospectively enrolled. Intermediate cervical plexus (5 mL of 0.5% ropivacaine) and costoclavicular (20 mL of 0.5% ropivacaine) blocks were administered under ultrasound guidance. The block procedure time, needle pass, patient discomfort, anesthesia quality, onset time, postoperative analgesia quality, adverse events, and patient satisfaction were assessed. Surgical and block success were achieved in 45 (90%; 95% confidence interval [CI], 78-97%) and 44 (88%; 95% CI, 76-95%) patients, respectively. Three patients required local anesthetic supplementation, and two required general anesthesia. The incidence of hemidiaphragmatic paralysis was 12.0% (95% CI, 4.5-24.3%). Postoperative pain control was effective for the first 24 h postoperative. Neurological deficits were not observed. The patients reported a high level of satisfaction. This study revealed that a combined cervical plexus and costoclavicular block provided effective surgical anesthesia for arthroscopic shoulder surgery with a 12% incidence of hemidiaphragmatic paralysis. Further randomized studies comparing this technique with interscalene block are required.

Intermediate cervical plexus block in the management of treatment resistant chronic cluster headache following whiplash trauma in three patients: a case series

OBJECTIVES

Cluster headaches are an intensely painful and debilitating headache disorder. Conventional management includes abortive and preventative agents. A fifth of patients with chronic cluster headaches can be refractory to conventional treatment. Cluster headache can develop following whiplash trauma to the head and neck.

CASE PRESENTATION

Three patients were referred to a tertiary pain medicine unit in a university teaching hospital with treatment-resistant chronic cluster headache. They were treated with a novel intervention namely, ultrasound-guided intermediate cervical plexus block with depot methylprednisolone. Patient one reported chronic cluster headache for three years. Patient two reported episodic cluster headache that appeared to be evolving into chronic cluster headache. Patient three reported bilateral cluster headache following a motor vehicle accident. Intermediate cervical plexus block provided significant and durable relief in three patients with treatment resistant chronic cluster headache.

CONCLUSIONS

The novel intervention may have played a role in aborting and preventing chronic cluster headaches.

Analgesic Efficacy of an Ultrasound-Guided Transversus Thoracis Plane Block Combined with an Intermediate Cervical Plexus Block on Postoperative Pain Relief After Trans-Areolar Endoscopic Thyroidectomy: A Single Center Prospective Randomized Controlled Study

Purpose

This study aimed to investigate the analgesic effect of ultrasound-guided transversus thoracis plane block (TTPB) combined with intermediate cervical plexus block (ICPB) in the early postoperative period after trans-areolar endoscopic thyroidectomy.

Patients and Methods

A total of 62 female patients undergoing trans-areolar endoscopic thyroidectomy were randomly classified to the TTPB combined with ICPB group with ropivacaine (block group) or superficial cervical plexus block group (control group). The primary outcome measures were resting visual analogue scale (VAS) in the chest area at 6 h after surgery. The secondary outcome measures included chest resting and movement VAS score, neck resting and movement VAS score within 24 h after surgery, intraoperative remifentanil consumption, postoperative analgesia rate and analgesic requirements and patient satisfaction score for pain management at discharge.

Results

Compared with the control group, the block group at rest showed consistently lower VAS scores in the chest area at 6 and 12 h after operation; the block group at rest showed lower VAS scores in the neck at 6, 12 and 24 h after operation. Regarding movement, the VAS scores of the chest and neck area at 2, 6, 12 and 24 h after the operation were lower in the block group than in the control group. The consumption of remifentanil, rate of postoperative analgesic requirements, and consumption of postoperative rescue analgesia in the block group were lower than those in the control group. Satisfaction with pain treatment at discharge was higher in the block group than in the control group.

Conclusion

Ultrasound-guided TTPB combined with ICPB provides good analgesic effect in the early postoperative period after trans-areola endoscopic thyroidectomy.

Effects of Unilateral Intermediate Cervical Plexus Block on the Diaphragmatic Function in Patients Undergoing Unilateral Thyroidectomy: A Randomized Controlled Study

Background and Purpose

Although unilateral intermediate cervical plexus block (ICPB) can be used for perioperative analgesia in neck surgery, its effect on diaphragm function remains controversial. This prospective study aimed to examine whether unilateral ICPB with different concentrations of ropivacaine resulted in the diaphragmatic dysfunction in unilateral thyroidectomy.

Methods

A total of 54 patients scheduled to undergo unilateral thyroidectomy under general anesthesia were randomly allocated to receive either 10 mL of 0.3% (Group L) or 0.5% (Group H) ropivacaine for ICPB. General anesthesia was then administered for surgery. The diaphragm thickness and diaphragmatic excursion were measured at three different times: before the ICPB, at 40 min and 4 h after the block. The primary outcome was the incidence of diaphragmatic dysfunction of the block side at 40 min and 4 h after ICPB. Secondary outcomes included the maximum pain score within 24 h after the surgery, rescue analgesics within 24 h after the surgery, and time to first ambulation.

Results

The incidence of diaphragmatic dysfunction on the block side of Group H was higher than that of Group L at 40 min after block (58% vs 29%, P = 0.01). However, the incidence of diaphragmatic dysfunction was comparable between Group H and Group L (65% vs 46%) at 4 h after block placement. Within 24 h after the operation, the maximum VAS pain score of Group H was significantly lower than Group L (P = 0.04), and fewer patients in Group H required rescue analgesics (P < 0.01).

Conclusion

The ICPB with different concentrations of ropivacaine can induce the ipsilateral diaphragmatic dysfunction. The high concentration of ropivacaine results in higher incidence of diaphragmatic dysfunction at 40 min, but comparable incidence at 4 h after block compared with lower concentration of ropivacaine.

Chinese Clinical Trial Registry

ChiCTR2000029348.

Anesthetic Management of a Patient Undergoing Cochlear Implantation With Superficial Cervical Plexus Block and Sedation: A Case Report

Avoidance of general anesthesia and endotracheal intubation has been shown to reduce respiratory complications in patients with severe lung disease. We describe the case of a 75-year-old patient with chronic obstructive pulmonary disease (COPD) who underwent cochlear implantation managed with nerve block and sedation. A superficial cervical plexus block (SCPB) was performed with 1% mepivacaine before surgery. A small amount of intravenous analgesic and sedative was administered. The patient experienced only slight pain during surgery. A SCPB had a good analgesic effect on the posterior auricle. Cochlear implantation in patients with COPD can be performed using a SCPB and sedation.

Cervical erector spinae plane block as a perioperative analgesia method for shoulder arthroscopy: a case series

Shoulder arthroscopy, a common intervention for severe rotator cuff injuries, is associated with severe postoperative pain. Upon performing cervical erector spinae plane (ESP) blocks at the C7 TP (tip or posterior tip) or the posterior tip of the C6 TP posterior tubercle in six patients undergoing shoulder arthroscopy, sensory block was detectable in congruent cervico-thoracic dermatomes. Effective intraoperative and postoperative analgesia were consistently obtained for all six patients. This preliminary study illustrated that the cervical ESP block can be considered a potential simple regional anesthesia method for providing analgesia during shoulder arthroscopy with low risks of diaphragmatic paresis, upper extremity motor paresis, nerve injury and persistent hypotension.