A Safe Regional Technique in a High-risk Patient: Cervical Plexus Blockage.

Regional anesthesia in the form of combined cervical plexus block is gaining popularity as a technique of choice for cervical spine surgeries, especially for urgent ones. An important advantage is that it allows continuous monitoring of patient's neurological status. The success of the block often depends on accurate placement of the local anesthetic. Landmarks for the block are therefore of great importance. In this case, we aimed to present a 74-year-old man with C4-5 odontoid fracture. We planned to perform a unilateral combined cervical plexus block for anterior cervical instrumentation and fusion (ACIF) operation because of his associated high-risk comorbid disorders.

INTRODUCTION

Cervical spine trauma is a wide range of severity from minor ligamentous injury to disability and even to death in some cases. The overall prevalence of cervical spine injury (CSI) among all trauma patients is 2%–5% annually.[1] Geriatric patients tend to have severe injuries but with worst clinic outcomes because of the degenerated joint changes, lesser mobility of vertebral spines, less muscle of ligament support with the inadequate multiorgan functional reservoir.[2] Deep cervical block anesthetizes three of the four strap muscles of the neck, geniohyoid, prevertebral muscles, sternocleidomastoid, levator scapulae, scalenes, trapezius. Deep plexus provides the muscular branches, while the superficial plexus provides the innervation of the skin of head and neck. Superficial cervical plexus block is adequate to produce anesthesia in the anterior and anterolateral aspects of neck. Deep plexus block is described in various forms, from extension of brachial plexus block, injection around the carotid, and finally classical deep cervical plexus block.

We present a case where general anesthesia is avoided due to the comorbid disorders in a 74-year-old patient. We conclude that combined cervical plexus block provides safe and highly effective anesthesia for cervical spine surgeries.

CASE REPORT

A 74-year-old man presented after a high-level fall. There was loss of consciousness after the accident. The patient's neck was stabilized at the accident site and he was transferred to our emergency department. He had no previous history concerning CSI. Physical examination consisted with a complete motor and sensory quadriplegia. Cervical spine computed tomography demonstrated fracture of C4–C5. Urgent surgery of anterior instrumentation was planned. After preoperative cardiology counseling, atrial fibrillation and 40% ejection fraction were determined. There was a history of 40 pack-years of smoking chronic obstructive pulmonary disease (COPD) asthma and productive cough; the patient was assessed high risk for surgery. In arterial blood gas analysis, PaO2: 68, PaCO2: 60, and SO2: 83% and his spirometry proved restrictive deficiency. Inefficient pulmonary function regional anesthesia was thought to be superior to general anesthesia. Superficial with deep cervical plexus block was decided to be performed. Informed consent was obtained after explaining the risks to the patient. Intravenous access with 16G cannula was obtained. The patient was treated with intravenous methylprednisolone before admitting to the operating room. On operating table, routine monitoring was commenced. His heart rate was 83/min, blood pressure was 155/79 mmHg, and oxygen saturation was 84%. The patient was put in supine position and oxygen supplementation was given with mask at a flow rate 4 L/min. In supine position and head turned away from the side to be blocked, a 21G Stimuplex needle was inserted behind the posterior border of sternocleidomastoid muscle at the midpoint of mastoid process and clavicular head of the sternocleidomastoid muscle. As the needle entered the investing fascia of neck, a loss of resistance was felt as a pop. At this point, 15 mL of 0.25% bupivacaine was injected after aspiration. For superficial cervical plexus block, three injections of 10 mL of 1% lidocaine were injected behind the posterior border of the sternocleidomastoid muscle subcutaneously, perpendicularly, cephalad, and caudad totally. Checking the loss of sensation top in prick over corresponding dermatomes block was assessed after 15 min. The surgery lasted about 120 min. He was transferred to the Intensive Care Unit. The whole intraoperative period was uneventful. Postoperative course in intensive care was unremarkable. At discharge, he had quadriplegic from the Intensive Care Unit.

He was discharged from the hospital on the 15th day for rehabilitation.

DISCUSSION

Cervical Spine Injury (CSI) often leads to disability and mortality seen commonly in trauma victims. Closed and open reduction followed by posterior fusion for subluxations or dislocations and anterior fusion or decompression for vertebral compression fractures offer the best chance for recovery recently.[3]

Early complications of CSI are neurogenic shock, bradyarrhythmias, hypotension, ectopic beats, abnormal temperature control, vasodilatation, and autonomic dysreflexia. Adult respiratory distress syndrome, aspiration, atelectasis, bronchitis, bronchospasm, lung abscess, pleural effusion, pneumonia, pneumothorax, hemothorax, pulmonary edema, pulmonary thromboembolism, tracheitis, upper respiratory infection, and ventilatory failure in patients admitted 48 h of spinal cord injury with a level of C1–T12.[45] This is challenging for anesthesiologists. Anesthetic management for CSI is usually general anesthesia. Wang et al. conducted a study on 356 patients who underwent anterior cervical discectomy and fusion surgery. The aim was to evaluate the results of the anesthetic techniques on perioperative mortality and morbidity. General anesthesia was found superior to cervical plexus group, but it entailed longer surgery and required more postoperative analgesic and anesthetic cost. Recently, cervical block is found to maintain fast recovery; it is cost-effective with less mortality and morbidity.[67]

Pandit performed a study using cervical plexus blockade with local anesthetic with the surgeon during surgery. They compared two groups consisting of 40 patients. Group 1 undergoing carotid endarterectomy received superficial plexus block with local anesthetic; Group 2 received combined cervical plexus block. They found no anesthetic difference between groups.[8]

Roy et al. used superficial and intermediate block for three cases because of the high risks of anesthesia; then, they concluded that cervical block was an excellent option where anesthesia has great risks.[9]

Cervical plexus block complications are inflammation, nerve injury, Horner syndrome, respiratory distress, and plexus brachialis paralysis. We did not observe any complications in our case.

Davies et al. used combined cervical plexus block on 128 patients having carotid endarterectomy under sedation.[10] We could not use sedation because of our patient's respiratory distress. Regional anesthetic techniques are relatively low-risk procedures, usually used as an adjunct to general anesthesia. They provide prolonged postoperative analgesia and reduce the need of opioid consumption. Here, we used Heidenhain technique for block. Newer techniques if available such as ultrasound-guided block can also be done easily. However, the latest outcome data from neurosurgery shows that regional block may provide sufficient surgical condition with good postoperative pain relief.[7]

Frankly, most clinicians would be very uncomfortable without the airway secured for ACDF operations with poor airway anatomy and central nervous system injury. We performed unilateral block. Bilateral blocks would seem risky for phrenic nerve paralysis and respiratory compromise. Our patient tolerated the surgery without sedation. The surgery was done with supine position. Prone position sedation might be needed. Moreover, the surgery was limited with the solely areas covered by cervical plexus. Our patient was not a candidate for general anesthesia due to his limited vital capacity.

We conclude that combined cervical plexus block can be considered as a safety anesthesia technique in high-risk patients undergoing neck surgeries with prolonged postoperative analgesia. Our study provides reference in surgical and anesthesia planning and the selection of methods for spinal surgeons and anesthetists.

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Conflicts of interest

There are no conflicts of interest.