Ultrasound guided selective upper trunk block for clavicle surgery.

Sir,

Various regional anaesthesia techniques have been described for pain management in clavicle fracture surgery. Superficial cervical plexus block alone or in combination with Interscalene Brachial Plexus Block, selective C5 nerve root block and selective supraclavicular nerve block have been reported in the literature.[1] We wish to describe a recent case where surgical fixation of the clavicle was performed solely under upper trunk blockade using a single point needle insertion.

A 25-year-old male patient presented for open reduction and internal fixation with plating of a displaced fracture of Lateral 1/3rd of the right clavicle. Ultrasound guided upper trunk block (selective C5 and C6 roots block of Brachial Plexus) was performed at interscalene groove with a 22-gauge, 50mm needle using an in-plane technique. About eight millilitres of 0.75% ropivacainewas injected - 4 ml between the prevertebral fascia and C5 root and 4 ml between C5 and C6 roots [Figure 1]. Within ten minutes of local anaesthetic deposition, the patient had lost cold sensation from the C3 to the C5dermatome of the anterior chest wall. Distal upper limb motor functions were intact and clinical signs of respiratory distress were not encountered. The surgery was performed in the beach chair position, the procedure lasted for 90 minutes. Intravenous paracetamol 1 gm, Dexamethasone 8 mg, and Ketorolac 30 mg were used as a part of multimodal analgesia. Oxygen was given via simple face mask and intravenous Dexmedetomidine infusion (0.7 mcg/kg/min) was used for conscious seadation during the surgery. The patient reported being comfortable throughout the surgery.

Figure 1

Schematic diagram of upper trunk block for clavicle surgery. Local anaesthetic spread is outlined by sky blue colour around C5 nerve root. SCM = Sternocleidomastoid Muscle, ASM = Anterior Scalene Muscle, MSM = Middle Scalene Muscle

The innervations of the clavicle is complex and possibly from superficial cervical plexus (SCP) through terminal branches of suprascapularnerve and C5 nerve root.[2] It is mentioned in the literature that, injection of a large volume of local anaesthetic (LA) in Interscalene approach often blocks the cervical plexus.[3] With our ultrasound guided technique, a single point entry and two injections above and below the C5 root of brachial plexus is sufficient to cover the surgical area. There was no need for a separate SCP block probably because of cephalad spread of LA from C5 root level and blockade up to C3 area. Cadaveric studies, dye injection studies are needed to confirm the spread of LA and randomized controlled trial to establish its efficacy and safety over other described techniques.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.