Date Published: June 3, 2018
Author(s): Onur Balaban, Turan Cihan Dülgeroğlu, Tayfun Aydın.
We aim to report our experiences regarding the implementation of the ultrasound-guided combined interscalene-cervical plexus block (CISCB) technique as a sole anesthesia method in clavicular fracture repair surgery.
Charts of patients, who underwent clavicular fracture surgery through this technique, were reviewed retrospectively. We used an in-plane ultrasound-guided single-insertion, double-injection combined interscalene-cervical plexus block technique. During the performance of each block, the block areas were visualized by using a linear transducer, and the needles were advanced by using the in-plane technique. Block success and complication rates were evaluated.
12 patients underwent clavicular fracture surgery. Surgical regional anesthesia was achieved in 100% of blocks. None of the patients necessitated conversion to general anesthesia during surgery. There were no occurrences of acute complications.
The ultrasound-guided combined interscalene-cervical plexus block was a successful and effective regional anesthesia method in clavicular fracture repair. Prospective comparative studies would report the superiority of the regional technique over general anesthesia.
Clavicle fractures account for 35% of injuries to the shoulder girdle and generally occur after blunt traumas. For displaced clavicle fractures with greater than 2 cm of shortening, current recommendation is operative management with open reduction and internal fixation [1, 2].
Patient charts were retrospectively reviewed starting from May 2014. All patients were informed about the treatment, surgery, and anesthesia method before the procedure. Informed consents for the surgery and anesthesia method were obtained. Block success, acute complications as inadvertent arterial puncture, hematoma formation, respiratory distress, Horner’s syndrome, pneumothorax, and signs of local anesthetic toxicity were evaluated.
The patient characteristics are summarized in Table 1. Totally, 12 patients underwent clavicle operation. Eleven patients underwent open reduction and internal fixation of the clavicle fracture (Figure 5). One patient underwent removal of the implant from the clavicle. One of the patients had liver disease, and one patient had diabetes mellitus. Other patients’ previous medical history was unremarkable.
This case series demonstrated that a combined interscalene-intermediate cervical plexus block under ultrasound guidance is feasible in clavicular fracture surgery. Before ultrasound, local anesthetic doses required for successful blocks were substantially high; therefore, the risk for systemic local anesthetic toxicity was high. Advances in the field of ultrasound-guided peripheral nerve blocks have allowed reduction of local anesthetic doses in interscalene blocks . Ultrasound-guided interscalene blocks are performed commonly in our clinic for shoulder surgeries. Cervical plexus blocks are also performed under ultrasound guidance for endarterectomy operations. The idea of using a combination of two blocks was encouraged by and came up after reduction of local anesthetic doses we used to administer to 10–20 milliliters. In consultation with the trauma surgeons, with the guarantee of converting to general anesthesia if surgical pain is felt, we have been offering this method to our patients undergoing clavicular surgery as an alternative to general anesthesia since 2014.
This clinical series is limited by its retrospective nature, and patients were not followed for a postoperative analgesia requirement. This may be a subject of prospective study in the future. As clavicular repair is a rarely performed intervention, the low number of cases was also a limitation. Several measurements were not evaluated such as the number of needle insertion attempts, needle redirections, block performing times, and onset times. Long-term complications were also not evaluated.
Our limited experience suggests that the combined interscalene-cervical plexus block is possible as a sole anesthesia method in patients who undergo clavicular fracture surgery. In this case series, regional anesthesia was successful, effective, and well tolerated in all of the patients. This method may be considered as an alternative to general anesthesia. Prospective (randomized) trials are required to determine which constitutes the best option for such operations.