Chapter 73 Head and Neck Blocks Flashcards

Question

Indications for trigeminal | ganglion blockade

Answer 1

Secondary trigeminal neuralgias from injury to the major divisions or the distal branches of the ganglion, in the treatment of chronic, intractable cluster headaches. Persistent idiopathic facial pain (formerly atypical facial pain)

Answer 2

Place the patient on the table in the supine position with the head slightly extended. Light sedation with midazolam and fentanyl is usually required. Sterilely prepare and drape the appropriateside, leaving the eye exposed. Utilizing continuous or pulsed fluoroscopy, locate foramen ovale by rotating the C-arm image intensifier obliquely away from the nose approximately 20 to 30 degrees, and then angle the C-arm image intensifier approximately 30 to 35 degrees in the caudocephalad direction to bring the foramen ovale into view.

Answer 3

Raise a skin wheal directly over the shadow of the foramen which will be ~2 to 2.5 cm lateral to the corner of the mouth. Insert a short, 16- or 18-gauge angiocatheter through the skin wheal and advance to the hub. Insert a gloved finger into the oral cavity to confirm that the buccal mucosa has not been breached. Re-glove before proceeding. Insert a 20- or 22-gauge, curved, blunt block needle through the angiocatheter and advance a few centimeters. Obtain a fluoroscopic image to check the trajectory of the needle. The goal is to advance the needle in a coaxial fashion toward the foramen ovale. With respect to external landmarks, the trajectory of the needle will be in a plane slightly superior to the external auditory meatus and medially toward the pupil in the midline. Advance the needle in 1- to 2-cm increments until bone is touched. Obtain a lateral image to check the position of the needle. If the foramen has not been traversed, adjust the needle tip (usually posterior) and advance through the foramen a distance of 0.5 to 1.0 cm.

Answer 4

inject 0.5 to 1.0 ml of nonionic, water-soluble contrast to confirm position and filling of Meckel’s cavity. Any vascular runoff requires repositioning of the needle. If cerebrospinal fluid is obtained, the needle tip can be withdrawn until fluid is no longer appreciated

Answer 5

the remainder of the procedure should be halted. With a significant leak, a high spinal block can be caused with even low volumes of local anesthetic. A small leak of cerebrospinal fluid may or may not cause a high spinal and if present, the pain practitioner should proceed with caution.

Answer 6

Inject local anesthetic in volumes of 0.25 to 0.5 ml at a time, up to 1 to 2 ml, and observe for effect. Remove the needle and apply an ice pack to the cheek to decrease swelling.

Answer 7

The mandibular division is rostral and lateral; the maxillary division is intermediate; and the ophthalmic division is mostly cephalad and medial.

Answer 8

the response to sensory and motor stimulation (50 Hz, 1 V, and 2 Hz, 2 V, respectively) of the ganglion. Paresthesia should be perceived at less than 0.3 V, with little to no muscle contraction of the masseter muscle at 0.6 to 1.0 V.

Answer 9

the ophthalmic or maxillary divisions.

Answer 10

inject 0.5 ml of 0.25% bupivacaine or 0.2% ropivacaine with steroid. Wait 30 to 60 sec and begin lesioning at 60° C for 90 sec.

Answer 11

corneal reflex during and after each lesion. Lesioning is typically started at temperatures of 55 to 65° C to preserve this reflex. One or two lesions are recommended. If the corneal reflex diminishes, lesioning should be stopped.

Answer 12

not a temperature-dependent technique. It is a nondestructive method of providing long-term pain relief

Answer 13

After proper positioning of the needle tip, perform two or three pulsed radiofrequency cycles for 120 sec each at 45 V. The temperature of the needle tip rarely exceeds 42° C, thus local anesthetic is not required. If significant masseter contraction is noted during pulsing, inject 1 to 2 ml of local anesthetic to diminish this, or hold the patient’s mouth closed with your hand while the cycles are completed.

Answer 14

Once through the foramen ovale, advance the needle until cerebrospinal fluid is observed returning through the needle. Place the patient in a semi-sitting position with the neck flexed. Inject water-soluble, nonionic contrast solution in 0.1-ml aliquots (up to 0.5 ml) into the trigeminal cistern. Once the cistern is visualized, draw back the contrast material by free flow. The flow of contrast is slower than cerebrospinal fluid. Inject the same amount of glycerol into the cistern. Flush the needle with 0.5 ml of saline prior to removal. Keep the patient in a semi-sitting position for 2 hr. During the procedure, patients often report pain, burning, or paresthesia in the affected division/s

Answer 15

complications considered for all neurolytic techniques, radiofrequency thermal lesioning had the highest number of complications (29.2%) followed by glycerol rhizotomy and balloon compression at 24.8% and 16.1%, respectively.

Answer 16

Retrobulbar hematoma (needle is advanced into the retrobulbar space) Exophthalmus (secondary to bleeding in the retrobulbar space) hematoma Masseter weakness (especially with lesioning of the mandibular division. The incidence is highest with balloon microcompression) Loss of the corneal reflex, keratitis (likely to occur after radio frequency lesioning and glycerol neurolysis), ulceration, and hypesthesia are observed in 3% to 15% of patients after a neurolytic procedure. Corneal anesthesia was highest for radiofrequency rhizotomy at 7%, and was observed with glycerol rhizotomy and balloon compression at 3.7% and 1.5%, respectively. Anesthesia dolorosa (deafferentation pain) occurs in up to 4% of patients with radiofrequency, followed by glycerol where it occurs in 2% of cases.

Answer 17

meningitis, dural arteriovenous fistulae, rhinorrhea, transient cranial nerve deficits, tissue sloughing, and even death

Answer 18

an expected occurrence after a properly performed neurolytic procedure. The incidence with radiofrequency rhizotomy is as high as 98%, followed by balloon compression (72%) and glycerol neurolysis (60%)

Answer 19

The ganglion resides in the pterygopalatine fossa. The fossa is bordered anteriorly by the maxillary sinus; posteriorly by the medial pterygoid plate; medially by the palatine bone; and superiorly by the sphenoid sinus.

Answer 20

The pterygomaxillary fissure allows passage of a needle into the fossa, while the pterygopalatine foramen is located medial to the ganglion and is just posterior to the middle turbinate. The fossa is approximately 1 cm wide and 2 cm high and resembles a V-shaped vase on a lateral fluoroscopic image.A large venous plexus overlies the fossa.

Answer 21

Foramen rotundum and the pterygoid canal are located on the superolateral and inferomedial aspect of the fossa, respectively

Answer 22

resides in the pterygopalatine fossa

Answer 23

pterygopalatine nerves and is medial to the maxillary nerve.

Answer 24

vidian nerve which is formed by the deep petrosal (sympathetic from the upper thoracic spinal cord) and greater petrosal (parasympathetic from the superior salivatory nucleus) nerves.

Answer 25

superior posterior lateral nasal and | pharyngeal nerves.

Answer 26

the greater and lesser palatine nerves

Answer 27

upper teeth, nasal membranes, soft palate, and some parts of the pharynx. A small number of motor nerves are believed to travel with the sensory trunks

Answer 28

sphenopalatine neuralgia, trigeminal neuralgia, migraine headaches, cluster headaches, atypical facial pain, and cancer of the tongue and floor of the mouth

Answer 29

sinus arrest in postherpetic neuralgia, vasomotor rhinitis, | complex regional pain syndrome of the lower extremity, low back pain, and post-traumatic headache.

Answer 30

The location of the SPG in relation to the middle turbinate as well as the lateral nasal mucosa

Answer 31

Four percent cocaine is the local anesthetic of choice secondary to its inherent vasoconstrictor property. If this is not available or there is a contraindication to using cocaine, 1% to 2% lidocaine or 0.25% to 0.5% bupivacaine or ropivacaine can be used instead. If these are chosen, the practitioner can pretreat the nare/s with neosynephrine to produce vasoconstriction.

Answer 32

Place the patient in the supine position. Estimate the depth of insertion by externally measuring the distance from the opening of the nare to the mandibular notch. Place a mark corresponding to this depth on the shaft of the cotton-tipped applicator. Soak the applicators in the local anesthetic for several minutes. Slowly insert the applicator into the nare and advance in a line parallel to the zygoma with the tip angled laterally. Do not advance the applicator in a cephalad direction. The endpoint should be the depth marked on the applicator. Place a second applicator into the nare using the same technique, except advance it ~ 0.5 to 1.0 cm deeper and superior to the first. If resistance is encountered at any time, slightly withdraw and redirect the applicator. The second applicator is not a necessity and the nares of some patients may not accommodate it. Leave the applicator(s) in for 30 to 45 min

Answer 33

ipsilateral tearing, conjunctival injection, and nasal congestion. If the SPG is a pain generator or transmitter, analgesia should also be apparent.

Answer 34

additional local anesthetic may be needed and can be trickling down the shaft of the applicator. Remove the cotton-tipped applicators after 45 min even if there are no signs of a block or analgesia. If there are no signs of a block or analgesia, the SPG may be too deep to be blocked by this technique, or is not involved in the transmission of pain.

Answer 35

fluoroscopic guidance is highly recommended. Noninvasive monitors should be used to record vital signs. Light sedation with midazolam and fentanyl can be used, but on occasion, deeper sedation may be necessary for radiofrequency lesioning. For pulsed radiofrequency, heavy sedation is not required. Place the patient in the supine position. Sterilely prep and drape the appropriate side of the face. Obtain a lateral fluoroscopic image.

Answer 36

Palpate the mandibular notch and anesthetize the skin. If the notch is not palpable, identify the notch on a lateral fluoroscopic view. Identify the pterygopalatine fossa (appears as a “V”) on the lateral image and superimpose the right and left fossae. The block can be performed with a 4.5-inch, 22-gauge, shortbevel needle with the distal tip bent at a 30-degree angle, or with a curved, blunt, 10-cm, 20- or 22-gauge needle. Anesthetize the skin and insert a 1.25-inch, 16-gauge angiocatheter through the skin and advance until it is just medial to the ramus of the mandible. This can be checked on an anteroposterior (AP) image. Pass the block needle through the angiocatheter and advance it medial, anterior, and slightly cephalad. Obtain a lateral image to check the direction of the needle. Your target is the mid portion of the pterygopalatine fossa. Get an AP view and advance the needle toward the middle turbinate, stopping when the tip is adjacent to the palatine bone. Once in the fossa, inject 0.5 to 1 ml nonionic, water soluble contrast, and observe for intravascular spread and/or intranasal placement of the needle. Once correct placement has been confirmed, inject 2 cc of local anesthetic, with or without steroids.

Answer 37

conventional radiofrequency lesioning (RFTC) | and pulsed electromagnetic field radiofrequency (P-EMF).

Answer 38

An insulated RF needle with a 3- or 5-mm active tip is placed using the infrazygomatic approach. Once in place, sensory stimulation is performed at 50 Hz up to 1 V. If the tip of the needle is adjacent to the SPG, the patient should perceive a paresthesia at the root of the nose at less than 0.3 V. If the paresthesia is felt in the hard palate, the needle should be redirected cephalad and medial. A paresthesia in the upper teeth indicates stimulation of the maxillary nerve and the needle should be more caudal and medial. Motor stimulation is not necessary. After appropriate sensory stimulation, RFTC can be performed at 67 to 80° C for 90 sec times two cycles. Before lesioning, 2 to 3 ml of local anesthetic should be injected. With P-EMF lesioning, two to four 120-sec lesions are performed at 45 V. Local anesthetic is not required for P-EMF.

Answer 39

bruising, bleeding, infection, damage to nerves, proptosis from retrobulbar hematoma, dysesthesias, paresthesias, and/or numbness from RFTC. Bradycardia (“Konen” reflex) has been noted during RFTC and P-EMF, and can be prevented with pretreatment with atropine or glycopyrolate

Answer 40

The term described an irritation of the greater occipital nerve (GON), and/or the lesser occipital nerve (LON). The International Headache Society defines occipital neuralgia as a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves or of the third occipital nerve, sometimes accompanied by diminished sensation or dysesthesia in the affected area. It is commonly associated with tenderness over the nerve concerned and the pain is often relieved with a local anesthetic block.

Answer 41

trauma to the greater and lesser occipital nerves, compression of the greater and/or lesser occipital nerves or C2 and/or C3 nerve roots by degenerative cervical spine changes, cervical disc disease, myofascial pain, referred pain from ipsilateral trigeminal distribution, and tumors involving the C2 and C3 nerve roots.

Answer 42

Management usually begins with conservative treatment such as physical therapy, massage, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, tricyclic antidepressants, and anticonvulsants.

Answer 43

local anesthetic blocks, botulinum toxin injections, medications, and occipital nerve stimulators.

Answer 44

cervicogenic headache, cluster headache, and occipital neuralgia

Answer 45

the cervical spine nerves.

Answer 46

dorsal ramus of the second cervical nerve and to a lesser extent the dorsal ramus of third cervical nerve. This nerve passes between the inferior capitis oblique and semispinalis capitis muscles and ascends to pierce the semispinalis capitis and the trapezius superiorly. At this point, it travels with the occipital artery to provide cutaneous innervation to the posterior scalp as far anterior as the vertex of the skull. Medially and over the occiput, this nerve communicates with the third occipital nerve (TON) and laterally with the LON( lesser occipital nerve).

Answer 47

composed of branches from the ventral ramus of the second and third cervical nerves and ascends toward the occiput by running parallel to the posterior border of the sternocleidomastoid muscle. Near the scalp it perforates the deep fascia, and is continued superiorly over the occiput where it supplies the skin over the posterior lateral portion of the scalp and above the ear.

Answer 48

The TON arises deep to the trapezius from the medial branch of the dorsal ramus of the third cervical nerve. This nerve ascends medial to the GON and is connected to it both over the occiput and as the GON rounds the inferior edge of the inferior capitis oblique.

Answer 49

the skin over the rostral end of the neck and the occiput near the external occipital protuberance

Answer 50

The patient is placed in a sitting position with the head slightly flexed downward. At the nuchal ridge a 1.5-inch, 22- or 25-gauge, B-bevel needle is inserted in the skin at the nuchal ridge and advanced until bony contact is made. The needle is then slightly withdrawn just of the bone and after negative aspiration a total of 3 to 5 ml of local anesthetic is injected. If a diagnostic block is planned a small volume should (1–1.5 ml) be used, to avoid any confusion in distinguishing greater occipital neuralgia from myofascial pain. The LON block is performed in a similar fashion at its location

Answer 51

The occipital protuberance, superior nuchal ridge, occipital artery, and mastoid process. The location of the GON is typically medial to the occipital artery one third the distance between the occipital protuberance and the mastoid process on the nuchal ridge. The LON is often found two thirds the distance from the occipital protuberance and the mastoid process on the nuchal ridge. When the occipital artery is palpated the GON should be located just medial to the artery.

Answer 52

piercing the occipital artery and bleeding. Compression of the occipital artery is usually effective in avoiding any significant problems.

Answer 53

neural entrapment within the muscle and fascia investing the suboccipital compartment and the posterior occiput.

Answer 54

infiltrate local anesthetic with or without steroid into the subcutaneous tissue around the course of the nerve after it has penetrated the trapezius muscle. The goal of infiltration at this point along the course of the nerve is the pharmacological blockade of nociceptive transmission. This treatment is effective when the entrapment is superficial, but fails when the entrapment occurs deeper within the suboccipital triangle.

Answer 55

conservative medical management, physical therapy, nerve stimulators, C2 gangliectomy, C2–C3 rhizotomy/root decompression, radiofrequency lesioning, and sectioning of the inferior oblique muscle. procedures such as surgical decompression of the nerves in the suboccipital compartment have proven effective for longer periods of time

Answer 56

a region of the posterior cervical neck that has the potential for neural structures to become entrapped at multiple locations. The triangle is composed of bony articulations, ligaments, fibro-fatty tissue and bounded by three different muscles: the rectus capitis posterior major, obliquus capitis inferioris (inferior oblique), and obliquus capitis superioris.

Answer 57

The contents of the triangle are the suboccipital nerve, greater occipital nerve, third occipital nerve and the vertebral artery.

Answer 58

the inferior | oblique muscle and outside the triangle, the trapezius

Answer 59

GON begins within the suboccipital triangle and courses downward and lateral in a posterior direction at the lower edge of the inferior oblique muscle where it bends around the muscle and ascends in a superior and medial direction above the rectus capitis toward the head of the semispinalis muscle. Here the nerves form another bend from its upward orientation in a deep to a superficial direction as it begins to move laterally. As the nerve courses upward and lateral it moves between the dorsal aspect of the semispinalis muscle and deep to the trapezius muscle. Here the nerve may pierce the semispinalis muscle or just continue upward until it pierces the trapezius muscle and travels subcutaneously upward toward the base of the occiput.

Answer 60

The patient is placed in a prone position with the neck slightly flexed. The superior nuchal ridge is palpated and the occipital protuberance is identified. Two to three centimeters lateral to the occipital protuberance at the nuchal ridge the skin is anesthetized with 1% lidocaine. Once anesthetized a 22-gauge, 1.5- to 3.5- inch, sharp or blunt Stealth™ (Epimed International) needle is advanced in a posterior-anterior direction perpendicular to the skin toward the arch of C1. Once the needle is advanced 2 to 3 cm into the tissue a lateral view is obtained. While in the lateral view, the needle is further advanced under live fluoroscopy toward the arch of C1. As the needle is advanced you should experience two to three distinct pops as each muscle fascial layer is penetrated. Once the needle tip is positioned at posterior arch of C1, contrast material is injected in the lateral radiographic view. The contrast spread should be limited around the muscle layers within that enclose the suboccipital compartment and no vascular uptake must be noted. After successful needle position is confirmed, a total of 5 to 10 ml of local anesthetic (0.2% Ropivacaine) and steroid (20 mg Depo-Medrol) is injected

Answer 61

rare and patients may complain of | slight dizziness immediately after the procedure

Answer 62

originates from the cranial part of the medulla oblongata. Its rootlets form one root and course forward and laterally until it reaches the jugular foramen. As it exits the jugular foramen it joins with the vagus and spinal accessory nerve and passes between the internal jugular vein (IJV) and the internal carotid artery (ICA). It continues to descend anterior to the ICA and dips medially behind the styloid process in close proximity to the vagus nerve, accessory nerve, and IJV emerging beneath the tip of the styloid and continuing to its terminal branches

Answer 63

a mixed nerve containing sensory, motor, and autonomic fibers. It provides sensation to the posterior one-third of the tongue, middle ear, palatine tonsils, and mucous membranes of the mouth and pharynx above the vocal cords. Additionally, it innervates the carotid sinus and the carotid bodies. The motor fibers innervate the stylopharyngeus muscle and its autonomic functions are related to the parotid gland via the otic ganglion

Answer 64

vagus and spinal accessory nerve. Specifically, they are in close approximation until they diverge at the midpoint of the styloid process. reported cases of GN paroxysms with associated bradycardia and asystole

Answer 65

the tractus solitarius to the dorsal motor nucleus of the vagal nerves result in reflex bradycardia or asystole

Answer 66

a potential of pharyngeal and trapezius weakness due to unwanted blockade of the closely situated nerves.

Answer 67

used for the treatment of glossopharyngeal neuralgia. The block can be done with local anesthetics as a diagnostic tool to determine if the patient truly has glossopharyngeal neuralgia or it can be performed with the addition of steroids for therapeutic treatment. The procedure also can be used for surgical anesthesia or as an adjunct to depress the gag reflex in an awake, endotracheal intubation. If a neurolytic procedure is considered, the block can be used prior to neurolysis as a prognostic indicator.

Answer 68

Two major landmarks must first be identified: the angle of the mandible anteriorly and the mastoid process posteriorly. The patient is placed supine and the head is turned slightly opposite the direction of the affected side. Once in correct position a lateral fluoroscopic view is obtained visualizing the angle of the mandible and the mastoid process. Once identified and marked a line is drawn between those two points inferior to the ear and the styloid process should lie midway between both points. When the target is identified a small skin wheal with 1% lidocaine is applied to the skin and a 22-gauge, 1.5-inch needle is advanced perpendicular toward the styloid process. Bony contact is typically obtained at 3 cm. After contact, the needle is slightly withdrawn and walked off the styloid process in an anterior direction, ~ 0.5 cm. Inject 1 ml of contrast agent under continuous fluoroscopy. After injecting the contrast then 2 to 3 ml of local anesthetic (0.2% Ropivacaine) and steroid (4 mg dexamethasone) is injected.

Answer 69

when there is an anatomic distortion externally by previous surgery or tumor. The patient is placed in a supine position with mouth wide open and the tongue is retracted downward and medially using a tongue depressor or a laryngoscope blade. The nerve will be located at the inferior portion of the tonsillar pillar and is accessed via the palatoglossal fold. Once the fold is identified, a topical local anesthetic spray or pledget with 1 ml of saline with epinephrine is applied for hemostasis. A 22- or 25-gauge needle with a slight distal bend (25 degrees) is advanced to a depth no more than 0.5 cm into the mucosa. After negative aspiration, 2 to 3 ml of local anesthetic (0.2% ropivacaine) and steroid (4 mg of dexamethasone) are injected.

Answer 70

lead to complications secondary to the close proximity of relation of the CN IX, CN X, CN XI, and CN XII at the styloid process. There can be accidental puncture of the vessels leading to vessel trauma and hematoma formation. Also inadvertent intravascular injection of the ICA or IJV may lead to seizures or even cardiovascular collapse

Answer 71

With the intraoral approach there is a potential of vessel trauma and neurotoxicity but much less that the extraoral approach. Other complications can occur with unwanted blockade of CN X, CN XI, and CN XII.

Answer 72

bradycardia, asystole, reflex tachycardia, and syncope, as well as dysphonia secondary to ipsilateral vocal cord paralysis

Answer 73

in temporary weakness of the trapezius muscle and the tongue

Answer 74

anesthesia and | analgesia involving the head and neck region

Answer 75

the anterior divisions of the first four upper cervical nerves (C1–C4) and the lower four nerves (C5–C8) together with the first thoracic ventral ramus (T1) form the brachial plexus.

Answer 76

deep to the internal jugular vein upon the | levator scapulae, scalene muscles and underneath the sternocleidomastoid muscle.

Answer 77

``` an ascending (superficial cervical plexus) and descending (deep cervical plexus) branch forming loops at each level with the corresponding nerves except for the first ramus. ```

Answer 78

primarily a motor nerve. Even though it lacks cutaneous innervation it does have some sensory function and communicates sensory information to deeper muscles in the suboccipital region as the suboccipital nerve.

Answer 79

its posterior and deeper | location.

Answer 80

anteriorly and surface lateral to the vertebral artery. The C2 and C3 nerves continue on and emerge at the midpoint of the posterior border of the SCM muscle and travel toward to their destination

Answer 81

the sternocleidomastoid toward the posterior and lateral part of the scalp.

Answer 82

posterior scalp behind the ear, the upper and posterior auricle as well as the mastoid and angle of the mandible as the lesser occipital and great auricular nerve.

Answer 83

an anterior and descending portion. The anterior branch runs in an anterior oblique direction where it gives cutaneous innervation to the lateral neck from the chin to the sternum as the transverse cervicalis. The descending branch continues along the SCM muscle into the posterior triangle of the neck beneath the platysma and deep cervical fascia and joins the fourth cervical nerve. Here these nerves provide cutaneous innervation to the upper trapezius, shoulder and pectoral region as the supraclavicular nerves.

Answer 84

medial and lateral branches. The medial branches supply the anterior and lateral neck muscles and gives rise to the phrenic nerve via the fourth cervical nerve as the main contributor. The lateral deep branch forms communicating branches between C1 and C2 rami to the vagus and hypoglossal nerves.

Answer 85

rectus capitus lateralis (C1), rectus capitus anterior (C1, C2), longus capitus (C1–C3), and longus colli (C2–C4). The muscular branches are distributed to the SCM (C2–C4), trapezius (C2, C3), levator scapulae (C3, C4) and scalene medius (C3, C4)

Answer 86

spinal accessory nerve and supply the deep surface of | the trapezius via the communicating branches.

Answer 87

a safe alternative to general anesthesia for procedures involving the anterior-lateral portion of the neck, upper shoulder, and posterior scalp. Its potential indications are many and include superficial neck procedures, neck dissection, thyroglossal and brachial cyst surgery, thyroidectomy, lymph node dissection, cervical node biopsy, carotid endarterectomy, and other head and neck neuralgias.

Answer 88

The sensory and motor component of the cervical plexus can each be blocked separately or together. A deep cervical plexus block provides motor and sensory blockade while a superficial plexus block only blocks the sensory component of the plexus.

Answer 89

the posterior and anterior auricular scalp region, lateral and anterior neck, and the upper shoulder region

Answer 90

postoperative pain relief; reduce nausea and vomiting with surgeries involving the tympanic-mastoid region, and for simple superficial procedures such as involved with plastics or superficial biopsies involving the neck. Additionally, this block is sometimes performed for carotid endarterectomy and thyroid surgery.

Answer 91

the lesser occipital, great auricular, transverse cervicalis and the supraclavicular nerves. For blockade of the deeper structures and the motor components a deep cervical plexus block is warranted

Answer 92

superficial and the deeper muscles | within the anterior and lateral neck up to the upper shoulder region.

Answer 93

This technique can be used for surgical anesthesia, post operative pain relief and diagnosis and treatment of painful conditions involving the neck, posterior scalp, and upper shoulder region. This block is performed for procedures such as thyroidectomy, tracheostomy, and laceration repairs under local anesthesia or any procedure that require muscle relaxation of the neck. One of the most common indications is for awake carotid endarterectomy

Answer 94

the treatment of intractable hiccups as the deep branches | innervate the muscle of the diaphragm

Answer 95

The patient is placed in a supine position with the head turned away from the side that is going to be blocked. Once in correct position, it is important to identify the posterior border of the SCM muscle. This can be done one of two ways. Two landmarks must be identified; the mastoid process and Chassaignac’s tubercle at C6. A line is drawn from the mastoid process to Chassaignac’s tubercle over the SCM muscle. The drawn line should overly the path of the superficial cervical plexus over the posterior border of the SCM muscle. The position of needle entry will be at the midpoint of line drawn from the mastoid process to Chassaignac’s tubercle. This is the site where the branches superficial plexus appear behind the posterior boundary of the SCM muscle. A 22- or 25-gauge, 4- to 5-cm needle is inserted subcutaneously 2 to 3 cm deep at the midpoint of the posterior border of the SCM muscle and 3 to 5 ml of local anesthetic is injected. The needle is then withdrawn and redirected subcutaneously in a superior direction toward the mastoid process while injecting 3 to 5 ml of local anesthetic in a fan-like fashion. The needle is then redirected in an inferior direction subcutaneously toward Chassaignac’s tubercle injecting 3 to 5 ml of local anesthetic in a fan-like fashion

Answer 96

the transverse processes of C2 to C4 will be targeted. The patient is placed in a supine position with the head turned away from the side that is going to be blocked. Once in correct position, two landmarks are identified; the mastoid process and Chassaignac’s tubercle at C6

Answer 97

A line is drawn from the mastoid process to chassaignac’s tubercle overlying the SCM muscle. Once the SCM is identified then the transverse processes of C2, C3, C4, and C6 must be identified. This is achieved by first identifying the cricoid cartilage. Once identified, a line is drawn from the inferior aspect of the cricoid to the SCM. The point where these two lines intersect at a right angle is the C6 transverse process. Next the thyroid notch and superior cornu is palpated. Once located, a line is drawn to the SCM, and the transverse process of C4 is identified at the point where the two lines intersect. Once the C4 transverse process is located, the transverse processes of C2 and C3 can be easily identified. This is done by taking half the distance between C4 and C6. This measurement will be the distance between the transverse processes at each level. Once the intertransverse process distances are determined it is plotted along the original line drawn from the mastoid to Chassaignac’s tubercle. Beginning at the C4 transverse process the distance is plotted upward toward the mastoid process and it should identify the C3 transverse process. The same distance is plotted from C3 to the mastoid and the C2 transverse process will be identified

Answer 98

After drawing out the points of interest the neck is prepped, cleaned, and draped in sterile fashion. The block is performed by using a 22-gauge, 1.5-inch needle, the transverse processes are located by entering the skin in a perpendicular fashion. The needle is always directed in a medial caudal direction to avoid any unintentional vertebral artery, epidural, subdural, or spinal injection. The needle is advanced slowly until the transverse process is contacted, which is typically 1.5 to 2.5 cm. the needle should be redirected slightly posteriorly as the spinal nerves are located just in front of the transverse process. When bony contact is made, withdraw the needle 1 cm and after negative aspiration, 3 to 5 ml of local anesthetic is injected slowly. The needle is then removed and the entire procedure is repeated at the other two transverse processes

Answer 99

For shorter duration procedures 2% lidocaine and mepivacaine may be desired as this may achieve blockade up to 4 hr. For longer procedures ropivacaine or bupivacaine can be used and this may prolong the block up to 8 hr. Higher concentrations of local anesthetic will also prevent required supplemental infiltrations from the surgeon. Lidocaine will have faster onset times than mepivacaine, ropivacaine and bupivacaine

Answer 100

A total amount of 0.4 or 0.5 ml/kg (30 ml) is usually considered sufficient to perform either the superficial, deep or a combination of both blocks. Furthermore, toxicity and systemic absorption can be decreased with the addition of epinephrine to the local anesthetics. Epinephrine will decrease systemic absorption of bupivacaine and lidocaine by 20% or more.

Answer 101

always a risk of infection, risk of hematoma, Local anesthetic toxicity, Intravascular injection (vertebral or carotid artery), Nerve injury. Temporary diaphragmatic paresis invariably will occur with the deep cervical plexus block. The blockade of the phrenic nerve cannot be avoided with this block. For that reason this procedure should never be performed in a bilateral fashion. The superficial plexus block will not cause blockade of the phrenic nerve. a high spinal (Avoid inserting the needle to deep as there is a possibilty of a cervical cord or intrathecal injection.)

Answer 102

central nervous system (CNS) or cardiac side effects. The CNS effects can vary and will most likely consist of perioral numbness, sedation, tinnitus, or even seizures. Cardiac effects can occur but usually happen with higher blood levels of local anesthetics.

Answer 103

the nerve or nerve sheath and injection of local anesthetics may lead to nerve ischemia and permanent damage.

Answer 104

some of the volume to back track into the epidural space and even the subarachnoid space leading to a high spinal. This will present as hypotension and loss of consciousness. Treatment will involve airway control and cardiovascular support until the local anesthetic is metabolized from the CNS.