Received 06/29/2020 Review began 07/02/2020 Review ended 07/02/2020 Published 07/08/2020 © Copyright 2020 Kukreja et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Ultrasound-Guided Clavipectoral Fascial Plane Block for Surgery Involving the Clavicle: A Case Series Promil Kukreja , Camille J. Davis , Lisa MacBeth , Joel Feinstein , Hari Kalagara 1. Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, USA Corresponding author: Promil Kukreja,
[email protected] Abstract The clavipectoral fascial plane block (CPB) is a novel regional anesthesia technique that has been utilized for clavicular fracture surgery. While the cutaneous innervation of the skin above the clavicle is well-known to be supplied by the supraclavicular nerve of the superficial cervical plexus (SCP), the sensory innervation of the clavicle itself is somewhat controversial. Despite this controversy, it has been hypothesized that the CPB is an effective regional anesthesia technique for peri-operative analgesia since the terminal branches of many of the sensory nerves like suprascapular, subclavian, lateral pectoral, and long thoracic nerves pass through the plane between the clavipectoral fascia and the clavicle itself. Categories: Anesthesiology, Pain Management, Orthopedics Keywords: sensory innervation, clavipectoral fascial plane block, peri-operative analgesia, regional anesthesia, brachial plexus, cervical plexus Introduction Clavicle fractures account for 2.6% of all fractures and are frequently encountered in both the emergency department and operating room settings [1]. The clavipectoral fascial plane block (CPB) is a novel regional anesthesia technique that has been utilized for clavicular fracture surgeries. Valdés-Vilches originally described the CPB in 2017 as an injection of 10-15 cc of local anesthetic under ultrasound guidance in between the clavipectoral fascia and the periosteum on the medial and lateral aspects of the area of clavicular injury [Presentation: Valdés-Vilches LF. Analgesia for Clavicular Surgery/Fractures. Symposia 01: Postoperative Analgesia for Orthopedic Upper and Lower Limb Surgery: Symposium conducted at the 36th Annual European Society of Regional Anaesthesia and Pain Therapy (ESRA) Congress, Lugano, Switzerland; September 13-16] Since this initial report, a handful of additional case reports have been published that support the efficacy of this block for clavicular surgery [2-5]. In comparison to other surgical sites of the upper extremity, the clavicle has a complex and variable innervation that is continuing to be elucidated, and it has led to numerous discussions as to which regional anesthetic technique is best suited for preventing postoperative pain in clavicle repairs. While the cutaneous innervation of the skin above the clavicle is well-known to be supplied by the supraclavicular nerve of the superficial cervical plexus (SCP), the sensory innervation of the clavicle itself is somewhat controversial. While some sources state that the clavicle is similarly supplied by the supraclavicular nerve of the SCP, other sources maintain that sensation is provided by branches of the brachial plexus such as the subclavian, long thoracic, and suprascapular nerves [6]. Due to this controversy, multiple different regional anesthesia techniques have been utilized in clavicular surgery, including most commonly the SCP block, brachial plexus blocks such as the interscalene, or a combination of the two. While 1 1 1 1 1 Open Access Case Report DOI: 10.7759/cureus.9072 How to cite this article Kukreja P, Davis C J, Macbeth L, et al. (July 08, 2020) Ultrasound-Guided Clavipectoral Fascial Plane Block for Surgery Involving the Clavicle: A Case Series. Cureus 12(7): e9072. DOI 10.7759/cureus.9072
multiple case reports support the use of these techniques [7-9], it can be time-consuming to perform two separate ultrasound-guided injections, and brachial plexus blocks have their own known set of adverse events. These include the almost invariable ipsilateral phrenic nerve palsy with interscalene blocks [10], somewhat common Horner's syndrome or vocal cord paralysis, and the more rare, albeit serious, adverse events of vertebral artery injection, total spinal anesthesia, and pneumothorax [11]. The CPB has proved to be an attractive alternative to the above given its singular injection, ease to perform, and advanced safety profile, especially for patients with respiratory disease. While further studies on this regional anesthetic technique’s safety are needed, no adverse events were noted in the above case reports or this case series. Compared to brachial plexus blocks such as the interscalene block, which prevent pain transmission more proximally and hence lie in close proximity to the neurovascular structures of the cervical spine and neck, the CPB likely offers an improved safety advantage due to its more lateral and superficial plane of injection with the clavicle serving as a natural backstop. It is hypothesized that the CPB provides pain relief by blocking many of the above nerves as their terminal branches pass through the plane between the clavipectoral fascia and the clavicle itself. This case series adds to the growing amount of evidence supporting the CPB through its description of three patients, including one adolescent, who received preoperative CPB for clavicular surgery. Case Presentation Three patients undergoing surgical procedures involving the clavicle were identified on the day of their surgeries as CPB candidates. Consent was obtained from these patients prior to surgery. The block was performed preoperatively under minimal sedation with required intravenous midazolam and fentanyl boluses with noninvasive blood pressure measurement every three minutes and continuous electrocardiogram, pulse oximetry, and capnography. Follow-up data were obtained from chart review of the electronic medical records. Informed consent was obtained for the submission of a case report. A CPB was performed using a high-frequency linear probe (Sonosite HFL38x/13-6 MHz; Fujifilm SonoSite, Bothell, WA) placed on the anterior surface of the clavicle. An in-plane technique was used to visualize needle advancing in a caudal to cephalad direction (Figure 1). FIGURE 1: Patient positioning and in-plane needle insertion 2020 Kukreja et al. Cureus 12(7): e9072. DOI 10.7759/cureus.9072 2 of 8
from caudad to cephalad direction The ultrasound image of the anatomical landmarks for the CPB is shown in Figure 2, and the ultrasound image of the in-plane needle path for the CPB is shown in Figure 3. FIGURE 2: Ultrasound landmarks to identify clavipectoral fascia 2020 Kukreja et al. Cureus 12(7): e9072. DOI 10.7759/cureus.9072 3 of 8
FIGURE 3: Ultrasound image of in-plane needle technique for CPB CPB: clavipectoral fascial plane block Case studies Case Study No. 1 A 32-year-old female with a history of hypertension and attention-deficit/hyperactivity disorder presented for right open distal clavicle excision for right acromioclavicular joint arthritis. The CPB was administered using an in-plane technique to visualize an 8-cm, 20-g Tuohy needle advancing in a caudal to the cephalic direction; 15 cc 0.5% ropivacaine was injected in between the clavipectoral fascia and the periosteum of the clavicle. Given the distal nature of the surgery, a right interscalene catheter was also placed with the same ultrasound probe/needle, and 10 cc 0.5% ropivacaine was given as an initial bolus with a continuous infusion of 0.2% ropivacaine solution at 8 cc/hr started postoperatively. No complications were noted during surgery under a general anesthetic, and pain scores remained zero in the post- anesthesia care unit (PACU). No opioids were given in the PACU, and the patient was discharged home after a 90-minute PACU stay. The patient reported 10/10 satisfaction with her regional anesthetic on the routine post-discharge phone follow-up. Case Study No. 2 2020 Kukreja et al. Cureus 12(7): e9072. DOI 10.7759/cureus.9072 4 of 8
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