Use of intermediate cervical plexus block in carotid endarterectomy -an alternative to deep cervical plexus block: a case series.

INTRODUCTION: Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery. METHODS: Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine. RESULTS: Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries. DISCUSSIONS: Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries . CONCLUSIONS: Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Ultrasound-Guided Clavipectoral Fascial Plane Block Combined With Intermediate Cervical Plexus Block for Surgery on a Displaced Midshaft Clavicular Fracture in an Adolescent Athlete: A Case Report.

Ultrasound-guided clavipectoral fascial plane block (CPB) and intermediate cervical plexus block (ICPB) have been used as novel approaches for clavicular fracture surgery in adults. However, there are few reports of ultrasound-guided CPB combined with ICPB for clavicular surgery in children under 18 years of age. A 16-year-old male baseball player (weight, 57 kg; height, 160 cm) was scheduled to undergo open reduction and internal fixation with superior plate placement for a left-sided displaced midshaft clavicular fracture. We performed ultrasound-guided CPB using 0.25% ropivacaine (10 mL each) on the medial and lateral sides of the clavicle fracture between the periosteum of the clavicle and the clavipectoral fascia and ICPB using 0.25% ropivacaine (5 mL) under general anesthesia. The surgery proceeded smoothly, and the postoperative pain was minimal. In this case, ultrasound-guided CPB combined with ICPB was used effectively and safely to treat clavicular fractures in an adolescent athlete.

Efficacy Comparison Between Interscalene Block with and Without Superficial Cervical Plexus Block for Anesthesia in Clavicle Surgery.

Background: Clavicle fractures account for over one-third of shoulder injuries and up to 3.3% of all fractures in adults. While the majority of these fractures can be managed non-surgically, there are instances where surgical intervention is performed. Regional anesthesia (RA) can be a preferred alternative to general anesthesia (GA) to avoid complications and high costs in this surgery. Moreover, the identification of the most optimal approach for RA remains challenging. Objectives: This study aimed to compare the efficacy of interscalene block (ISB) with and without superficial cervical plexus block (SCPB) as an anesthetic technique for clavicular fracture operation. Methods: This double-blinded, non-inferiority clinical trial was conducted on 120 patients randomly divided into 2 groups: One receiving ISB and the other receiving ISB with SCPB. The primary outcome was defined as the conversion to GA. Various factors were recorded, including surgery duration, nerve block initiation, analgesics required in the postanesthesia care unit (PACU), and sedation during surgery. Pain was evaluated using the Visual Analog Scale (VAS) in PACU. SPSS version 26 was used for statistical analysis, performing descriptive analysis, Student's t-tests, and Mann-Whitney U tests to compare non-parametric variables between the 2 groups. Statistically significant results had a P value of less than 0.05. Results: A total of 120 patients were randomly divided into 2 equal groups, each consisting of 50 males and 10 females. The mean age of intervention and case groups were 37.23 ± 13.30 and 38.43 ± 11.95 years, respectively. After performing statistical tests (Student's t-test and Mann-Whitney U test), there was no significant difference in the initiation time of nerve block, surgery initiation time, surgery duration, the amount of required sedation, VAS scores, and meperidine consumption (P > 0.05). None of the patients in both groups required conversion to GA. Conclusions: The primary goal was achieved in all included cases, and no patients required conversion to GA. The efficacy of ISB is the same whether or not it is combined with a SCPB. Interscalene block is an alternative RA approach for clavicle fractures. Thus, ISB alone is as efficient as when used in combination with SCPB.

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial.

BACKGROUND: Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cervical region. Our hypothesis is that an intermediate cervical plexus (IC) block can provide adequate postoperative analgesia compared to a cervical erector spinae (ES) block in patients undergoing anterior cervical spine surgery. METHODS: In this double-blind prospective trial, 58 patients were randomly assigned into two equal groups prior to the administration of general anesthesia. Patients in the IC group (n = 29) underwent ultrasound-guided bilateral intermediate cervical plexus block with 15 ml of bupivacaine 0.25% administered to each side. The ES group (n = 29) underwent ultrasound-guided bilateral cervical erector spinae plane blocks with 15 ml of 0.25% bupivacaine administered to each side at the C6 level. The primary outcome was to record the time to the first call for rescue analgesia (nalbuphine), and the secondary outcomes were to measure the performance time, the onset of the sensory block, the intraoperative fentanyl consumption, postoperative pain intensity using VAS, the postoperative total nalbuphine consumption, and postoperative complications such as nausea, vomiting, hypotension, and bradycardia. RESULTS: The performance and onset of sensory block times were significantly shorter in the IC group compared to the ES group. The time to first call for nalbuphine was significantly shorter in the IC group (7.31 ± 1.34 h) compared to the ES group (11.10 ± 1.82 h). The mean postoperative VAS scores were comparable between the two groups at the measured time points, except at 8 h, where it was significantly higher in the IC group, and at 12 h, where it was significantly higher in the ES group. The total nalbuphine consumption was significantly higher in the IC group (33.1 ± 10.13 mg) compared to the ES group (22.76 ± 8.62 mg). CONCLUSIONS: For patients undergoing anterior cervical spine surgery, the intermediate cervical plexus block does not provide better postoperative regional analgesia compared to the cervical erector spinae block. Performance time and onset time were shorter in the IC group, whereas nalbuphine consumption was lower in the ES group. TRIAL REGISTRATION: The trial was registered at clinicaltrials.gov. (NCT05577559, and the date of registration: 13-10-2022).

Effect of ultrasound-guided bilateral superficial cervical plexus block versus perioperative intravenous lidocaine infusion on postoperative quality of recovery in patients undergoing thyroidectomy: A randomised double-blind comparative trial.

Background and Aims: Recent studies have found that ultrasound-guided (USG) bilateral superficial cervical plexus block (BSCPB) and intravenous infusion of lidocaine (IVL) have the potential to improve the quality of postoperative recovery. This study aimed to investigate and compare their effects on postoperative quality of recovery in patients undergoing thyroidectomy. Methods: A total of 135 patients were randomised to Group N: BSCPB with 10 mL 0.75% ropivacaine on each side, Group L: intravenous lidocaine (1.5 mg/kg for 10 min, followed by 1.5 mg/kg/h) and Group C: intravenous saline combined with BSCPB saline. The primary objective was quality of recovery-40 (QoR-40). Other parameters compared were numeric rating pain scale (NRS) score, haemodynamic data, opioid dosage and incidence of adverse effects. Statistical analysis was performed using the one-way analysis of variance (ANOVA), the Kruskal-Wallis test and the Chi-square test. Results: Compared to Group C, both groups N and L had higher QoR-40 total scores as well as scores indicating physical comfort, emotional state and pain dimensions on postoperative day (POD) 1 and POD2 (P < 0.001). The QoR-40 total and pain dimension scores in Group N were higher on POD1 and POD2 (P < 0.05). The NRS scores and the change in haemodynamics were lower in Group N compared to groups L and C (P < 0.05). The results of other parameters were lower in groups N and L than in Group C (P < 0.05). Conclusion: USG BSCPB and IVL are comparable in improving the quality of postoperative recovery in patients undergoing thyroidectomy.

Does Interventional Pain Management Play a Role in the Treatment of Cervical Post-Surgical Neuropathic Pain?

Post-surgical neuropathic pain is still an underdiagnosed medical condition with persistent pain occurring in 10-50% of patients submitted to surgery. We present a case of a 52-year-old patient with persistent paracervical, supraclavicular, and upper chest neuropathic pain after the excision of a massive deep right cervical tumor, concluded to be an accessory spinal nerve schwannoma. A thorough physical and ultrasound examination helped conclude injury of the superficial cervical plexus. Therefore, an ultrasound-guided hydrodissection of several neuromas was performed at the level of the superficial cervical plexus. After three procedures, pain and quality of life scores improved, with a reduction of anxiety and depression symptoms. Due to the positive response, the patient was referred for a peripheral nerve stimulator implantation, allowing self-control of pain, in a home setting.

The efficacy and safety of opioid-free anesthesia combined with ultrasound-guided intermediate cervical plexus block vs. opioid-based anesthesia in thyroid surgery-a randomized controlled trial.

PURPOSE: In the context of the current comfort medicine and enhanced recovery after surgery, there is a demand for a new anesthesia method to reduce adverse reactions and accelerate recovery after surgery. This randomized controlled trial aimed to compare the efficacy and safety between opioid-free anesthesia (OFA) combined with ultrasound-guided intermediate cervical plexus block (ICPB) and opioid-based anesthesia in patients after thyroid surgery. METHODS: In this study, 75 patients scheduled for thyroid surgery under general anesthesia were randomly allocated into two groups. The primary outcome included the incidence of nausea within 24 h after surgery. The main secondary outcomes included the incidence of vomiting and the visual analog score (VAS) scores within 24 h after surgery as well as the quality of recovery 40 questionnaires (QoR-40) scores 24 h after surgery. RESULTS: In the OFA group, the incidence of postoperative nausea was 6.1%, compared to 39.4% in the control group (p = 0.001). No patient presented with postoperative vomiting in the OFA group, while 15.2% of patients suffered from postoperative vomiting in the control group (p = 0.063). The VAS scores of patients in the postanesthetic care unit (PACU) and 2 h, 4 h, and 6 h after surgery were lower in the OFA group, and the difference is statistically significant. Besides, the VAS scores of patients at rest (p = 1.000) and during swallowing (p = 1.000) 24 h after surgery were comparable. CONCLUSION: Compared with opioid-based anesthesia, the OFA combined with the ultrasound-guided ICPB can better improve patients' postoperative recovery, reduce nausea, and decrease pain scores. TRIAL REGISTRATION: Chinese Clinical Trial Regisrty, ChiCTR2200056344, https://www.chictr.org.cn.

The analgesic effects of bilateral superficial cervical plexus block in thyroid surgery: A systematic review and meta-analysis.

Background and Aims: Thyroid surgery is moderately painful, and many techniques to reduce postoperative pain have been studied. Regional techniques are a part of multimodal analgesia employed for various surgical cases. Bilateral superficial cervical plexus block (BSCPB) is a commonly used regional anaesthesia technique for analgesia for thyroid surgery. A previous meta-analysis by this group had left questions about some facets of the technique, to which further trials have contributed. Methods: The systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) CRD42022315499. It is an update to a previously published paper in 2018. An updated systematic search, critical appraisal, and analysis of clinical trials were performed. Trials investigating preoperative or postoperative BSCPB compared to control in patients undergoing thyroid surgery were included in the search. The primary outcome was postoperative opioid consumption. The secondary outcomes were the duration of analgesia (time to request of analgesia), Visual Analogue Scale (VAS) pain scores at 0, 4, 12, and 24 h, postoperatively, rates of postoperative nausea and vomiting (PONV), postoperative rescue analgesic consumption, and intraoperative morphine use. Results: A total of 31 studies and 2,273 patients were included in this analysis. BSCPB significantly reduced post-thyroidectomy opioid consumption (P < 0.001). Additionally, the duration of analgesia was prolonged following BSCPB. VAS scores for 24 h (postoperatively), intraoperative morphine use, and rescue analgesia (postoperatively) remained significantly lower in patients who received BSCPB. There was also a statistically significant reduction in PONV (P = 0.02). Conclusion: BSCPB offers superior postoperative analgesia with a reduction in opioid use, reduction in PONV, and improvement in VAS scores.

Effectiveness of Intermediate Cervical Plexus Block in Whiplash-Associated Disorder: A Prospective Observational Trial in Fifty Patients.

BACKGROUND: Whiplash trauma can result in a range of symptoms, including chronic neck pain, headache, facial pain, upper back pain, and tinnitus, which comprises whiplash-associated disorder (WAD). Intermediate cervical plexus block (iCPB) is a novel intervention that targets the upper cervical nerves and anecdotal reports suggest benefits in WAD. OBJECTIVES: We hypothesized that the cervical plexus may have a role in the pathogenesis of WAD and blocking the cervical plexus may provide analgesia. STUDY DESIGN: Prospective observational trial. SETTING: Tertiary pain medicine unit at a university teaching hospital. METHODS: Adult patients who presented with refractory chronic neck pain following whiplash were included in a prospective observational trial. The pragmatic trial studied the effectiveness of 2 sequential cervical plexus blocks (iCPB with local anesthetic [iCPB-LA] and iCPB with steroid and LA mixture [iCPB-Steroid]) in refractory chronic neck pain following whiplash. Patients who reported < 50% relief at 12 weeks after iCPB-LA were offered iCPB-Steroid. Primary outcome was "neck pain at its worst in the last 24 hours" at 12 weeks. Secondary outcomes included change in neck disability index, employment status, and mood. RESULTS: After excluding cervical zygapophyseal joint dysfunction, 50 patients underwent the iCPB-LA between June 2020 and August 2022. Five patients reported > 50% relief (durable relief) at 12 weeks and 3 patients were lost to follow-up. Forty-two patients received iCPB-Steroid. iCPB-Steroid was associated with significant reduction in neck pain, neck disability, and improvement in mood at 12 weeks when compared to the block with LA. In addition, iCPB-Steroid was associated with significant reduction in neck pain and disability at 24 weeks. Due to functional improvement, 34 patients (34/50, 78%) were able to maintain employment. LIMITATIONS: This is an open-label, observational, single-center study in a limited cohort under a single physician. Cervical facet joint dysfunction was ruled out clinically and radiologically. CONCLUSIONS: Cervical plexus may play a central role in the pathogenesis of WAD. iCPB could potentially be a treatment option in this cohort.

Hemodynamic Safety and Effect of Dexmedetomidine on Superficial Cervical Block Quality for Carotid Endarterectomy: A Prospective Study.

OBJECTIVE: Dexmedetomidine as an adjuvant to local anesthetics (LAs) in regional anesthesia has demonstrated a positive effect on the quality of regional blocks, but there are no studies on usage in superficial cervical block (SCB) for carotid endarterectomy (CEA), in which the management of mean arterial pressure is essential. The authors designed a prospective, randomized, double-blinded study to investigate the effects of the addition of dexmedetomidine on the hemodynamic management and quality of SCB. DESIGN: A prospective, randomized, double-blinded study. SETTING: A single-center study at a university hospital center. PARTICIPANTS: Ultrasound-guided SCB was performed on 60 patients classified as American Society of Anesthesiologists Grades II and III undergoing elective CEA surgery who were assigned into 2 groups randomly. INTERVENTION(S): Both groups received 2 mg/kg of 0.5% levobupivacaine with 2 mg/kg of 2% lidocaine. The intervention group additionally received 50 µg of dexmedetomidine. MEASUREMENTS AND MAIN RESULTS: The onset and duration of sensory block and analgesia, hemodynamic parameters, and adverse effects were recorded. There were minimum effects on hemodynamic parameters and no differences in the incidence of adverse effects. The time to first analgesia was longer in the intervention group than in the control group (N = 30). There was no difference in the duration of the sensory block between groups. The log-rank test indicated a significant difference in the probability of the Numeric Pain Rating Scale <3. CONCLUSION: The addition of 50 µg of dexmedetomidine to 0.5% levobupivacaine and 2% lidocaine for SCB did not influence the hemodynamics and frequency of adverse effects. The median sensory block duration time showed no statistical difference between the groups, but the quality of analgesia postoperatively was much improved in the study group.

Ultrasound-Guided Maxillary Nerve Block and Superficial Cervical Plexus Block During Surgery for Maxillary Malignancy: A Case Report.

We report a case of ultrasound-guided craniocervical nerve blocks performed with ropivacaine for perioperative local/regional anesthesia in a patient who underwent right partial maxillary resection and neck dissection under general anesthesia. The patient was an 85-year-old woman with multiple medical comorbidities in whom analgesia using nonsteroidal anti-inflammatory drugs and opioids was expected to increase the risk of postoperative complications. Bilateral ultrasound-guided maxillary (V2) nerve blocks and a right superficial cervical plexus block were performed, which provided adequate perioperative anesthesia and avoided postoperative complications. The use of ultrasound-guided craniocervical nerve blocks with ropivacaine can be an effective approach for providing prolonged perioperative local anesthesia and analgesia, minimizing the need for other potentially problematic analgesics.

A comparison of efficacy of parenteral and perineural dexmedetomidine with 0.25% ropivacaine for post-thyroidectomy analgesia using bilateral superficial cervical plexus block.

Background and Aims: Opioids are conventionally used for post-thyroidectomy pain, regional anesthesia is becoming popular due to its feasibility and efficacy in minimizing use of opioids and hence its side effects. This study compared analgesic efficacy of bilateral superficial cervical plexus block (BSCPB) using perineural and parenteral dexmedetomidine with 0.25% ropivacaine in thyroidectomy patients. Material and Methods: In this double-blind study, 60 American Society of Anesthesiologists (ASA) physical status I and II thyroidectomy patients, aged 18-65 years were randomized into two groups. Group A (n = 30) received BSCPB with 0.25% ropivacaine, 10 mL on each side with dexmedetomidine 0.5 µg/kg IV infusion. Group B (n = 30) received 0.25% ropivacaine plus dexmedetomidine 0.5 µg/kg, ten mL on each side. Duration of analgesia by measuring pain visual analog scores (VAS), total dose of analgesic requirement, Haemodynamics parameters and adverse events were recorded for 24 h. Categorical variables were analyzed using Chi-square test and continuous variables were computed as mean with standard deviation and analyzed using independent sample t-test. Mann-Whitney U test was used for analysis of ordinal variables. Results: Time to rescue analgesia was longer in Group B (18.6 ± 3.27 h) as compared to Group A (10.2 ± 2.11 h) (P < 0.001). Total analgesic dose required was also found to be lesser in Group B (50.83 ± 20.37 mg) as compared to Group A (73.33 ± 18.27 mg) (P < 0.001). No significant hemodynamic changes or side effects were observed in both groups; (P > 0.05). Conclusion: Perineural dexmedetomidine with ropivacaine in BSCPB significantly prolonged the duration of analgesia with reduced rescue analgesic requirement.

Post-operative analgesic efficacy of 0.25% ropivacaine with dexmedetomidine versus dexamethasone as an adjuvant in bilateral superficial cervical plexus block for thyroidectomy under general anaesthesia - A comparative randomized clinical study.

Background and Aims: The bilateral superficial cervical plexus block (BSCPB) is efficacious for post-operative analgesia in thyroid surgeries. We assessed the analgesic efficacy of dexmedetomidine and dexamethasone administered as adjuvants with 0.25 percent ropivacaine in BSCPB for thyroidectomy under general anaesthesia with regard to the duration of analgesia, total amount of rescue analgesic requirement, changes in intra- and post-operative haemodynamic parameters, VAS scores, and adverse events, if any. Methods: A prospective double-blind trial was planned with 80 adults undergoing thyroidectomy, randomized into two equal groups and given BSCPB with 20 ml 0.25% ropivacaine with adjuvants as either dexmedetomidine 50mg (group A) or dexamethasone 4mg (group B), 10 ml on each side, after the induction of general anaesthesia. Post-operative pain was monitored using the visual analog scale and the duration of analgesia was measured by time to first rescue analgesia. Post-operative haemodynamics and any adverse events were recorded. Results: The mean duration of analgesia was slightly prolonged in group A but statistically non-significant as compared to group B (1037 ± 97 vs. 1004 ± 122 minutes; P0.18). The post-operative median VAS scores and vital parameters were relatively comparable for both groups (P > 0.05) for the first 24h. There was a significant reduction in the incidence of PONV (P < 0.05) in group B. Conclusion: Although dexamethasone offers a slight advantage of decreased incidence of PONV, BSCPB using ropivacaine with either dexmedetomidine or dexamethasone as an adjuvant imparted adequate analgesia with stable haemodynamics and may be used as a pre-emptive analgesic technique in thyroid surgeries.

Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block or interscalene brachial plexus block in clavicle surgery: a single-centre, double-blind, randomized controlled trial.

The sensory innervation of the clavicle is complex, and the best regional block technology for clavicular surgery has yet to be determined. The purpose of this study was to compare the application of ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block verses interscalene brachial plexus block in clavicular surgery. Fifty patients undergoing internal fixation surgery for elective clavicle fractures were randomly divided into two groups (n = 25 for each group): group I and group II. Superficial cervical plexus block combined with clavipectoral fascial plane block was used in group I, and superficial cervical plexus block combined with interscalene brachial plexus block was used in group II. The primary outcome measure was the duration of analgesia. The duration of analgesia in group I was significantly longer than that in group II (P < 0.05). The modified Bromage scale function score in group II was lower than that in group I (P < 0.01). There was no significant difference in the skin acupuncture pain score 30 min after block and visual analog scale (VAS) scores at 6 and 12 h after surgery. However, the 24 h VAS score in group I was lower than that in group II (P < 0.05). The incidence of diaphragmatic paralysis was significantly increased in group II (P < 0.01). Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block can be used for clavicular surgery. It has a long postoperative analgesia time, can retain the motor function of the involved upper limb and does not cause hemidiaphragmatic paresis.Clinical trial number and registry URL: Clinical Trials.gov; Trial registration number: ChiCTR2000039383; Date of registration: 25 October 2020.

Intermediate cervical plexus block in the management of treatment resistant chronic cluster headache following whiplash trauma in three patients: a case series.

OBJECTIVES: Cluster headaches are an intensely painful and debilitating headache disorder. Conventional management includes abortive and preventative agents. A fifth of patients with chronic cluster headaches can be refractory to conventional treatment. Cluster headache can develop following whiplash trauma to the head and neck. CASE PRESENTATION: Three patients were referred to a tertiary pain medicine unit in a university teaching hospital with treatment-resistant chronic cluster headache. They were treated with a novel intervention namely, ultrasound-guided intermediate cervical plexus block with depot methylprednisolone. Patient one reported chronic cluster headache for three years. Patient two reported episodic cluster headache that appeared to be evolving into chronic cluster headache. Patient three reported bilateral cluster headache following a motor vehicle accident. Intermediate cervical plexus block provided significant and durable relief in three patients with treatment resistant chronic cluster headache. CONCLUSIONS: The novel intervention may have played a role in aborting and preventing chronic cluster headaches.

Regional Anesthesia for Vascular Surgery and Pain Management.

Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.

Anesthetic and surgical management of tracheotomy in a patient with Kennedy's Disease.

Introduction: Kennedy's disease (KD) is a rare X-linked recessive motor-neuron neuropathy also known as Spinal and Bulbar Muscular Atrophy (SBMA). Case report: We report a case of Kennedy's disease (KD) with acute laryngeal stridor and dysphagia whose anesthesiologic management required a tracheotomy. The surgical procedure was conducted under local anesthesia performed by ultrasound-guided superior laryngeal nerve block and superficial cervical plexus block using 2% lidocaine. The surgical procedure was well tolerated without any discomfort reported from the patient. Conclusions: In KD local anesthesia should be preferred to general anesthesia as general anesthesia is associated with increased potential for laryngospasm, pulmonary aspiration, and respiratory insufficiency related to the use of neuromuscular blocking agents and opioids. At the best of our knowledge, this is the first case of tracheostomy in KD patient under locoregional anesthesia performed thorough superior laryngeal nerve and superficial cervical plexus block.

A Prospective Observational Study of the Efficacy of Combined Interscalene Block and Superficial Cervical Plexus Block using Peripheral Nerve Stimulator and Landmark-Based Technique, as a Sole Anesthetic for Surgeries on the Clavicle in the COVID-19 Pandemic.

Background: Fractures of the clavicle are usually operated under general anesthesia (GA) as they need dense anesthesia, and the airway is difficult to access intraoperatively. There is no established regional anesthesia (RA) technique for clavicular fractures, also as the innervation is contentious. Some studies have been done using RA techniques, but they are all small case numbers. RA is superior to GA in many ways, and we wished to avoid GA specifically during the COVID-19 pandemic. Aims: This study aimed to use a peripheral nerve stimulator and a landmark-based technique to give interscalene block (ISB) and superficial cervical plexus block (SCPB) as a sole anesthetic for clavicular fracture surgeries during the COVID-19 pandemic. Settings and Design: This was a prospective observational study in a tertiary care teaching hospital in eastern India. Materials and Methods: After approval from our ethics committee and informed consent, thirty patients of American Society of Anesthesiologists Class I or II, aged 18-65 years, after exclusion criteria were selected who had to undergo clavicular surgery. Three 10-mL syringes were made, each with 5 mL of 0.75% ropivacaine, 2 mL of 2% lignocaine with 1:200,000 adrenaline, and 3 mL of saline. Using the HNS Stimuplex (B. Braun Melsungen AG, Melsungen, Germany) nerve stimulator, 20 mL was given for an ISB and 5 mL for the SCPB. RA was considered successful if there was no conversion to GA and surgery could be performed. Results: With an onset time of 6.53 ± 2.17 min, good operating conditions were obtained in all our patients. Horner's syndrome was noted in two patients. Surgery was successfully carried out in all thirty patients under RA. Pain relief lasted postoperatively for 5 ± 0.92 h. Conclusion: ISB combined with SCPB is safe and effective as a sole anesthetic for clavicular surgery. We successfully avoided the use of a general anesthetic in these patients during the COVID-19 pandemic and gave them a safe and effective alternative.