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Abstract
Background and Aims Carotid Endarterectomy (CEA) is a prophylactic surgery performed to prevent embolic stroke in patients with atheromatous disease in the carotid bifurcation. Reducing perioperative stress is critical in minimizing cardiovascular and cerebrovascular complications. Both superficial and deep cervical plexus block (CPB) have been described to provide effective analgesia and anaesthesia for head and neck surgery. Recently, an intermediate cervical plexus block has been described as a variant. We report a case that was successfully managed with ultrasound guided intermediate cervical plexus block for CEA in a high-risk patient.
Methods Patient consent was obtained for the case report. A 63-year-old male patient was scheduled for a left sided CEA with synthetic patch grafting. The patient presented with a history of right sided sensory-motor syndrome with a CT four vessel angiogram demonstrating worsening of stenosis in the left proximal cervical segment of internal carotid artery. An ultrasound-guided Intermediate CPB was performed with Ropivacaine 0.4% 10 mL via a BBraun Stimuplex 22G 50 mm insulated needle preoperatively (figure 1). The patient opted for a general anaesthesia for the surgery. Intraoperative course was uneventful during both cross clamping of the carotid artery and internal carotid artery shunting.
Results Postoperatively, the patient was conscious, oriented, pain-free with no focal neurological deficits. The patient was monitored in surgical intensive care unit for a day and discharged to the ward.
Transverse sonogram of the lateral cervical area at the C4 level. The posterior cervical space is located between the sternocleidomastoid (SCM), longus colli (LC) and scalene (SM) muscles. Solid white arrow indicates the needle location for intermediate cervical plexus block where local anaesthetic (LA) spreads towards the carotid sheath
Conclusions We demonstrated the Intermediate CPB to be feasible, effective and safe with low perioperative complications. Further studies are still required to explore this technique, including dose-finding studies to achieve optimum analgesia.