title: [Ultrasound-guided intermediate cervical plexus block. Anatomical study].
abstract: OBJECTIVE
  The innervation of the human cervical region is complex and subject to relevant anatomical variability involving sections of the cervical plexus, brachial plexus and cranial nerves.
  
  
  OBJECTIVE
  The objective was to demonstrate the dissemination of injected dye solution by anatomical preparation and to define a suitable target compartment for an ultrasound-guided block technique.
  
  
  METHODS
  Own anatomical preparations are compared to recent review articles on the subject. The focus is on clinically relevant conclusions for performing cervical plexus blocks. In three non-embalmed cadavers six intermediate ultrasound-guided blocks of the cervical plexus were carried out, each with 20 ml methylene blue. Following preparation of the cervical plexus photographic documentation of the spread of the injected marker was performed.
  
  
  RESULTS
  In five cases the target compartment was correctly identified. In these cases, a cranio-caudal spread of the injectate within the double layer of the cervical fascia was observed. In addition, the superficial layer was permeable to the injected methylene blue. The injection solution disseminated with the sensitive terminal branches of the cervical plexus below the platysma. In all cases an anastomosis (superficial cervical ansa) between the facial nerve (ramus colli) and the cervical plexus (transverse cervical nerve) could be demonstrated. The prevertebral lamina proved to be impermeable to injected methylene blue and no evidence of a porous structure of the prevertebral lamina was found.
  
  
  CONCLUSIONS
  The compartment between the superficial and the prevertebral layer of the cervical fascia is a suitable target for cervical plexus blocks. This injection site describes an intermediate cervical plexus block. As the compartment contains the sensory terminal branches of the spinal nerves C2-4, it may be referred to as C2-C4 compartment. The cranio-caudal spread of the injectate allows lateromedial needle guidance in the horizontal plane. As the superficial lamina is not a barrier to the injectate an additional subcutaneous infiltration of the nerve area appears dispensable. The prevertebral lamina proved to be impermeable to injected methylene blue. Whether phrenic nerve blocks are preventable with more distal intermediate cervical plexus blocks (selective block of the supraclavicular nerves, e.g. for surgery of the clavicle) must be investigated in clinical trials. The permanent anastomosis (superficial cervical ansa) between the cervical plexus and the ramus colli of the facial nerve provides an anatomically reasonable explanation for inadequate cervical plexus blocks.
authors.affiliation: Klinik für Anästhesiologie und Intensivmedizin, HELIOS-Kliniken Schwerin, Wismarsche Str. 393-397, 19049, Schwerin, Deutschland, ronald.seidel@helios-kliniken.de.
authors.forename: R
authors.initials: R
authors.lastname: Seidel
authors.forename: M
authors.initials: M
authors.lastname: Schulze
authors.forename: K
authors.initials: K
authors.lastname: Zukowski
authors.forename: A
authors.initials: A
authors.lastname: Wree
mesh_terms: D059925:Anatomic Landmarks; D000765:Anesthesia, Conduction / Q000379:methods; D002102:Cadaver; D002572:Cervical Plexus / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D066008:Cervical Plexus Block / Q000379:methods*; D002574:Cervical Vertebrae / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D004396:Coloring Agents; D005154:Facial Nerve / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D006801:Humans; D008751:Methylene Blue; D013127:Spinal Nerves / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D018084:Ultrasonography, Interventional / Q000379:methods*
chemical_list: D004396:Coloring Agents; D008751:Methylene Blue