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Anesth Analg 2002;95:746-750
© 2002 International Anesthesia Research Society

REGIONAL ANESTHESIA

The Analgesic Efficacy of Bilateral Combined Superficial and Deep Cervical Plexus Block Administered Before Thyroid Surgery Under General Anesthesia

Sophie Aunac, MD, Marianne Carlier, MD, Francois Singelyn, MD PhD, and Marc De Kock, MD PhD

Department of Anesthesiology, University of Louvain, St. Luc Hospital, Brussels, Belgium

Address correspondence and reprint requests to M. De Kock, MD, Department of Anesthesiology, St. Luc Hospital, av. Hippocrate 10-1821, 1200 Brussels, Belgium. Address e-mail to dekock{at}anes.ucl.ac.be


   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
In this study we evaluated the analgesic efficacy of combined deep and superficial cervical plexus block in patients undergoing thyroidectomy under general anesthesia. For this purpose, 39 patients undergoing elective thyroid surgery were randomized to receive a bilateral combined deep and superficial cervical block (14 mL per side) with saline (Group 1; n = 13), ropivacaine 0.5% (Group 2; n = 13), or ropivacaine 0.5% plus clonidine 7.5 µg/mL (Group 3; n = 13). Deep cervical plexus block was performed with a single injection (8 mL) at the C3 level. Superficial cervical plexus block consisted of a subcutaneous injection (6 mL) behind the lateral border of the sternocleidomastoid muscle. During surgery, the number of additional alfentanil boluses was significantly reduced in Groups 2 and 3 compared with Group 1 (1.3 ± 1.0 and 1.1 ± 1.0 vs 2.6 ± 1.0; P < 0.05). After surgery, the opioid and non-opioid analgesic requirements were also significantly reduced in Groups 2 and 3 (P < 0.05) during the first 24 h. Except for one patient in Group 3, who experienced transient anesthesia of the brachial plexus, no side effect was noted in any group. We conclude that combined deep and superficial cervical plexus block is an effective technique to alleviate pain during and immediately after thyroidectomy.

IMPLICATIONS: Combined deep and superficial cervical plexus block is an effective technique to reduce opioid requirements during and after thyroid surgery.


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
In contrast to other procedures, anesthesia for thyroid surgery may appear quite simple. In uncomplicated cases, surgical stimulation during dissection of the gland is gentle. Such procedures have been successfully performed under regional anesthesia or hypnosis only (1,2). It is surprising that when general anesthesia is used, relatively deep anesthesia is required. This is probably related to the combination of surgery and frequent tracheal stimulation associated with movements of the endotracheal tube during surgical manipulations. Deep anesthesia for such short-lasting procedures may delay recovery. The use of short-acting opioids may appear attractive for several reasons, but postoperative hyperalgesia is a major drawback (3). In this setting, the use of regional anesthesia may lighten the level of general anesthesia required and provide prolonged postoperative analgesia, reducing the requirements for opioid analgesics. The goal of this study was to evaluate the intra- and postoperative analgesic efficacy of bilateral superficial and deep cervical plexus block for thyroid surgery.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
The study was approved by the Ethics Committee of the Catholic University of Louvain for human investigations, and written, informed consent was obtained from each patient. Thirty-nine ASA physical status I–II adult patients scheduled for elective thyroid surgery under general anesthesia were included. All patients were euthyroid before surgery; the same surgeon performed all the procedures, which always took place between 8:00 AM and 11:00 AM.

Noninclusion criteria included intolerance or contraindication to any medication used in the study and inability to understand the study protocol or the pain scale. All the patients were instructed the day before surgery about the study protocol and particularly about the use of the visual analog scale (VAS). Patients were premedicated with lormetazepam (2 mg orally) 2 h before surgery. General anesthesia was induced with IV propofol until loss of consciousness and supplemented with alfentanil 3 µg/kg. Orotracheal intubation was facilitated by the administration of 0.4 mg/kg of atracurium. All patients received 4 µg/kg of IV clonidine over 15 min. Anesthesia was maintained with propofol 3 mg · kg-1 · h-1. Additional doses of propofol (0.5 mg/kg) were given when the heart rate or the systolic arterial blood pressure increased more than 20% compared with a baseline value recorded during stable unstimulated anesthesia. If the heart rate or systolic arterial blood pressure did not return to baseline 3 min after a propofol bolus, 3 µg/kg of alfentanil IV was injected. Additional doses of propofol (0.5 mg/kg) were administered to maintain a bispectral index of <65.

By use of a random number sequence, patients were randomized to receive isotonic sodium chloride solution (Group 1), 0.5% plain ropivacaine (Group 2), or 0.5% plain ropivacaine plus clonidine 7.5 µg/mL (Group 3) to complete the bilateral cervical block. After the induction of general anesthesia, the cervical plexus blocks were performed bilaterally by an anesthesiologist unaware of the solutions used. The deep block was performed according to a technique modified from that of Winnie et al. (4). A 23-gauge, short-beveled needle (Pole, Top, Japan) was inserted behind the lateral border of the sternocleidomastoid muscle, 3 cm distal to the mastoid process. After negative aspiration for blood, 8 mL of solution was injected. The superficial block was performed by using the same needle inserted at the midpoint of the lateral border of the sternocleidomastoid muscle. After negative aspiration, 6 mL of solution was injected in four directions (1.5 mL in each direction) to block the main branches (lesser occipital, greater auricular, transverse cervical, and supraclavicular nerves) of the plexus. The injection was given with unlabeled syringes prepared by an anesthesiologist not involved in the patient’s care or pain assessment. The specific treatment given was unknown to the patient, anesthesiologist, surgeon, or nurse in charge of pain assessment. When the patient arrived in the postanesthetic care unit (PACU) and 2 h later, sensory block in the C2, C3, and C4 areas was assessed by using an ether swab.

Postoperative pain management was standardized as follows. In the PACU, where patients stayed for 2 h, IV propacetamol 2 g (Prodafalgan®; Upsa Medica, Waterloo, Belgium) was given to all patients at their arrival. Piritramide (Dipidolor®; Jansens Pharmaceutica, Beerse, Belgium), a µ-opiate agonist, was titrated in 2-mg IV increments when pain scores were >4 at rest and >6 when swallowing. Scores were assessed with a horizontal VAS consisting of a line going from left (score 0; no pain) to right (score 10; maximal pain). On the ward, during the day of surgery, piritramide 10 mg IM was given when pain scores were >4 at rest and >6 when swallowing. Propacetamol (2 g IV) was given to alleviate moderate pain (VAS 4 or less at rest and 6 or less with swallowing). On the first postoperative day, patients were allowed to receive pain therapy orally. For severe pain (same criteria as before), 50 mg of tramadol (Contramal®; Continental Pharma, Brussels Belgium) was given, and paracetamol 1 g was administered for moderate pain. Additionally, 50 mg of IV diclofenac was administered in all patients on the first postoperative day.

The analgesic efficacy of the cervical block was assessed with the following variables:

  1. Intraoperative anesthetic (propofol) and analgesic (alfentanil) requirements.
  2. Postoperative narcotic analgesic requirements at 2, 12, and 24 h.
  3. Postoperative nonnarcotic analgesic requirements at 2, 12, and 24 h.
  4. In addition to the VAS performed before analgesic administration, pain was evaluated at rest and swallowing by using the VAS at recovery time, 2 h after the end of the procedure, and every 6 h until 24 h after the end of surgery.

Side effects related to the regional anesthetic technique, such as cervical epidural analgesia and diaphragmatic palsy, were recorded. Particularly, patients were clinically evaluated by an experienced anesthesiologist for respiratory distress related to bilateral diaphragmatic palsy at recovery and in the PACU. Should this occur, dynamic chest radiograph examination would be performed to ascertain the diagnosis. Other side effects, such as bradycardia, hypotension, nausea, vomiting, antiemetic requirements, and excessive sedation, were recorded.

Assuming that bilateral superficial and deep cervical plexus block would reduce the dose of intra- and postoperative narcotics by 50%, the number of patients required in each group to observe such reduction was at least 10 with {alpha} = 0.05 and ß = 0.08. Continuous parametric variables are reported as mean ± SD and were analyzed with analysis of variance. Tukey’s tests were used for post hoc comparison. The normal distribution of the data was assessed with the Kolmogorov-Smirnov test. Categorical variables were analyzed with {chi}2 tests, with continuity correction if appropriate. Nonparametric data were compared by using the Kruskal-Wallis test. A value of P < 0.05 was considered significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
All 39 patients enrolled completed the study protocol. Demographic characteristics were similar in the three groups except for the duration of surgery, which was significantly shorter in Group 1 (Table 1). Significantly fewer propofol boluses were required in Groups 2 and 3. The time between cessation of the propofol infusion and extubation was significantly shorter in these two groups (Table 1).


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  		Table 1. Table 1. Patient Characteristics (means ± sd)
 
Intra- and postoperative analgesic requirements are summarized in Table 2. When compared with Group 1, opioid requirements were significantly reduced in Groups 2 and 3 (P < 0.05). In the PACU, 10 patients in Group 1 versus 4 in Group 2 and 2 in Group 3 received piritramide (2.6 ± 2.0 mg in Group 1 versus 0.6 ± 1.2 mg in Groups 2 and 3; P < 0.05). On the ward, during the day of surgery, two patients in Group 1 still required IM piritramide, versus none in Groups 2 and 3. On the first postoperative day, tramadol was required in four patients of Group 1 versus one in Group 2 and none in Group 3. When compared with Group 1, the requirements for non-opioid analgesics were significantly reduced in Group 3 on the day of surgery and in Groups 2 and 3 on the first postoperative day.


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  		Table 2. Table 2. Intra- and Postoperative Analgesic Requirements (means ± sd)
 
Pain scores at rest and when swallowing are presented in Figure 1. No significant difference was noted among the different groups during the observation period.



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  		Figure 1. Visual analog scale (VAS) scores at rest (A) and during swallowing (B). Results are means ± SD. No significant difference was noted. T0–T24 represents VAS immediately after the surgical procedure and at 2, 6, 12, 18, and 24 h. {blacksquare}, Group 1; {blacktriangleup}, Group 2; •, Group 3.

 
All patients in Groups 2 and 3 presented a complete or partial sensory block in the C2 to C4 nerve dermatomes on admission to the PACU (Table 3). Two hours later, regression of the block starting from the subclavicular region and the lowest part of the neck (C4 area) was recorded in the majority of the patients. No significant difference was noted between Groups 2 and 3. Six hours later, sensory block had resolved in all patients. None of the patients studied presented with respiratory distress in recovery, and consequently no chest radiograph evaluation was performed.


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  		Table 3. Table 3. Number of Patients (n) in Groups 2 and 3 Presenting with Loss of Cold Sensation in the C2, C3, or C4 Cervical Area at Admission to the PACU and 2 h Later (R/L = right/left)
 
At recovery, one patient in Group 3 presented with partial motor (weakness at motion of the shoulder, difficulties in performing abduction and antepulsion) and sensory blocks (thermoanalgesia in C6 and C7 nerve area, block of the right arm territory). The partial brachial plexus block completely resolved in 4 h. Three patients in Group 1 versus one patient in Groups 2 and 3 presented with postoperative nausea and vomiting requiring antiemetic medications (not significant). No other side effect was noted in any group. In particular, no patient experienced laryngeal palsy or postoperative bleeding.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Our results show that bilateral superficial and deep cervical plexus block performed with 0.5% plain ropivacaine significantly reduced intraoperative requirements of anesthetics and analgesics in patients undergoing thyroidectomy. Postoperative analgesics were significantly reduced during the first 24 hours after surgery.

Recently, Dieudonne et al. (5) pointed out the analgesic advantages of bilateral superficial cervical block administered immediately after thyroid surgery. In this study, 45% of the patients who benefited from such a block did not require opiate analgesics during the first 2 hours after surgery, and 34% were free from opiates during the first 24 hours. In our study, which used comparable criteria for rescue analgesic administration, 73% and 69% of the patients with bilateral superficial and deep cervical blocks, respectively, were free from opiates during the first 2 and 24 hours after surgery. Several reasons may account for this difference. In this study, deep cervical blocks were performed, likely resulting in more complete regional analgesia. Our data, however, do not prove that the observed benefits can be ascribed to the deep cervical block. Although the blocks were tested by cold sensation, sensory block in the C2 to C4 dermatomes may result from either deep or superficial cervical plexus blocks. Another possible explanation is the administration of clonidine at the induction of anesthesia. This {alpha}2-adrenergic agonist improves analgesia and reduces postoperative opiate demand in patients undergoing various type of surgery (6,7). It may account for the slightly larger proportion of opiate-free patients (20%) in the saline group observed in our study than in the control groups of Dieudonne et al. (5) and others (8) (±10%). Moreover, systemic clonidine prolongs and intensifies local anesthetic regional block (9). Finally, in our investigation, a more concentrated solution of local anesthetic was used (0.5% ropivacaine instead of 0.25% bupivacaine). This was done on the basis of studies of epidural or intrathecal use that clearly indicate a 40% to 45% reduced potency of ropivacaine compared with bupivacaine (10,11). Ropivacaine was chosen because this local anesthetic is less toxic after IV administration than bupivacaine, even at equipotent doses (12). This is an important advantage when relatively large volumes of local anesthetic are administered near vascular structures.

Combined superficial and deep cervical plexus block is a technique that was initially developed to avoid general anesthesia for carotid endarterectomy (13). It has already been successfully used to perform thyroidectomy during light sedation (1,14). Although it provides better analgesia, deep cervical plexus block is technically more difficult to perform and may be associated with more serious complications than superficial cervical plexus block. The potential serious complications associated with deep cervical block include vertebral artery, subarachnoid, or epidural injections and phrenic nerve palsy. Phrenic nerve palsy appears frequently after deep cervical plexus block (55%) (15). However, it is relatively well tolerated when the block is unilateral in patients with normal respiratory function (15). In our study, bilateral deep and superficial blocks were performed in patients under general anesthesia. This is not a recommended clinical practice, and was done primarily to mainly to preserve study blinding. This approach renders paresthesia undetectable and masks signs of intravascular injection. In the case of bilateral phrenic nerve palsy and cervical epidural or intrathecal injections, major respiratory distress would have resulted. When the block is performed in anesthetized patients, should this complication occur, the treatment (mechanical ventilation until block resolution) is already initiated. On recovery from anesthesia, this complication would have been detected, because only one intubating dose of atracurium and a small amount of alfentanil were given. Bilateral phrenic palsy manifests as respiratory distress occurring when the patient breathes spontaneously before tracheal extubation, in contrast to recurrent nerve paralysis, which is manifested after extubation.

The lack of objective variables to ascertain uni- or bilateral diaphragmatic palsy may appear as a flaw of our study. Study protocol included a chest radiograph in case of respiratory difficulty. Fortunately, no patient had difficulty with breathing in the PACU, suggesting a small incidence of bilateral phrenic paresis in our patients. This may be attributed to the technique used: deep cervical plexus block was performed with a single-injection technique at the C3 level instead of the classic three-injection technique, and a smaller volume of local anesthetic (8 mL) was injected, in comparison to previous studies (16–18). Nevertheless, additional study considering preoperative and early postoperative pulmonary function or diaphragmatic ultrasound investigation has to be completed before the safety of this technique can be determined.

Surprisingly, adding clonidine to ropivacaine did not afford additional clinical benefit. Two explanations can be given. First, as previously mentioned, systemic clonidine prolongs local anesthetic-induced sensory block (9). This effect may have obscured the action of local clonidine. Second, a local analgesic effect of clonidine was demonstrated only in the presence of local inflammatory reaction. In our study, local clonidine was given before the inflammatory process was established (19).

In conclusion, combined deep and superficial cervical plexus block is an effective technique to reduce opioid analgesic requirements during and after thyroid surgery. However, the exact extent of the additional risk for the patients remains to be evaluated by large-scale studies. Moreover, when considering the reduced amount of general anesthetic required in patients in the cervical block groups, the possibility of performing thyroid surgery under regional anesthesia alone deserves attention.


   Acknowledgments
 
Supported by the Department of Anesthesiology of the University of Louvain, St. Luc Hospital.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Saxe AW, Brown E, Hamburger S. Thyroid and parathyroid surgery performed with the patient under regional anesthesia. Surgery 1988; 103: 415–20.[ISI][Medline]
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  5. Dieudonne N, Gomola A, Bonichon P, Ozier Y. Prevention of postoperative pain after thyroid surgery: a double-blind randomized study of bilateral superficial cervical plexus blocks. Anesth Analg 2001; 92: 1538–42.[Abstract/Free Full Text]
  6. Bernard JM, Hommeril JL, Passuti N, Pinaud M. Postoperative analgesia by intravenous clonidine. Anesthesiology 1991; 75: 577–82.[ISI][Medline]
  7. De Kock M, Pichon G, Scholtes JL. Intraoperative clonidine enhances postoperative morphine patient-controlled analgesia. Can J Anaesth 1992; 39: 537–44.[Abstract/Free Full Text]
  8. Gozal Y, Shapira SC, Gozal D, Magora F. Bupivacaine wound infiltration in thyroid surgery reduces postoperative pain and opioid demand. Acta Anaesthesiol Scand 1994; 38: 813–5.[ISI][Medline]
  9. Bonnet F, Brun-Buisson V, Saada M, et al. Dose-related prolongation of hyperbaric tetracaine spinal anesthesia by clonidine in humans. Anesth Analg 1989; 68: 619–22.[Abstract/Free Full Text]
  10. Gautier P, De Kock M, Van Steenberge , et al. Intrathecal ropivacaine for ambulatory surgery: a comparison between intrathecal bupivacaine and intrathecal ropivacaine for knee arthroscopy. Anesthesiology 1999; 91: 1239–45.[ISI][Medline]
  11. Capogna G, Celleno D, Fusco P, et al. Relative potencies of bupivacaine and ropivacaine for analgesia in labour. Br J Anaesth 1999; 82: 371–3.[Abstract/Free Full Text]
  12. Dony P, Dewinde V, Vanderick B, et al. The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats. Anesth Analg 2000; 91: 1489–92.[Abstract/Free Full Text]
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  14. Kulkarni RS, Braverman LE, Patwardhan NA. Bilateral cervical plexus block for thyroidectomy and parathyroidectomy in healthy and high risk patients. J Endocrinol Invest 1996; 19: 714–8.[ISI][Medline]
  15. Castresana MR, Masters RD, Castresana EJ, et al. Incidence and clinical significance of hemidiaphragmatic paresis in patients undergoing carotid endarterectomy during cervical plexus block anesthesia. J Neurosurg Anesthesiol 1994; 6: 21–3.[ISI][Medline]
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Accepted for publication May 7, 2002.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press