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CASE REPORTS

An Indication for Continuous Cervical Paravertebral Block (Posterior Approach to the Interscalene Space)

Department of Anesthesia, University of Iowa, Iowa City, Iowa

Address correspondence and reprint requests to André P. Boezaart, MD, PhD, Department of Anesthesia, University of Iowa Hospital and Clinics, 200 Hawkins Dr., 6-JCP, Iowa City, IA 52240-1079. Address e-mail to andre-boezaart{at}uiowa.edu

	Abstract

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IMPLICATIONS: In this case report, we describe a patient who received perioperative analgesia with continuous nerve block for shoulder disarticulation, performed as a last option for management of intractable pain. As the result of anatomic considerations, a continuous cervical paravertebral block (posterior approach to the interscalene space) was performed.

	Introduction

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Kappis (1) first described the posterior approach to the brachial plexus in 1912. Thereafter, Pippa et al. (2) reintroduced this approach in 1990. Although this approach has been described as easy to perform and effective, it never gained popularity, possibly because of the associated posterior neck pain. Recently a modification of the approach has been described by which penetration of the posterior extensor muscles of the neck is avoided and a catheter for continuous infusion is placed while the nerves are stimulated through both the needle and the catheter (3,4). We present a report of a patient with severe upper extremity pain who was scheduled for shoulder disarticulation. Because of severe scarring, tumor infiltration, and torticollis, a posterior approach to the brachial plexus was chosen.

	Case Report

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A 51-yr-old woman of average build (weight, 82 kg; height, 166 cm) presented for shoulder disarticulation to be performed as a last resort for pain management. Six years previously, she had undergone left modified radical mastectomy and radiotherapy for breast carcinoma. The tumor subsequently spread to the left axillary lymph nodes and brain. She underwent successful removal of the metastatic brain lesion but developed severe lymphedema and brachial plexopathy of her left arm, resulting in extreme pain and complete loss of function. Unsuccessful efforts to control her pain included bulk-reducing liposuction, as well as IV patient-controlled analgesia with hydromorphone and morphine sulfate 15 mg/d (later changed to hydromorphone 5 mg/d) by intrathecal injection and fentanyl 200 µg/h, changed every 72 h by transdermal patch. A trial of adjuvant analgesics in the form of amitriptyline and gabapentin was included in the pain-treatment regimen in an effort to minimize the neuropathic pain, but this was unsuccessful. The opioids caused severe nausea and fatigue, and pain was still reported as 9–10 on the visual analog scale (VAS), where 0 equals no pain and 10 equals the worst pain imaginable. Metastatic tumor, surgical scarring, and radiotherapy had resulted in severe left-sided torticollis.

Continuous cervical paravertebral block was performed with the patient in the sitting position, as previously described (3,4). No sedation was required for the procedure. After thorough infiltration of the subcutaneous tissue down to the pars intervertebralis of the sixth cervical vertebra with 1% lidocaine, an insulated 17-gauge Tuohy needle (StimuCath^TM; Arrow International, Reading, PA) was used to perform the block. The needle was introduced through the skin at the apex of the V shape formed by the trapezius and levator scapulae muscles at the level of the spinous process of C6 (7 cm lateral to the spinous process of C6 in this case) and directed anteriorly, caudally, and medially, aiming toward the suprasternal notch, until contact was made with the transverse process of C6 at a depth of 5 cm from the skin (Figs. 1 and 2 ). The needle was attached to a peripheral nerve stimulator set at an output of 1.2 mA with a pulse width of 200 µs and to a loss-of-resistance-to-air syringe. The needle was "walked off" the transverse process laterally, and loss of resistance to air and twitching of the shoulder girdle muscles occurred simultaneously when the space between the anterior and middle scalene muscles was entered approximately 0.5 cm beyond the bony structures. Optimal needle placement was assumed when muscle twitches were still brisk at a nerve stimulator output of 0.5 mA.

View larger version (160K): [in this window] [in a new window]   Figure 1. Posterolateral view of the neck. The needle enters the skin at the apex of the V shape formed by the trapezius and levator scapulae muscles, and the needle is aimed inferomedially toward the suprasternal notch.

View larger version (139K): [in this window] [in a new window]   Figure 2. Transection of the neck at the level of the sixth cervical vertebra. 1 = brachial plexus; 2 = anterior scalene muscle; 3 = middle scalene muscle; 4 = vertebral artery; 5 = trapezius muscle; 6 = levator scapulae muscle; 7 = phrenic nerve; 8 = carotid artery; 9 = internal jugular vein; 10 = thyroid gland. The needle enters between the trapezius muscle (5) and the levator scapulae muscle (6) and is aimed inferomedially toward the suprasternal notch until the transverse process of C6 is encountered. The needle is then "walked off" this bony process, and loss of resistance to air and nerve stimulation occur simultaneously when the brachial plexus (1) is reached. Note that the bony processes of the vertebrae guard the vertebral artery (4), provided that the entry is from the posterior direction and that bony contact is achieved.

Before the placement of the block and before surgery, which was performed under total IV general anesthesia with propofol, the baseline pain level was reported to be 9—10 on a VAS of 0–10. The surgery was uneventful, and 0.25% bupivacaine was infused after surgery at 5 mL/h, which provided excellent analgesia throughout the postoperative period. The VAS was never reported to be >2 after surgery, and no systemic analgesics were required throughout the postoperative period. The infusion was discontinued and the catheter removed on the fifth postoperative day. The neuropathic pain from the brachial plexopathy persisted, but it was successfully managed with transdermal fentanyl. The patient did not report any phantom limb pain after 5 mo of follow-up.

	Discussion

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Continuous interscalene block (5) has been used successfully in treating pain associated with shoulder surgery. In our patient, altered anatomy made this traditional approach difficult, and supraclavicular, infraclavicular, and axillary approaches were likewise impractical. The last three techniques would also have required suprascapular nerve and lateral pectoral nerve blocks (6). Because of the previous pain-control failures with opioids, the use of cervical epidural catheterization and paravertebral block was considered. Unilateral cervical epidural has been described (7), but because of the likelihood of bilateral block, we selected a paravertebral approach for this patient.

Generally described as easy to perform (8), continuous cervical paravertebral block has been criticized for causing pain at the catheter or needle entry site (9). There is also a potential for epidural or subarachnoid spread of local anesthetic or hematoma formation (9). Subarachnoid spread after cervical paravertebral block has been reported (10), but this complication has also been documented for the anterior interscalene approach (11–13). The use of a Tuohy needle or bullet-tip catheter may prevent this complication for both approaches (14). Pain with needle or catheter placement is probably the primary reason why this approach to the brachial plexus never gained popularity. Boezaart (4) recently addressed the issue of pain with needle insertion by proposing a modified approach to the paravertebral space that avoids penetrating the extensor muscles of the neck. In this approach, the needle enters between the anterolateral border of the trapezius muscle and the posteromedial border of the levator scapulae muscle, in the apex of the V shape made by these two muscles (Fig. 1). The needle is aimed toward the suprasternal notch (Fig. 2). The patient described in this report had no pain at the needle and catheter entry site, although this may have been masked by the transdermal fentanyl.

Cervical paravertebral block was the most feasible alternative for this patient, for whom other options were difficult or impossible because of anatomical derangements. Medical management with opioids alone or with adjuvants had previously failed to provide adequate pain relief with acceptable side effects. This block was a valuable asset in the management of this difficult clinical situation.

	Footnotes

 
Dr. Boezaart initiated the concept of nerve stimulation via both the needle and catheter and the development of the StimuCath^TM. He also acted as a consultant to Arrow International in the development of the StimuCath^TM.

	References

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1. Macintosh RR, Mushin WW. Brachial plexus. In: Macintosh RR, Mushin WW, eds. Local analgesia. 4th ed. Edinburgh: E&S Livingston Ltd, 1967: 8.
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10. Aramideh M, van der Oever HL, Walstra GJ, Dzoljic M. Spinal anesthesia as a complication of brachial plexus block using the posterior approach. Anesth Analg 2002; 94: 1338–9.[Abstract/Free Full Text]
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