What nerve blocks are recommended for clavicle surgery?

Nerve Blocks for Clavicle Surgery

For clavicle surgery, the most effective nerve block approach is a combination of ultrasound-guided interscalene brachial plexus block with superficial cervical plexus block, which provides superior analgesia compared to general anesthesia alone. 1

Optimal Nerve Block Approach for Clavicle Surgery

Primary Recommendation

• Combined interscalene brachial plexus block with superficial cervical plexus block
  • This combination effectively addresses the complex innervation of the clavicle region 2
  • Provides effective intraoperative anesthesia and postoperative analgesia 1
  • Results in significantly lower postoperative pain scores and reduced opioid consumption compared to general anesthesia 1

Technical Considerations

• Use ultrasound guidance for precise needle placement
• For interscalene block:
  • Ropivacaine 0.75% is recommended for initial injection 3
  • Volume: 15-20 mL for adequate spread
• For superficial cervical plexus block:
  • Ropivacaine 0.5% is effective 4
  • Volume: 5-10 mL along the posterior border of sternocleidomastoid

Alternative Approaches

If the primary approach is contraindicated (e.g., patient refusal, coagulopathy, infection at injection site):

1. Supraclavicular brachial plexus block with superficial cervical plexus block

   • Consider when respiratory concerns exist with interscalene approach
   • Use nerve stimulation with a minimal threshold of 0.9 mA for supraclavicular blocks 5

2. Infraclavicular brachial plexus block with superficial cervical plexus block

   • May be considered for more distal clavicular procedures
   • Double-stimulation technique is optimal for infraclavicular blocks 5

Important Clinical Considerations

Respiratory Function

• Interscalene blocks can affect respiratory function due to phrenic nerve involvement
• If respiratory concerns exist, consider alternative approaches such as axillary or infraclavicular brachial plexus block 6
• Supraclavicular brachial plexus block may be chosen over interscalene block in patients with respiratory compromise 6

Pharmacological Management

• Ropivacaine 0.5-0.75% provides effective anesthesia for brachial plexus blocks 7
• For continuous infusion techniques, ropivacaine 0.2-0.3% is recommended 3
• Duration of analgesia:
  • Single-shot blocks: 6-8 hours
  • Continuous blocks: up to 48-72 hours 3

Monitoring and Safety

• Monitor patients for at least 30 minutes following local anesthetic injection
• Watch for signs of local anesthetic systemic toxicity (LAST)
• Assess respiratory function, particularly with interscalene approach
• Maximum recommended dose of ropivacaine should not be exceeded (typically 3 mg/kg) 7

Common Pitfalls and How to Avoid Them

1. Incomplete analgesia

   • The clavicle has complex innervation from multiple sources
   • Solution: Use combined blocks (interscalene + superficial cervical plexus) rather than single approach

2. Respiratory compromise

   • Phrenic nerve paralysis is common with interscalene blocks
   • Solution: Consider alternative approaches in patients with respiratory disease

3. Block failure

   • Solution: Use ultrasound guidance and ensure adequate local anesthetic spread around target nerves

4. Vascular puncture

   • Solution: Use ultrasound guidance and careful aspiration before injection

The evidence strongly supports that combined interscalene brachial plexus block with superficial cervical plexus block is the most effective regional anesthesia technique for clavicular surgery, providing excellent intraoperative conditions and postoperative analgesia while avoiding the risks associated with general anesthesia 1, 2.