Awake Single-Stage Bilateral Clavicle Surgeries Under a Bilateral Clavipectoral Fascial Plane Block: A Case Report and Review of Literature

Abstract

The clavicle is a frequently fractured bone with an infrequent bilateral occurrence. Regional anesthesia (RA) for clavicle surgeries is always challenging due to its complex innervation arising from the two plexuses (cervical and brachial). Various RA techniques described for clavicle surgeries include plexus blocks, fascial plane blocks, and truncal blocks. Plexus blocks are associated with undesirable effects, such as phrenic nerve blockade and paralysis of the entire upper limb, limiting their application for bilateral regional clavicle surgeries. The clavipectoral fascial plane block (CPB) is a novel, procedure-specific, phrenic-sparing, and motor-sparing RA technique that can provide anesthesia or analgesia for clavicle surgeries. The decision to use the CPB and/or other RA techniques may depend on the site of clavicle injury or variations in clavicular innervation.We report a case of single-stage bilateral clavicle surgery successfully managed with a bilateral CPB alone using ultrasound guidance and landmark guidance separately. The patient was kept awake and comfortable throughout the surgery.In conclusion, CPB can be an effective alternate RA technique in avoiding undesired side effects of more proximal techniques such as phrenic nerve involvement and motor blockade of upper limbs. Landmarkguided CPB can be an alternative with equianalgesic efficacy as of ultrasound-guided CPB in resource-poor or emergency settings.

In Response

“…Several case reports even illustrated that CPB could be considered as a sole and effective alternate regional anesthesia technique for midshaft clavicle surgery. 5,6 The anatomical results by Labandeyra et al 1 show us the right way, following which we could explain our clinical findings, but there is still a gap between clinical "hyperreality" and anatomical reality. We wonder whether the different tissue elasticity between cadaver and living patient and the effect of spontaneous breathing or intrathoracic pressure on the spread of local anesthetic would contribute to these discrepant realities.…”

Bilateral clavipectoral fascial plane block in single-stage surgery for bilateral midshaft clavicle fractures

“…It may also be useful in clavicle fracture surgery for patients with a poor respiratory status or phrenic nerve paralysis on the uninjured side. It has been reported that single-stage awake surgery can be performed for bilateral midshaft clavicle fractures [ 4 ]. In this report, we used a combination of general anesthesia and bilateral CPB.…”

Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

“…The patient was placed supine with the head turned towards the contralateral side. Ultrasound-guided modified right CFPB was performed as described by Sonawane et al [2]. A highfrequency linear probe (Sonosite HFL 38xp/13-6 MHz; Fujifilm SonoSite Inc., Bothell, WA, USA) was placed on the skin over the anterior surface of the clavicle.…”