562 LETTERTOTHEDIRECTOR
Clavipectoral
fascia
plane
block
for
analgesia
after
clavicle
surgery
夽Bloqueo
del
plano
de
la
fascia
clavipectoral
para
analgesia
tras
cirugía
de
clavícula
TotheEditor,
Clavicularfractureisthemostcommoninjuryofthe shoul-dergirdle,andhasanincidenceof35%.Itmainlyoccursin youngmen,usuallyasa resultof sportsactivities or traf-ficaccidents,andthemostcommonfractureoccursinthe middle third or diaphysis of the clavicle. Although most such diaphyseal fractures can be treated non-surgically, thereisgrowingevidencethatbetterfunctionaloutcomes areachievedwithsurgical treatment.1 Painmanagement, therefore,afterclavicularfractureorsurgeryisvery impor-tant. Since initial post-fracture pain may not respond to opioids, peripheral nerve blocks may be a useful com-plementto oral medication. A thorough understanding of the sensory innervation of the peripheral nerve is essen-tialtoachievegoodanalgesiafollowingclavicularfracture or surgery. This innervation is complex, and the supra-clavicular,subclavian,long thoracic/suprascapularnerves, alone or together, may be responsible for pain trans-mission after clavicular fracture and surgery. Superficial cervical plexus block, interscalene block, and combined superficial cervical plexus-interscalene block can be used toanaesthetisetheclavicle.2Thesuperficialcervicalblock can alsobe combinedwith the clavipectoral fascia plane block. The clavipectoral fascia is a thick fascia located on the clavicular portion of the pectoralis major muscle that extends superior, medial and superolateral fromthe clavicle, the costochondral joints, and the coracoid pro-cess, respectively. It suspends the floor of the axillaand protectstheneurovascularstructure,occupyingthespace between the clavicle and the pectoralis minor muscle. The clavipectoral fascia completely surrounds the clavi-cle, andthe nerveendings of the clavicle penetrate this fascia.3
Theclavipectoral fasciaplaneblockwasfirstdescribed byValdésin2017.4Followingthis,Roquésetal.presented thecombinedsuperficialcervical plexus-clavipectoral fas-ciaplane block for clavicular surgery at the 44th Annual RegionalAnesthesiology and AcutePain Medicine Meeting in 2019.5 In their presentation, they describe inject-ing 10---50ml of long-acting local anaesthetic into the fascia of the medial and lateral thirds, towards the clavicle fracture. They reported that this technique provided good quality anaesthesia, and also gave pro-longed analgesia for fractures of the medial third of the clavicle.
夽 Pleasecitethisarticleas:AtalayYO,MurselE,CiftciB,Iptec
G.Bloqueodelplanodelafasciaclavipectoralparaanalgesiatras cirugíadeclavícula.RevEspAnestesiolReanim.2019;66:562---563.
We present a case of successful postoperative pain managementusingsuperficialcervicalplexus-clavipectoral fasciaplaneblockina47-year-oldwoman,ASAII (hypothy-roidism),weight63kg,height165cm,whounderwentright clavicle fracture surgery under general anaesthesia. The patient read the manuscript and gave her consent for publication.Afterobtainingthepatient’sconsentfor post-operativenerveblock,weperformedanultrasound-guided superficialcervicalplexus---clavipectoralfasciaplaneblock of theclavipectoralfasciaat theendof surgery.The pro-cedurewasperformed underasepticconditionsusingaGE Vivid Q® ultrasound device (GE Healthcare, USA) with a
12MHz linear transducer. The patientwas placed supine, with her head turned slightly to the left. After blocking the superficial cervical plexus, the ultrasound probe was placedontheanteriorsuperiorborderofthemedialthird of the clavicle, and a 22 gauge needle wasinserted in a caudal-cranialdirection. Aftervisualizing theclavicle and clavipectoral fascia,andperformingaspirationtoruleout intravascularpuncture,2mlofsalinewasinjectedto con-firmcorrectpositioning,andthen20mlof0.25%bupivacaine was depositedbetween the periosteum andthe clavipec-toralfascia(Fig.1).IVibuprofen800mgwasadministered 30minbeforetheendofsurgeryformultimodal postopera-tiveanalgesia.Thepatientwasextubatedandtransferred to thepost-anaesthesia care unit (PACU),where her pain was evaluatedona visual analogue scale (VAS).Pain was ratedat0,sonoanalgesiawasadministered.After obtain-ingamodifiedAldretescoreof≥9,shewasdischargedfrom the PACU, and received ibuprofen 400mg every 8h. The maximumVASscorereportedbythepatientwas2at rest, duetoheadache.Shedidnotexperiencepainatthe surgi-calsiteuntil24hafter surgery,whenshe reportedapain scoreofVAS3,whichwetreatedwithmultimodal analge-sia(NSAIDsandtramadol).Roquésetal.usedthiscombined block(superficialcervicalplexus-clavipectoralfasciaplane block)foranaesthesiainclavicularfracture,injectinglocal anaestheticintothemedialandlateralthirdsoftheaffected clavicle. When the patient is in thebeach-chair position, we usually prefergeneralanaesthesia; for thisreasonwe performedtheblockforpostoperativeanalgesia,andsince thesurgeryencompassedtheentireclaviclewedidnot per-form2puncturesforthenerveblock.We,likeRoquésetal., observedthatsuperficialcervicalplexus-clavipectoralfascia planeblock isasimple, safeprocedurethatprovides pro-longedanalgesia(24h)forfracturesofthemedialthirdof the clavicle. We believe that this nerve block is suitable not only for anaesthesia and postoperative pain manage-ment,butalsoforemergencypainmanagementinpatients with acute clavicular fracture, and for biopsies or curet-tageofclaviclebonetumours.Furtherrandomisedtrialsare needed tocompare the effectivenessof theclavipectoral fasciaplaneblockwithothercurrentlyusednerveblocks.
Funding
Nonedeclared.
Conflicts
of
interest
LETTERTOTHEDIRECTOR 563
Figure1 Ultrasoundviewoftheclavipectoralfasciaplaneblock.Observethespreadoflocalanaestheticbetweentheclavicle andtheclavipectoralfasciaplane.
References
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http://dx.doi.org/10.1097/AAP.0000000000000012.
3.DrakeR,VoglAW,MitchellA.Gray’sanatomyforstudents.4th
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4.Valdés L. As part of the lecture: analgesia for clavicular
surgery/fractures.In:36thannualESRAcongress.2017.
5.RoquésV,ValdésL,PradereA,etal.HowIdoit:PoCUSand
fas-cialplaneblocks.In:Videopresentedat:IS-09AsktheExperts
Interactive Session. Clavipectoral fascia plain blockfor
clavi-clesurgery.44thannualregionalanesthesiologyandacutepain
medicinemeeting.2019.
Y.O.Atalay∗,E.Mursel,B.Ciftci,G.Iptec
IstanbulMedipolUniversity,DepartmentofAnesthesiology andReanimation,Istanbul,Turkey
∗Correspondingauthor.
