Classification of the patterns of the emerging branches of the superficial cervical plexus / Clasificación de los patrones de las ramas emergentes del plexo cervical superficial

SUMMARY: The cutaneous branches of the superficial cervical plexus (SCP) emerge at variable points, from beneath the posterior margin of the sternocleidomastoid muscle and from this point radiate like "spokes of a wheel" antero-inferiorly and postero-superiorly. This study aimed to classify the emerging points of the branches of the superficial cervical plexus in relation to their location on the sternocleidomastoid muscle. In order to classify the emerging points of the superficial cervical plexus, the sternocleidomastoid muscle was first measured from mastoid process to clavicle; subsequently each branch of the superficial cervical plexus was measured from the mastoid process to their exit points. The emerging points of the superficial cervical plexus branches were classified according to Kim et al. (2002) seven categories: Type I (32 %); Type II (13 %); Type III (35 %); Type IV (13 %); Type V, VI, VII (2 %). The order in which the superficial cervical plexus branches emerged from the posterior margin of the sternocleidomastoid muscle remained constant, i.e. lesser occipital, great auricular, transverse cervical and supraclavicular nerves. Knowledge of emerging points may assist in the effective anaesthesia to all branches of the superficial cervical plexus during surgical procedures of the neck, viz. carotid endarterectomy and thyroid surgery.

RESUMEN: Las ramas cutáneas del plexo cervical superficial (SCP) emergen en puntos variables, desde el margen pos- terior del músculo esternocleidomastoideo y desde este punto inferior irradian como "radios de rueda" anteroinferior y postero-superior. Este estudio tuvo como objetivo clasificar los puntos emergentes de las ramas del plexo cervical superficial en relación a su ubicación en el músculo esternocleidomastoideo. Para clasificar los puntos emergentes del plexo cervical superficial, primero se midió el músculo esternocleidomastoideo desde el proceso mastoides hasta la clavícula; posteriormente se midió cada rama del plexo cervical superficial desde el proceso mastoideo hasta sus puntos de salida. Los puntos emergentes de las ramas del plexo cervical superficial se clasificaron según Kim et al. (2002) en siete categorías: Tipo I (32 %); Tipo II (13 %); Tipo III (35 %); Tipo IV (13 %); Tipo V, VI, VII (2 %). El orden en el que las ramas del plexo cervical superficial emergían del margen posterior del músculo esternocleidomastoideo se mantuvo constante, es decir, los nervios occipital menor, auricular magno, cervical transverso y supraclavicular. El conocimiento de los puntos emergentes puede ayudar a la anestesia eficaz de todas las ramas del plexo cervical superficial durante los procedimientos quirúrgicos del cuello, a saber, endarterectomía carotídea y cirugía de tiroides.

Perioperative analgesic efficacy of bilateral superficial cervical plexus block in patients undergoing thyroidectomy: a randomized controlled trial / Eficácia analgésica perioperatória do bloqueio bilateral do plexo cervical superficial em pacientes submetidos à tireoidectomia: estudo clínico randomizado

Abstract Introduction: Bilateral superficial cervical plexus block (BSCPB) is a common method used for analgesia in thyroid surgery. We investigated the analgesic efficacy of bilateral superficial cervical plexus block in the intraoperative and postoperative periods. Materials and methods: Patients (n = 46) undergoing thyroidectomy were randomly separated into the following 2 groups: the general anesthesia group (GA; n = 23) and the general anesthesia plus BSCPB group (GS; n = 23). The intraoperative analgesic requirement (remifentanil) and visual analog scale (VAS) score at multiple time points during the postoperative period (after extubation, at 15 , 30 minutes and 1, 2, 6, 12, 24, and 48 hours post operation) were evaluated. Total tramadol and paracetamol consumption as well as the amount of ondansetron used was recorded. Results: The intraoperative remifentanil requirement was significantly lower in the GS Group than in the GA Group (p= 0.009). The postoperative pain scores were significantly lower in the GS Group than in the GA Group at 15 (p< 0.01), 30 (p< 0.01) minutes, and 1 (p< 0.01), 2 (p< 0.01), 6 (p< 0.01), 12 (p< 0.01) and 24 (p= 0.03) hours. The postoperative tramadol requirement was significantly lower in the GS Group than in the GA Group (p= 0.01). The number of patients that used ondansetron was significantly lower in the GS Group than in the GA Group (p= 0.004). Conclusion: We concluded that BSCPB with 0.25% bupivacaine reduces the postoperative pain intensity and opioid dependency in thyroid surgery patients.

Resumo Introdução: O bloqueio bilateral do plexo cervical superficial (BPCS) é um método comumente usado para analgesia em tireoidectomia. Avaliamos a eficácia analgésica do bloqueio bilateral do BPCS nos períodos intraoperatório e pós-operatório. Materiais e métodos: Os pacientes (n = 46) submetidos à tireoidectomia foram randomicamente separados em dois grupos para receber anestesia geral (Grupo GA; n = 23) e anestesia geral mais bloqueio bilateral do BPCS (Grupo GS; n = 23). Avaliamos a necessidade de analgésico no intraoperatório (remifentanil) e os escores VAS (Visual Analog Scale) em vários momentos no pós-operatório (após a extubação, aos 15 e 30 minutos e em 1, 2, 6, 12, 24 e 48 horas de pós-operatório). O consumo total de tramadol e paracetamol e a quantidade usada de ondansetrona foram registrados. Resultados: A necessidade de remifentanil no intraoperatório foi significativamente menor no Grupo GS do que no Grupo GA (p = 0,009). Os escores de dor pós-operatória foram significativamente menores no Grupo GS do que no grupo GA aos 15 (p < 0,01) e 30 (p < 0,01) minutos e em 1 (p < 0,01), 2 (p < 0,01), 6 (p < 0,01), 12 (p < 0,01) e 24 (p = 0,03) horas de pós-operatório. A necessidade de tramadol no pós-operatório foi significativamente menor no Grupo GS do que no grupo GA (p = 0,01). O número de pacientes que recebeu ondansetrona foi significativamente menor no Grupo GS do que no Grupo GA (p = 0,004). Conclusão: O bloqueio bilateral do BPCS com bupivacaína a 0,25% reduz a intensidade da dor pós-operatória e a dependência de opioides em pacientes submetidos à tireoidectomia.

Efectividad de anestesia de plexo cervical superficial preoperatorio para control de dolor postoperatorio en cirugía de tiroides / Analgesic effects of bilateral superficial cervical plexus block with Bupivacaine after thyroidectomy

Background: Bilateral superficial cervical plexus block is a simple non-invasive technique that can be used as preventive analgesia in the perioperative period of thyroidectomy. Aim: to assess the analgesic effects of the technique during the postoperative period of thyroidectomy. Material and Methods: Patients with indication of total thyroidectomy, with a low operative risk according to the American Society of Anesthesiology, were studied. All were operated with general anesthesia using Fentanyl, Propofol, Vecuronium and Isoflurane. Patients were randomly and blindly assigned to superficial cervical plexus block using Bupivacaine 0.25% or to a placebo injection. Postoperative pain, need for analgesics and patient satisfaction were assessed...

Introducción: La cirugía de la glándula tiroides es reconocida como un procedimiento que produce un dolor leve a moderado. El bloqueo bilateral de plexo cervical superficial es una técnica simple, poco invasiva, que pudiera ser beneficioso en estos pacientes como modelo de analgesia preventiva. Objetivos: Evaluar la calidad de la analgesia del postoperatorio de la cirugía de tiroides, con el uso de bloqueo bilateral del plexo cervical superficial. Material y Métodos: Se estudiaron pacientes ASA I y II propuestos para cirugía de tiroides bajo anestesia general. En todos los pacientes se hizo anestesia general balanceada con Fentanyl, Propofol, Vecuronio e Isoflurano. En forma aleatoria y ciega se asignaron los pacientes en 2 grupos: grupo A, Bupivacaína 0,25% 20 ml y grupo B placebo. Se evaluó características demográficas, dolor postoperatorio, necesidad de analgésicos de rescate, náuseas, vómitos y satisfacción del paciente...

The Sympathetic and Parasympathetic Contributions to the Cardiac Plexus: a Fetal Study / Contribuciones Simpáticas y Parasimpáticas al Plexo Cardíaco: Estudio Fetal

The cardiac plexus is formed by sympathetic nerves originating from the superior, middle, inferior cervical or cervicothoracic ganglia as well as from the first to the fifth thoracic ganglia. Furthermore, the vagus nerve and its counterpart, the recurrent laryngeal nerve supply the cardiac plexus with parasympathetic cardiac nerves. This investigation aimed to review and record the medial contributions of the cervical ganglia, first to fifth thoracic ganglia and medial contributions of the vagus and recurrent laryngeal nerves to the cardiac plexus. The study involved bilateral micro-dissection of forty cadaveric fetal specimens (n=80). The origins of sympathetic contributions to the cardiac plexus were described as either ganglionic, inter-ganglionic or from both the ganglion and the inter-ganglionic sympathetic chain. The number of cervical sympathetic ganglia varied from two to five in this study; the superior cervical ganglion was constant while the middle cervical, vertebral, inferior cervical or cervicothoracic ganglia were variable. The prevalence of cardiac nerves were as follows: superior cervical cardiac nerve (95%); middle cervical cardiac nerve (73%); vertebral cardiac nerve (41%); inferior cervical cardiac nerve (21%) and cervicothoracic cardiac nerve (24%). This investigation records the thoracic caudal limit of the thoracic sympathetic contributions to the cardiac plexus as the T5 ganglion. The findings of this study highlight the importance of understanding the medial sympathetic contributions and their variations to the cardiac plexus as this may assist surgeons during minimal access surgical procedures, sympathectomies, pericardiectomies and in the management of diseases like Raynaud's Phenomenon and angina pectoris.

El plexo cardíaco está formado por los nervios simpáticos procedentes de los ganglios cervicales superior, medio e inferior o cervicotorácico, así como los ganglios torácicos desde el primero al quinto. Por otra parte, el nervio vago y su contraparte, el nervio laríngeo recurrente suministra al plexo cardíaco nervios cardíacos parasimpático. Esta investigación tuvo como objetivo revisar y registrar las contribuciones mediales de los ganglios cervicales, ganglios torácicos del primero al quinto ganglios y contribuciones mediales de los nervios laríngeos recurrentes y vagos en el plexo cardíaco. Se realizó la micro-disección bilateral de cuarenta especímenes cadavéricos fetales (n = 80). Los orígenes de las contribuciones simpáticas hacia el plexo cardíaco se describen de forma independiente como ganglionar o inter-ganglionar, o desde ambos ganglios y la cadena simpática interganglionar. El número de ganglios simpáticos cervicales varió de dos a cinco; el ganglio cervical superior fue constante, mientras que los ganglios medio-cervical, vertebral, cervical inferior o cervicotorácico fueron variables. La prevalencia de los nervios cardíacos fueron: nervio cardíaco cervical superior (95%); nervio cardíaco cervical medio (73%); nervio cardiaco vertebral (41%); nervio cardíaco cervical inferior (21%) y nervio cardíaco cervicotorácico (24% ). La investigación registró el límite torácico caudal de las contribuciones torácicas simpáticos al plexo cardíaco como el ganglio T5. Los resultados de este estudio muestran la importancia de comprender las contribuciones simpáticas mediales y sus variaciones en el plexo cardíaco, ya que podrían ayudar a los cirujanos durante los procedimientos quirúrgicos mínimanente invasivos, simpatectomías, pericardiectomías y en el manejo de enfermedades como el fenómeno de Raynaud y la angina de pecho.