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Ultrasound-Guided Cervical Plexus Nerve Block
Table of Contents
Ultrasound-Guided Cervical Plexus
Nerve Block
Thomas F. Bendtsen, Sherif Abbas, and Vincent Chan
FACTS
Indications: carotid endarterectomy, superficial neck surgery (Figure 1)
Transducer position: transverse over the midpoint of the sternocleidomastoid muscle
(posterior border)
Goal: local anesthetic spread around the superficial cervical plexus or deep to the
sternocleidomastoid muscle
Local anesthetic: 5–15 mL
Figure 1. Expected sensory distribution of cervical plexus block.
GENERAL CONSIDERATIONS
The goal of the ultrasound (US)-guided technique of superficial cervical plexus nerve block is to
deposit local anesthetic within the vicinity of the sensory branches of the nerve roots C2, C3,
and C4 (Figures 2 and 3). Advantages over the landmark-based technique include the ability
to visualize the spread of local anesthetic in the correct plane, which therefore increases the
success rate, and to avoid a needle insertion that is too deep and the inadvertent puncture of
neighboring structures.
Figure 2. Site of injection of local anesthetic for superficial, intermediate, and deep cervical
plexus nerve blocks.
Figure 3. Anatomy of the deep cervical plexus and its main branches and anastomoses.
Both US-guided superficial and deep cervical plexus nerve blocks have been well described.
The deep cervical plexus nerve block is an advanced nerve block with a risk of potentially
serious complications, such as intrathecal injection or injection into the vertebral artery. For this
reason, we will focus primarily on the superficial cervical plexus nerve block technique. It is
simpler, safer, and, for most indications, it is equally as suitable as the deep cervical plexus
nerve block. An understanding of the fascial planes of the neck and the location of each of
these nerve blocks is necessary (Figure 2). For the superficial cervical plexus nerve block, local
anesthetic is injected superficially to the deep cervical fascia. For the superficial (intermediate)
cervical plexus nerve block, the injection is made between the investing layer of the deep
cervical fascia and the prevertebral fascia, whereas for the deep cervical plexus nerve block,
local anesthetic is deposited deep to the prevertebral fascia.
ULTRASOUND ANATOMY
The sternocleidomastoid muscle (SCM) forms a “roof” over the nerves of the superficial cervical
plexus (C2–4) (see Figure 2). The roots combine to form the four terminal branches (the lesser
occipital, greater auricular, transverse cervical, and supraclavicular nerves) and emerge from
behind the posterior border of the SCM (Figures 3, 4 and 5). The plexus can be visualized as a
small collection of hypoechoic nodules (honeycomb appearance or hypoechoic [dark] oval
structures) immediately deep or lateral to the posterior border of the SCM (see Figure 5), but
this is not always apparent.
Occasionally, the greater auricular nerve is visualized on the superficial surface of the SCM as a
small, round, hypoechoic structure. The SCM is separated from the brachial plexus and the
scalene muscles by the prevertebral fascia, which can be seen as a hyperechoic linear
structure. The cervical plexus lies posterior to the SCM and immediately superficial to
the prevertebral fascia overlying the interscalene groove (see Figure 5). Strictly speaking, the
technique we describe, with an injection between the investing layer of the deep cervical fascia
and the prevertebral fascia, is thus an intermediate cervical plexus nerve block.
Figure 4. Anatomy of the cervical plexus. The cervical plexus is seen emerging behind the
posterior border of the sternocleidomastoid muscle at the intersection of the muscle with the
external jugular vein. 1: Sternocleidomastoid muscle. 2: Mastoid process. 3: Clavicle. 4: External
jugular vein. 5: Greater auricular nerve. Supraclavicular nerves are seen rossing the clavicle.
Figure 5. Cervical plexus (transverse view). Branches of the cervical plexus (CP) are seen
superficial to the prevertebral fascia, which covers the middle (MSM) and anterior (ASM)
scalene muscles, and posterior to the sternocleidomastoid muscle (SCM). White arrows,
investing fascia of deep cervical fascia; CA, carotid artery; PhN, phrenic nerve.
DISTRIBUTION OF ANESTHESIA
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From the Compendium of Regional Anesthesia: Cognitive priming for a cervical plexus
block.
The superficial cervical plexus nerve block results in anesthesia of the skin of the anterolateral
neck and the ante-auricular and retro-auricular areas, as well as the skin overlying and
immediately inferior to the clavicle on the chest wall Figures 1 and 6). The mental, infraorbital,
and supraorbital nerves are branches of the trigeminal nerve and are not blocked with cervical
plexus nerve block.
Figure 6. Innervation of the head and neck.
The equipment needed for a cervical plexus nerve block includes the following:
• Ultrasound machine with a linear transducer (8–18 MHz), sterile sleeve, and gel
• Standard nerve block tray
• A 10-mL syringe containing local anesthetic
• A 5 cm, 23- to 25-gauge needle attached to low-volume extension tubing
• Sterile gloves
Learn more about Equipment for Regional Anesthesia.
LANDMARKS AND PATIENT POSITIONING
Any patient position that allows for comfortable placement of the ultrasound transducer and
needle advancement is appropriate. This nerve block is typically performed in the supine or
semi-sitting position, with the head turned slightly away from the side to be blocked to facilitate
operator access (Figure 7). The patient’s neck and upper chest should be exposed so that the
relative length and position of the SCM can be assessed. The posterior border of the SCM can
be difficult to locate, especially in obese patients. Asking the patient to lift his or her head off
the bed can facilitate palpation of the posterior border of the SCM.
Figure 7. Cervical plexus nerve block. (A) Transverse approach.(B) Longitudinal approach.
GOAL
The goal of this nerve block is to place the needle tip in the fascial layer underneath the SCM
adjacent to the cervical plexus, which is contained within the tissue space between the Cervical
fascia and posterior sheath of the SCM. If the elements of the cervical plexus are not easily
visualized, the local anesthetic can be deposited in the plane immediately deep to the SCM and
superficial investing layer of deep cervical fascia and superficial to the prevertebral fascia. A
volume of 5-10 mL of local anesthetic usually suffices.
From the Compendium of Regional Anesthesia: Reverse Ultrasound Anatomy for a
cervical plexus block with needle insertion in-plane and local anesthetic spread (blue).
GaN, greater auricular nerve; SCM, sternocleidomastoid muscle; LCa, longus capitis
muscle; LCo, longus Colli muscle; MSM, middle scalene muscle; LsCa, longissimus capitis
muscle; LS, levator scapulae muscle; SPL, splenius capitis muscle; SECM, semispinalis
capitis muscle.
TECHNIQUE
With the patient in the proper position, the skin is disinfected and the transducer is placed on
the lateral neck, overlying the SCM at the level of its midpoint (approximately the level of the
cricoid cartilage).
Once the SCM has been identified, the transducer is moved posteriorly until the tapering
posterior edge is positioned in the middle of the screen. At this point, an attempt should be
made to identify the brachial plexus and/or the interscalene groove between the anterior and
middle scalene muscles. The cervical plexus is visible as a small collection of hypoechoic
nodules (honeycomb appearance) immediately superficial to the prevertebral fascia that
overlies the interscalene groove (see Figure 2 and 5).
Once the plexus has been identified, the needle is passed through the skin, platysma, and
investing layer of the deep cervical fascia, and the tip is placed adjacent to the plexus (Figure
8). Because of the relatively shallow position of the target, both in-plane (from the medial or
lateral sides) and out-of-plane approaches may be used. Following negative aspiration, 1–2 mL
of local anesthetic is injected to confirm the proper injection site. The remainder of the local
anesthetic (5–15 mL) is administered to envelop the plexus (Figure 9).
Figure 8. Superficial cervical plexus (transverse view): needle path (1) and position to nerve
block the cervical plexus (CP).The needle is seen positioned underneath the lateral border of
the sternocleidomastoid muscle (SCM) and superficial to the prevertebral fascia with the
transducer in a transverse position (see Figure 7a). ASM, anterior scalene muscle; CA, carotid
artery; MSM, middle scalene muscle.
Figure 9. Cervical plexus (transverse view): desired distribution of local anesthetic (blue-shaded
area) to nerve block the cervical plexus. Needle path: 1. ASM, anterior scalene muscle; CA,
carotid artery; CP, cervical plexus; MSM, middle scalene muscle; SCM, sternocleidomastoid
muscle.
If the plexus is not visualized, an alternative sub sternocleidomastoid approach may be used. In
this case, the needle is passed behind the SCM, and the tip is directed to lie in the space
between the SCM and the prevertebral fascia, close to the posterior border of the SCM
(Figures 7b, 10 and 11). Local anesthetic (5–15 mL) is administered and should be visualized
layering out between the SCM and the underlying prevertebral fascia (Figure 12). If the
injection of local anesthetic does not appear to result in an appropriate spread, needle
repositioning and further injections may be necessary. Because the cervical plexus is made up
of purely sensory nerves, high concentrations of local anesthetic are usually not required;
ropivacaine 0.25–0.5%, bupivacaine 0.25%, or lidocaine 1% is a sufficient
Figure 10. Cervical plexus (longitudinal view): Elements of the cervical plexus (CP) underneath
the lateral border of the sternocleidomastoid muscle (SCM).
Figure 11. Cervical plexus (longitudinal view): needle position to nerve block the cervical plexus
(CP).
Figure 12. Cervical plexus (longitudinal view): desired spread of local anesthetic under the
deep cervical fascia to nerve block the cervical plexus (CP).
TIPS
Visualization of the plexus is not necessary to perform this nerve block because the plexus may
not always be readily apparent. Administration of 10 mL of local anesthetic deep to the SCM
provides a reliable nerve block without the position of the plexus needing to be confirmed.
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