Scalp block and cervical plexus block techniques - UpToDate 14/12/21 22&59

Official reprint from UpToDate®

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Scalp block and cervical plexus block techniques

Authors: Meg A Rosenblatt, MD, Yan Lai, MD, MPH
Section Editor: Robert Maniker, MD
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2021. | This topic last updated: Jul 22, 2021.

INTRODUCTION

Scalp blocks and cervical plexus blocks are used for operative anesthesia and/or
postoperative analgesia for a variety of surgeries. This topic will discuss the innervation of
the scalp and neck, indications, techniques and drugs used for these blocks, and
complications specific to each block. Equipment used, contraindications, and
complications common to all nerve blocks are discussed separately. Nerve blocks for
airway anesthesia for awake intubation and infraorbital and mental nerve blocks are also
discussed separately. (See "Overview of peripheral nerve blocks" and "Flexible scope
intubation for anesthesia", section on 'Airway anesthesia' and "Assessment and
management of facial lacerations", section on 'Facial nerve blocks'.)

PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19

Understanding of coronavirus disease 2019 (COVID-19) is evolving. UpToDate has added

information on many aspects of COVID-19, including infection control, airway and other
aspects of anesthetic management, and general and intensive care in topic reviews linked
here and others. Regional anesthesia is not contraindicated in patients with COVID-19.
Regional anesthesia may avoid the need for general anesthesia and airway management,
with associated aerosolization of airway secretions and viral spread. The American Society
of Regional Anesthesia and Pain Medicine and the European Society of Regional

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Anesthesia and Pain Therapy have published practice recommendations for neuraxial
anesthesia and peripheral nerve blocks for patients with COVID-19. (See "Overview of
peripheral nerve blocks", section on 'Patients with suspected or confirmed COVID-19'.)

UpToDate topic reviews of COVID-19 related issues include the following:

● (See "COVID-19: Anesthetic concerns, including airway management and infection

control".)
● (See "COVID-19: Management in hospitalized adults".)
● (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

SCALP BLOCK

Individualized, targeted nerve blocks of the scalp have evolved to become sophisticated
and effective techniques compared with traditional local anesthetic (LA) infiltration [1-4].

Applications of scalp blocks — Scalp nerve blocks are useful for awake and routine
craniotomies, deep brain stimulation, stereotactic procedures, craniosynostosis repair in
pediatric patients, and for treatment of chronic pain syndromes of the head and neck [1-
3].

Scalp blocks are performed for craniotomy in order to blunt the hemodynamic response
to skull pinning and to reduce postoperative pain [4-6]. Preoperative scalp block can
reduce intraoperative opioid requirement, which can facilitate early postoperative
neurologic assessment [5-7]. As an example, a 2013 meta-analysis of seven trials with 320
patients found a reduction in pain scores up to 12 hours after craniotomy and a reduction
in cumulative opioid requirements over the first 24 postoperative hours with the use of
scalp nerve blocks [1]. (See "Anesthesia for craniotomy", section on 'Surgical steps'.)

Anatomy — Four branches of the trigeminal nerve (TN) and two branches of the cervical
nerve roots C2 and C3 provide innervation to the anterior and posterior scalp ( figure 1)
[2,3]. The supraorbital and supratrochlear nerves are sensory nerves that innervate the
forehead and upper eyelids. They are derived from the ophthalmic division (V1) of the TN.
The zygomaticotemporal nerve is from the maxillary division (V2) of the TN and supplies a
small area lateral to the outer canthus of the eye. The auriculotemporal nerve is a branch
of the mandibular division (V3) of the TN and provides sensation anterior and superior to

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the ear. The greater occipital nerve arises from the dorsal ramus of C2 and ascends
through the posterior scalp medial to the occipital artery. The lesser occipital nerve
originates from the ventral rami of C2 and C3 and courses upward from the posterior neck
to innervate the scalp behind the ear ( figure 2) [2,3].

Scalp block technique — Six nerves are blocked on each side for complete scalp block.
This block is performed with long-acting LA (eg, bupivacaine 0.25 or 0.5%, or ropivacaine
0.2 or 0.5%) using a 1.5-inch, 25- or 27-gauge needle, using the following techniques (
figure 3):

Supraorbital and supratrochlear nerve blocks — With the patient in supine position,
palpate the supraorbital notch in the medial third of the supraorbital ridge. The notch is
usually located directly above the midpoint of the pupil ( figure 4). Insert the needle 0.5
to 1 cm deep, perpendicular to the skin, until bone is contacted. Withdraw the needle
slightly, and after negative aspiration, inject 3 mL of LA to block the supraorbital nerve.
Redirect the needle medially under the skin, advance approximately 1 cm, and after
negative aspiration, inject 2 to 3 mL of LA to block the supratrochlear nerve. If paresthesia
is elicited, the needle should be repositioned prior to injection.

Auriculotemporal nerve block — The following technique minimizes the chance of

anesthetizing the facial nerve, which runs near the auriculotemporal artery at the level of
the tragus [8].

Palpate the superior temporal artery 1 cm cephalad to the level of the tragus of the ear.
Insert the needle perpendicular to the skin, just posterior to the temporal artery. Loss of
resistance or a click can usually be felt when the needle passes through the temporalis
fascia, at a depth of 1 to 2 cm. After negative aspiration, inject 2 mL of LA below the fascia
and another 1 mL superficial to the fascia as the needle is withdrawn.

Zygomaticotemporal nerve block — Palpate a groove along the zygomatic arch just
lateral to the lateral canthus of the eye. At that point, insert the needle perpendicular to
the skin and advance until loss of resistance or a click is felt as the needle passes through
the temporalis fascia. After negative aspiration, inject 1 to 2 mL of LA below the fascia.

Greater occipital nerve block — Palpate the occipital artery midway between the
occipital protuberance and the mastoid process. Insert the needle medial to the artery
and, after negative aspiration, inject 5 mL of LA.

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Lesser occipital nerve block — Insert the needle 2.5 cm lateral to the injection point for
the greater occipital block and, after negative aspiration, inject 5 mL of LA.

Complications of scalp block — The auriculotemporal nerve block can cause transient
facial nerve paralysis [8,9]. Facial nerve block should be self-limited and should resolve as
the scalp block wears off, but it may complicate assessment of facial nerve trauma related
to surgery. The incidence of facial nerve block may be reduced by minimizing the volume
of LA injected for auriculotemporal block and by performing the block as described above
[8].

CERVICAL PLEXUS BLOCKS

Superficial and deep cervical plexus blocks are the peripheral nerve blocks used for neck
surgery. An intermediate cervical plexus block has also been described. These blocks can
be used as primary anesthetics for carotid endarterectomy, where neurologic monitoring
of an awake patient may identify cerebral thromboembolic or ischemic events. In this
setting, coverage from a cervical plexus block may be variable and may require
supplemental local anesthetic (LA) infiltration by the surgeon. (See "Anesthesia for carotid
endarterectomy and carotid stenting", section on 'Local/regional anesthesia technique'.)

Cervical plexus block can also be utilized for postoperative pain control after thyroid,
parathyroid, trachea, and medial clavicle surgeries; cervical spine procedures; and after
other neck procedures [10-12].

Deep cervical plexus blocks, especially landmark-based techniques, are rarely performed,
for the following reasons:

● The incidence of significant complications (eg, vertebral artery or subdural injection

of LA) is higher with deep block compared with superficial block. (See 'Complications'
below.)

● Inadequate block is more common with deep cervical plexus block than with
superficial block [13].

● Superficial cervical plexus block supplemented with intraoperative neck infiltration is

often sufficient to provide postoperative analgesia.

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● Deep cervical plexus block is more difficult to perform than superficial block.

Anatomy — The cervical plexus is composed of the ventral rami of the first four cervical
spinal nerves (ie, C1 through C4). The ventral rami of C2 through C4 emerge from the
posterior border of the sternocleidomastoid muscle (SCM) ( figure 5). There are four
cutaneous branches of the cervical plexus, all of which are derived from C2 to C4. They are
the lesser occipital nerve, the greater auricular nerve, the transverse cervical nerve, and
the supraclavicular nerve. The cervical plexus supplies the skin of the anterolateral neck
and posterolateral scalp, the skin around the ear, and the muscles of the neck, including
the scalenes and strap muscles ( figure 6). The cervical plexus also innervates the
diaphragm via the phrenic nerve (C3, C4, C5) [13,14].

Cervical plexus blocks are defined by injections relative to the two layers of the deep
cervical fascia (ie, the superficial, or investing, layer and the deep layer). A superficial
cervical plexus block involves injection superficial to the investing layer, the intermediate
block involves injection between these two layers, and the deep block involves injection
deep to the deep layer ( image 1) [15].

Cervical plexus block technique

Superficial cervical plexus block technique — Superficial cervical plexus block is easier
to master than deep cervical plexus block, is associated with few complications, and does
not usually require ultrasound guidance. Nevertheless, we prefer ultrasound guidance
because it can provide more precise deposition of LA in the posterior fascial plane of the
SCM with visualization of the needle through the SCM. Ultrasound also allows
identification of central vessels, allows navigation away from more superficial vessels (eg,
external jugular vein), and may help avoid LA spread to the brachial plexus in the
interscalene groove.

The patient is positioned supine, with the head slightly away from the side to be blocked.

● Ultrasound guidance – Ultrasound guidance can be used, with the following

technique:

• Place a small, linear ultrasound probe in transverse orientation at the posterior

border of the SCM, midway between the mastoid process and the C6 transverse
process ( figure 7 and picture 1). Visualize the posterior fascia of the SCM.
The cervical plexus, when it can be seen, may be visualized as a collection of small

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hypoechoic (black) ovals, immediately deep or lateral to the posterior border of

the SCM.

• Insert the needle in plane to the transducer ( picture 2) with a lateral to medial
trajectory and advance until the tip is adjacent to the nerves ( image 2). After
negative aspiration, inject 10 mL of LA in 5 mL increments, with gentle aspiration
between injections. If the plexus is not visualized, place the needle tip in the plane
between the posterior fascia of the SCM and the prevertebral fascia below. Inject
10 mL of LA as the needle is advanced, with intermittent aspiration. LA should be
visualized spreading in the fascial plane.

● Anatomic technique – Draw a line from the mastoid process to the C6 transverse
process (ie, the Chassaignac tubercle) along the posterior border of the SCM (
figure 7). Insert the needle at the midpoint of this line. After negative aspiration,
inject 10 to 15 mL of LA in 5 mL increments along the posterior border of the SCM,
fanning the injection 2 to 3 cm above and below the needle insertion site, with gentle
aspiration between injections. Injection deeper than 2 cm should be avoided to
reduce injury to deep vessels and nerves.

Deep cervical plexus block technique — The deep cervical plexus block can be thought
of as a cervical paravertebral block that targets the C2 to C4 spinal nerves. The patient is
positioned supine, with the head slightly away from the side to be blocked.

● Ultrasound guidance – We suggest using ultrasound guidance for deep cervical

plexus block to avoid neuraxial and vascular complications. The following technique
is used [16]:

• Place a small, linear ultrasound probe in transverse orientation just below the
mastoid process. Scan caudally in a line between the mastoid process and the C6
transverse process. Visualize the loop of the vertebral artery to avoid vascular
puncture. The transverse process of C2 is approximately 1 cm caudal to the loop
or in the vicinity of the artery and should be identified by a hyperechoic bony
structure with a large, dark drop-off shadow deep to the bone.

• Insert the needle in plane ( picture 2) to the transducer in an anterior-to-

posterior orientation and advance until the tip contacts the superficial tip of the
transverse process of the C2 vertebra. After negative aspiration, slowly inject 5 mL

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of LA. LA should be visualized spreading adjacent to the transverse process.

• Scan caudally to the transverse processes of C3 and C4, and repeat injections.

● Anatomic technique – Where ultrasound is unavailable, the following landmark-

based approach can be used:

• Palpate the bony C6 transverse process (ie, the Chassaignac tubercle) at the level
of the cricoid cartilage by applying digital pressure in a posteromedial direction.
Draw a line from the mastoid process to the Chassaignac tubercle. Mark needle
insertion sites for C2, C3, and C4 at 2 cm, 4 cm, and 6 cm caudal to the mastoid
process, respectively. Insert the needle in a posteromedial and inferior
orientation until the transverse process is contacted at 1 to 2 cm, at each level.
After negative aspiration, slowly inject 3 to 5 mL of LA per level, with frequent
aspiration. Avoid fanning and injection deeper than 2 cm.

Intermediate cervical plexus block technique — The intermediate cervical plexus

block consists of a slightly more posterior superficial cervical block at C4. LA is deposited
between the superficial and deep cervical fascia in the posterior triangle of the neck [17].
This block is performed using ultrasound guidance as follows:

● Place a small, linear ultrasound probe in transverse orientation in the posterior

triangle of the neck at the level of the transverse process of C4. Insert the needle in
plane to the transducer in an anterior-to-posterior orientation through the SCM and
past the prevertebral fascia. The posterior cervical space is bounded by prevertebral
fascia superficially, deep cervical paravertebral fascia medially, middle scalene or
levator scapulae muscles posteriorly, and longus capitis or anterior scalene muscles
anteriorly.

● After negative aspiration, inject 15 mL of LA in 5 mL increments, with gentle

aspiration between injections. LA should be visualized spreading within the space
described above.

Local anesthetic choice — A longer-acting, relatively dilute LA is preferred for most neck
procedures (eg, 0.2% ropivacaine or 0.25% bupivacaine). Higher concentrations are not
required because there is no need to block motor function ( table 1) [14]. (See "Overview
of peripheral nerve blocks", section on 'Drugs'.)

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Complications — Complications are rare but are more common with deep cervical plexus
blocks than with superficial blocks [11,13,14]. With deep block, potential complications
include intravascular injection of LA into surrounding vessels, such as the carotid artery
and external and internal jugular veins, but more commonly into the vertebral artery.
Vertebral artery injection can cause immediate seizures even with injection of only a few
mL of LA. Thus the LA should be injected very slowly and in small increments under
ultrasound guidance. Other complications of this block include respiratory compromise
with diaphragmatic or vocal cord paralysis, and, very rarely, intrathecal injection of LA.

A systematic review of complications of superficial and deep cervical plexus blocks

reported that conversion to general anesthesia was more common with deep blocks (odds
ratio [OR] 5.15) [13]. The most common reasons for conversion to general anesthesia were
block failure and patient anxiety or lack of cooperation.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: Local and
regional anesthesia" and "Society guideline links: Local anesthetic systemic toxicity".)

SUMMARY AND RECOMMENDATIONS

● Scalp nerve blocks can provide intraoperative and postoperative analgesia for
craniotomy and for other procedures on the scalp and skull. They can also be used
for treatment of chronic pain syndromes of the head and neck. (See 'Applications of
scalp blocks' above.)

● A total of 12 nerves (six on each side) are blocked to achieve a complete scalp block (
figure 3). Complete scalp block includes blocks of the supraorbital, supratrochlear,
auriculotemporal, zygomaticotemporal, greater occipital, and lesser occipital nerves.
(See 'Scalp block technique' above.)

● Scalp blocks are performed using an anatomic technique, injecting 1 to 5 mL of long-

acting local anesthetic (LA; eg, bupivacaine 0.25 or 0.5%, or ropivacaine 0.2 or 0.5%)
using a 1.5-inch, 25- or 27-gauge needle. (See 'Scalp block technique' above.)

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● The auriculotemporal nerve block can cause transient facial nerve paralysis, which
can be avoided by minimizing the volume of LA injected and by using the technique
described. (See 'Complications of scalp block' above.)

● Superficial and deep cervical plexus blocks anesthetize the anterior and lateral neck
and scalp. These blocks are particularly useful for awake carotic endarterectomy, in
which neurologic monitoring of an awake patient may identify cerebral
thromboembolic or ischemic events. They can also be used for postoperative
analgesia for neck surgery. (See 'Cervical plexus blocks' above.)

● Superficial or intermediate cervical plexus block is usually preferred, rather than

deep cervical plexus block, because the more superficial blocks are easier to
perform, usually more effective, and are associated with less complications than
deep cervical plexus block. (See 'Cervical plexus blocks' above.)

● We prefer using ultrasound guidance for superficial cervical plexus block, though an
anatomic technique can be used as an alternative. (See 'Superficial cervical plexus
block technique' above.)

● We suggest using ultrasound guidance rather than an anatomic technique for deep
cervical plexus block (Grade 2C), to reduce the risk of complications. (See 'Deep
cervical plexus block technique' above.)

● Cervical plexus blocks are performed with long-acting dilute LA (eg, 0.2% ropivacaine
or 0.25% bupivacaine). (See 'Local anesthetic choice' above.)

● Complications of cervical plexus block are rare, and include intravascular injection of
LA, diaphragm or vocal cord paralysis, and very rarely, intrathecal injection of LA.
(See 'Complications' above.)

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REFERENCES

1. Guilfoyle MR, Helmy A, Duane D, Hutchinson PJ. Regional scalp block for
postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg 2013;
116:1093.

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2. Pinosky ML, Fishman RL, Reeves ST, et al. The effect of bupivacaine skull block on the
hemodynamic response to craniotomy. Anesth Analg 1996; 83:1256.
3. Osborn I, Sebeo J. "Scalp block" during craniotomy: a classic technique revisited. J
Neurosurg Anesthesiol 2010; 22:187.

4. Nguyen A, Girard F, Boudreault D, et al. Scalp nerve blocks decrease the severity of
pain after craniotomy. Anesth Analg 2001; 93:1272.

5. Geze S, Yilmaz AA, Tuzuner F. The effect of scalp block and local infiltration on the
haemodynamic and stress response to skull-pin placement for craniotomy. Eur J
Anaesthesiol 2009; 26:298.

6. Bala I, Gupta B, Bhardwaj N, et al. Effect of scalp block on postoperative pain relief in
craniotomy patients. Anaesth Intensive Care 2006; 34:224.
7. Ayoub C, Girard F, Boudreault D, et al. A comparison between scalp nerve block and
morphine for transitional analgesia after remifentanil-based anesthesia in
neurosurgery. Anesth Analg 2006; 103:1237.
8. Bebawy JF, Bilotta F, Koht A. A modified technique for auriculotemporal nerve
blockade when performing selective scalp nerve block for craniotomy. J Neurosurg
Anesthesiol 2014; 26:271.
9. McNicholas E, Bilotta F, Titi L, et al. Transient facial nerve palsy after auriculotemporal
nerve block in awake craniotomy patients. A A Case Rep 2014; 2:40.
10. Suh YJ, Kim YS, In JH, et al. Comparison of analgesic efficacy between bilateral
superficial and combined (superficial and deep) cervical plexus block administered
before thyroid surgery. Eur J Anaesthesiol 2009; 26:1043.

11. Guay J. Regional anesthesia for carotid surgery. Curr Opin Anaesthesiol 2008; 21:638.
12. Mayhew D, Sahgal N, Khirwadkar R, et al. Analgesic efficacy of bilateral superficial
cervical plexus block for thyroid surgery: meta-analysis and systematic review. Br J
Anaesth 2018; 120:241.
13. Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep cervical plexus block for
carotid endarterectomy: a systematic review of complications. Br J Anaesth 2007;
99:159.
14. Masters RD, Castresana EJ, Castresana MR. Superficial and deep cervical plexus block:
technical considerations. AANA J 1995; 63:235.
15. Sait Kavaklı A, Kavrut Öztürk N, Umut Ayoğlu R, et al. Comparison of Combined (Deep

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and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound

Guidance for Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2016; 30:317.
16. Sandeman DJ, Griffiths MJ, Lennox AF. Ultrasound guided deep cervical plexus block.
Anaesth Intensive Care 2006; 34:240.
17. Usui Y, Kobayashi T, Kakinuma H, et al. An anatomical basis for blocking of the deep
cervical plexus and cervical sympathetic tract using an ultrasound-guided technique.
Anesth Analg 2010; 110:964.
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GRAPHICS

Sensory distribution scalp block

The purple-shaded areas show the extent of sensory anesthesia after scalp
block.

Graphic 106221 Version 1.0

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Cutaneous innervation of the head and neck

The sensory distribution of the trigeminal nerve (cranial nerve V) and its
three divisions (V1, V2, V3) is shown along with branches of the cervical
spinal nerves that innervate cutaneous regions of the head and neck.

Graphic 70877 Version 5.0

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Scalp block insertion sites

The numbered dots in this graphic show the needle insertion sites for injection
of local anesthetic for the six nerve blocks that comprise the scalp block, as
follows:

(1) Supraorbital and supratrochlear nerve blocks

(2) Zygomaticotemporal nerve block

(3) Auriculotemporal nerve block

(4) Lesser occipital nerve

(5) Greater occipital nerve

For details of block technique, refer to UpToDate topic on nerve blocks of the
scalp, neck, and trunk, section on scalp block.

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n.: nerve.

Modified from: Guilfoyle MR, Helmy A, Duane D, et al. Regional scalp block for postcraniotomy
analgesia: A systematic review and meta-analysis. Anesth Analg 2013; 116:1093.

Graphic 105117 Version 2.0

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Supraorbital and supratrochlear nerve block

This block anesthetizes the forehead and anterior third of the scalp.
To perform, locate the supraorbital nerve foramen in the medial
aspect of the supraorbital ridge as shown in A. After cleansing,
insert a small needle (25 or 27 gauge) to a depth of 0.5 to 1 cm just
medial and directed towards the foramen as shown in B. Inject 1 to 3
mL of local anesthetic. In older children, adolescents, and adults
who report paresthesias, withdraw the needle until paresthesias
resolve prior to injection of anesthetic. Allow 5 to 10 minutes for
complete anesthesia to occur.

Reproduced with permission from: Cimpello LB, Deutsch RJ, Dixon C, et al. Illustrated

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techniques of pediatric emergency procedures. In: Textbook of Pediatric Emergency

Medicine, 6th edition, Fleisher GR, Ludwig S (Eds), Lippincott Williams & Wilkins,
Philadelphia 2010. Copyright © 2010 Lippincott Williams & Wilkins. www.lww.com.

Graphic 66299 Version 10.0

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Cervical plexus 2

The cervical plexus is composed of the ventral rami of the first four cervical
spinal nerves (ie, C1 through C4). The anterior rami of C2 through C4 emerge
from the posterior border of the sternocleidomastoid muscle.

Graphic 106135 Version 1.0

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Sensory distribution cervical plexus block

The purple-shaded area shows the extent of sensory anesthesia after

cervical plexus block.

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Neck scan showing cervical fascia

Axial scan of neck. Superficial (investing) layer of the deep cervical fascia (blue line); deep layer of the deep
cervical fascia (orange line); sternocleidomastoid muscle (purple area); posterior cervical space (red area);
carotid bifurcation (yellow line); internal jugular vein (green line); vertebral artery (pink line). The local
anesthetic injection sites for superficial, intermediate, and deep cervical plexus blocks are shown in this
graphic. For further information refer to UpToDate content on cervical plexus blocks.

Reproduced from: Sait Kavakli A, Kavrut Ozturk N, Umut Ayoglu R, et al. Comparison of Combined (Deep and Superficial) and
Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2016;
30:317. Illustration used with the permission of Elsevier Inc. All rights reserved.

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Superficial cervical plexus block

For the superficial cervical plexus block using anatomic landmarks, a line is drawn
from the mastoid process to the C6 transverse process (ie, Chassaignac tubercle)
along the posterior border of the sternocleidomastoid muscle (line shown in
blue). The midpoint of this line is marked (red dot) as the injection site. After
negative aspiration, 10 to 15 mL of local anesthetic is injected in 5-mL increments
along the posterior border of the sternocleidomastoid muscle, fanning the
injection 2 to 3 cm above and below the needle insertion site, with gentle
aspiration between injections. Injection deeper than 2 cm should be avoided.
Refer to UpToDate content on nerve blocks of the neck for more details.

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Superficial cervical plexus block ultrasound probe

placement

For ultrasound-guided superficial cervical plexus block, the ultrasound probe is

placed in a transverse orientation at the posterior border of the
sternocleidomastoid muscle, midway between the mastoid process and the C6
transverse process. For further details on this block, refer to the UpToDate topic
on nerve blocks of the scalp, neck, and trunk.

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In-plane needle placement

Courtesy of Christina L Jeng, MD

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Superficial cervical plexus block ultrasound

The cervical plexus can sometimes be visualized as a collection of hypoechoic ovals, posterior to the
posterior fascia of the sternocleidomastoid muscle. The arrow indicates needle insertion. For further
details, refer to the UpToDate topic on nerve blocks of the scalp, neck, and trunk.

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Local anesthetics commonly used for peripheral nerve block

Maximum
Duration of Duration of dose* ¶
Onset
Anesthetic anesthesia* analgesia* (mg/kg)
(minutes)
(hours) (hours) without/with
epi
2% lidocaine 10 to 20 2 to 5 3 to 8 4.5/7

1.5% 10 to 20 2 to 5 3 to 10 5/7
mepivacaine

0.2% ropivacaine 15 to 30 n/a 5 to 16 3/3.5

0.5% ropivacaine 15 to 30 4 to 12 5 to 24 3/3.5

0.25% 15 to 30 n/a 5 to 26 2.5/3

bupivacaine

0.5% bupivacaine 15 to 30 5 to 15 6 to 30 2.5/3

(+epi)

epi: epinephrine; n/a: not applicable.

* Duration varies widely by site of injection. These are generalized ranges of duration.

¶ Maximal doses represent general guidelines for tissue infiltration, nerve block, or epidural
injection. Systemic toxicity may occur with doses below the recommended range, particularly with
intravascular injection. Doses in excess of the recommended maximums have been administered
without toxicity. These recommendations do not account for the site of injection, rate of
administration, or the presence of risk factors for systemic toxicity (eg, renal or hepatic
dysfunction, cardiac failure, pregnancy, or extremes of age).

Adapted from: Gadsen J. Local Anesthetics: Clinical Pharmacology and Rational Selection. The New York School of Regional
Anesthesia website, October 2013.

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Contributor Disclosures
Meg A Rosenblatt, MD No relevant financial relationship(s) with ineligible companies to disclose. Yan
Lai, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Robert
Maniker, MD No relevant financial relationship(s) with ineligible companies to disclose. Marianna
Crowley, MD No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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