- Email: [email protected]
Technique for regional anesthesia: Thyroidectomy and parathyroidectomy
Technique for Regional Anesthesia: Thyroidectomy and Parathyroidectomy Paul Lo Gerfo, MD, and Lucy J. Kim, MD
Local/regional anesthesia for thyroid surgery has been used in small periodic experiences since the late 19th century and recently has been shown to be a safe and comparable alternative to general anesthesia. In addition, the technique of local/regional anesthesia described here allows for a shorter hospital stay. The anatomy of the cervical plexus is described in 1. The cervical plexus block is shown in 2. The success of local/regional anesthesia for thyroidectomy/parathyroidectomy is based on an adequate interval between time of injection and time of incision. Injecting From the Department of Surgery, Columbia-Presbyterian Medical Center, New York, NY. Address reprint requests to Paul L. Gerfo, MD, Department of Surgery, Columbia-Presbyterian Medical Center, 161 Ft Washington Ave, New York, NY 10032. Copyright 9 1999 by WB. Saunders Company 1524-153X/99/0101-0009510.00/0
anesthesia before scrubbing allows approximately 10 minutes for the anesthesia to take effect. Effective cervical blockade depends on a large volume of local anesthetic. A 20-mL mixture of 0.5% Xylocaine with 0.25% Marcaine is required for each side. The duration of Marcaine anesthesia is longer and allows for re-exploration under local anesthesia if postoperative bleeding occurs. This also allows for a shorter hospital stay. Classically, a superficial or a deep Cervical block is used for thyroidectomies and parathyroidectomies. The superficial block consists of inserting a 22-gauge needleat the midpoint of the posterior margin of the sternocleidomastoid muscle. The local anesthesia is then injected posterior and immediately deep to the muscle. The needle is also redirected superiorly and inferiorly along the posterior border of the sternocleidomastoid muscle, and additional anesthesia is injected.
Operative Techniques in General Surgery, Vol 1, No 1 (September), 1999: pp 95-102
95
96
Lo Gerfo and Kim
Lesser occipital nerve
Greater auricular nerve
,Transverse cervical nerve
2%
Supraclavicular nerve
1
Anatomy. The sensory innervation of the cervical plexus is derived from C-2, C-3, and C-4, with branches that are divided into superficial and deep. The superficial branches, the lesser occipital, great auricular, transverse cervical, and supraclavicular nerves, pierce the deep cervical fascia just posterior to the sternocleidomastoid muscle at its midpoint. The first branch, the lesser occipital nerve, radiates upward and backward to supply part of the posterior surface of the upper part of the ear and the skin behind the ear; the greater auricular nerve, the second branch, runs upward and forward and supplies the skin over the posterior surface of the ear, the anterior lower third of the ear, and the angle of the mandible; the third branch, the transverse cervical nerve, runs anterior to the sternocleidomastoid and supplies the skin from the chin to the suprasternal notch; and the supraclavicular nerves, the fourth branches, run inferiorly and supply the skin over the inferior aspect of the neck and clavicle. These branches supply the skin over the neck from the mandible and clavicle anteriorly and laterally and supply innervation to the thyroid region. Numbness in the ears (C-2) can aid in the evaluation in the block. The middle cervical ganglion, or thyroid ganglion, is the smallest of the three cervical ganglia. It is found opposite the sixth cervical vertebra, close to the inferior thyroid artery and is not always present. It is formed by the coalescence of two ganglia corresponding to the fifth and sixth cervical nerves. The thyroid branches are small filaments that accompany the inferior thyroid artery to the thyroid gland; they communicate, on the artery, with the superior cardiac nerve, and, in the gland, with branches from the recurrent and external laryngeal nerves. The superior thyroid artery is also accompanied by a small nerve that innervates the thyroid gland that is also not part of the cervical plexes. The branchial plexus communicates with the cervical plexus by a branch from the fourth to the fifth nerve. This communication is usually clinically irrelevant.
97
Technique for Regional Anesthesia
Mastoid
process
c4
Cricoid cartilage
A
Chassaignac's tubercle (C-6)
2 The deep cervical block consists of injecting the local anesthetic at the transverse processes of C-2 to C-4. The sites of insertion are located by reference to al[ne that joins the tip of the mastoid process with Chassaignac's tubercle (the anterior tubercle of the transverse process of C-6), which is palpated at the level of the cricoid cartilage (A and B). The C-2 transverse process is usually located about one fingerbreadth below the mastoid process along this line. C-3 and C-4 are caudal at similar intervals along this same line. A 22-gauge needle is inserted until the tip feels the transverse processes at a depth approximately 1.5 to 3 cm, at which point the local anesthetic is injected.
98
Lo Gerfo and Kim
Mastoid process
q C-2
B 2
(continued)
99
Technique for Regional Anesthesia
0-2
J g-...
3 Although these methods have been well described and conventionally used, our experience finds that each individual method is somewhat limiting and that a cervical block that incorporates both techniques is superior. We have found that injecting the space between the sternocleidomastold muscle and the transverse processes of C-2 and C-3 more ideal. The patient is positioned supine with the head turned opposite the side to be injected. A 22-gauge needle is inserted until the tip of the transverse process of C-2 is identified. The needle is withdrawn until it is positioned in the fat pad posterior to the sternocleidomastoid muscle. Approximately 10 mL of local anesthetic is then injected. Similarly, the space between C-3 and the sternocleidomastoid muscle is anesthetized.
100
Lo Gerfo and Kim
Incision Cricoid cartilage ... prominence
4 An incision high in the neck at the level of the cricoid cartilage is made. This allows the relatively unfixed lower pole of the thyroid to be brought up into the wound without much manipulation. This also allows for adequate visualization of the superior thyroid vessels. The platysma is divided in the usual manner.
101
Technique for Regional Anesthesia
5':
Superior thyroid artery
iV
~
Once the superior thyroid artery is visualized, additional local anesthesia is injected near the vessel to block the nerve that usually accompanies the superior thyroid artery. Occasionally, the tissue around the inferior thyroid artery requires anesthesia if the patient continues to experience discomfort. Closure is different from standard protocol in that only the upper part of the strap muscles are closed to allow for shorter detection of postoperative hematoma. If a postoperative hematoma develops, re-exploration can often be performed under local anesthesia given the long half-life of marcaine.
102 Complications Complications from local/regional anesthesia are related to accidental injection of anesthesia intraarterially. These complications include arrhythmia, hypotension, and seizures. Rarely if the injection is given too deep or if the large volume of local anesthesia infiltrates deep, the phrenic nerve can be blocked. Hoarseness is also a possible complication if the recurrent laryngeal nerve is also accidentally anesthetized. Excess manipulation under local/regional anesthesia is avoided because occasionally the patient maintains a cough reflex. We have also observed occasional unexplained hypertension and tachycardia.
Lo Gerfo and Kim
RECOMMENDED READINGS Ditkoff BA, Chabot J, Feind C, et al: Parathyroid surgery using monitored anesthesia care: An alternative to general anesthesia. AmJ Surg 172:698-703, 1996 Lo Gerfo P: Local/regional anesthesia for thyroidectomy: Evaluation as an outpatient procedure. Surgery 124:975-979,1998 Murphy TM: Somatic blockade of head and neck, in Cousins MJ (ed): Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA, Lippincott, 1988, pp 533-558 Schwartz AE, Clark OH, Ituarte P, et al: Therapeutic controversy: Thyroid surgery--The choice. J Clin Endosc Metab 83:1097-1105, 1998 Tucker JH, Flynn JF: Head and neck regional blocks, in Brown DL (ed): Regional Anesthesia and Analgesia. Philadelphia, PA, Saunders, 1996, pp 240-253
Local/regional anesthesia for thyroid surgery has been used in small periodic experiences since the late 19th century and recently has been shown to be a safe and comparable alternative to general anesthesia. In addition, the technique of local/regional anesthesia described here allows for a shorter hospital stay. The anatomy of the cervical plexus is described in 1. The cervical plexus block is shown in 2. The success of local/regional anesthesia for thyroidectomy/parathyroidectomy is based on an adequate interval between time of injection and time of incision. Injecting From the Department of Surgery, Columbia-Presbyterian Medical Center, New York, NY. Address reprint requests to Paul L. Gerfo, MD, Department of Surgery, Columbia-Presbyterian Medical Center, 161 Ft Washington Ave, New York, NY 10032. Copyright 9 1999 by WB. Saunders Company 1524-153X/99/0101-0009510.00/0
anesthesia before scrubbing allows approximately 10 minutes for the anesthesia to take effect. Effective cervical blockade depends on a large volume of local anesthetic. A 20-mL mixture of 0.5% Xylocaine with 0.25% Marcaine is required for each side. The duration of Marcaine anesthesia is longer and allows for re-exploration under local anesthesia if postoperative bleeding occurs. This also allows for a shorter hospital stay. Classically, a superficial or a deep Cervical block is used for thyroidectomies and parathyroidectomies. The superficial block consists of inserting a 22-gauge needleat the midpoint of the posterior margin of the sternocleidomastoid muscle. The local anesthesia is then injected posterior and immediately deep to the muscle. The needle is also redirected superiorly and inferiorly along the posterior border of the sternocleidomastoid muscle, and additional anesthesia is injected.
Operative Techniques in General Surgery, Vol 1, No 1 (September), 1999: pp 95-102
95
96
Lo Gerfo and Kim
Lesser occipital nerve
Greater auricular nerve
,Transverse cervical nerve
2%
Supraclavicular nerve
1
Anatomy. The sensory innervation of the cervical plexus is derived from C-2, C-3, and C-4, with branches that are divided into superficial and deep. The superficial branches, the lesser occipital, great auricular, transverse cervical, and supraclavicular nerves, pierce the deep cervical fascia just posterior to the sternocleidomastoid muscle at its midpoint. The first branch, the lesser occipital nerve, radiates upward and backward to supply part of the posterior surface of the upper part of the ear and the skin behind the ear; the greater auricular nerve, the second branch, runs upward and forward and supplies the skin over the posterior surface of the ear, the anterior lower third of the ear, and the angle of the mandible; the third branch, the transverse cervical nerve, runs anterior to the sternocleidomastoid and supplies the skin from the chin to the suprasternal notch; and the supraclavicular nerves, the fourth branches, run inferiorly and supply the skin over the inferior aspect of the neck and clavicle. These branches supply the skin over the neck from the mandible and clavicle anteriorly and laterally and supply innervation to the thyroid region. Numbness in the ears (C-2) can aid in the evaluation in the block. The middle cervical ganglion, or thyroid ganglion, is the smallest of the three cervical ganglia. It is found opposite the sixth cervical vertebra, close to the inferior thyroid artery and is not always present. It is formed by the coalescence of two ganglia corresponding to the fifth and sixth cervical nerves. The thyroid branches are small filaments that accompany the inferior thyroid artery to the thyroid gland; they communicate, on the artery, with the superior cardiac nerve, and, in the gland, with branches from the recurrent and external laryngeal nerves. The superior thyroid artery is also accompanied by a small nerve that innervates the thyroid gland that is also not part of the cervical plexes. The branchial plexus communicates with the cervical plexus by a branch from the fourth to the fifth nerve. This communication is usually clinically irrelevant.
97
Technique for Regional Anesthesia
Mastoid
process
c4
Cricoid cartilage
A
Chassaignac's tubercle (C-6)
2 The deep cervical block consists of injecting the local anesthetic at the transverse processes of C-2 to C-4. The sites of insertion are located by reference to al[ne that joins the tip of the mastoid process with Chassaignac's tubercle (the anterior tubercle of the transverse process of C-6), which is palpated at the level of the cricoid cartilage (A and B). The C-2 transverse process is usually located about one fingerbreadth below the mastoid process along this line. C-3 and C-4 are caudal at similar intervals along this same line. A 22-gauge needle is inserted until the tip feels the transverse processes at a depth approximately 1.5 to 3 cm, at which point the local anesthetic is injected.
98
Lo Gerfo and Kim
Mastoid process
q C-2
B 2
(continued)
99
Technique for Regional Anesthesia
0-2
J g-...
3 Although these methods have been well described and conventionally used, our experience finds that each individual method is somewhat limiting and that a cervical block that incorporates both techniques is superior. We have found that injecting the space between the sternocleidomastold muscle and the transverse processes of C-2 and C-3 more ideal. The patient is positioned supine with the head turned opposite the side to be injected. A 22-gauge needle is inserted until the tip of the transverse process of C-2 is identified. The needle is withdrawn until it is positioned in the fat pad posterior to the sternocleidomastoid muscle. Approximately 10 mL of local anesthetic is then injected. Similarly, the space between C-3 and the sternocleidomastoid muscle is anesthetized.
100
Lo Gerfo and Kim
Incision Cricoid cartilage ... prominence
4 An incision high in the neck at the level of the cricoid cartilage is made. This allows the relatively unfixed lower pole of the thyroid to be brought up into the wound without much manipulation. This also allows for adequate visualization of the superior thyroid vessels. The platysma is divided in the usual manner.
101
Technique for Regional Anesthesia
5':
Superior thyroid artery
iV
~
Once the superior thyroid artery is visualized, additional local anesthesia is injected near the vessel to block the nerve that usually accompanies the superior thyroid artery. Occasionally, the tissue around the inferior thyroid artery requires anesthesia if the patient continues to experience discomfort. Closure is different from standard protocol in that only the upper part of the strap muscles are closed to allow for shorter detection of postoperative hematoma. If a postoperative hematoma develops, re-exploration can often be performed under local anesthesia given the long half-life of marcaine.
102 Complications Complications from local/regional anesthesia are related to accidental injection of anesthesia intraarterially. These complications include arrhythmia, hypotension, and seizures. Rarely if the injection is given too deep or if the large volume of local anesthesia infiltrates deep, the phrenic nerve can be blocked. Hoarseness is also a possible complication if the recurrent laryngeal nerve is also accidentally anesthetized. Excess manipulation under local/regional anesthesia is avoided because occasionally the patient maintains a cough reflex. We have also observed occasional unexplained hypertension and tachycardia.
Lo Gerfo and Kim
RECOMMENDED READINGS Ditkoff BA, Chabot J, Feind C, et al: Parathyroid surgery using monitored anesthesia care: An alternative to general anesthesia. AmJ Surg 172:698-703, 1996 Lo Gerfo P: Local/regional anesthesia for thyroidectomy: Evaluation as an outpatient procedure. Surgery 124:975-979,1998 Murphy TM: Somatic blockade of head and neck, in Cousins MJ (ed): Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA, Lippincott, 1988, pp 533-558 Schwartz AE, Clark OH, Ituarte P, et al: Therapeutic controversy: Thyroid surgery--The choice. J Clin Endosc Metab 83:1097-1105, 1998 Tucker JH, Flynn JF: Head and neck regional blocks, in Brown DL (ed): Regional Anesthesia and Analgesia. Philadelphia, PA, Saunders, 1996, pp 240-253