A COMPARATIVE EFFICACY OF ULTRASOUND GUIDED INTERSCALENE BRACHIAL PLEXUS BLOCK COMBINED WITH SUPERFICIAL CERVICAL PLEXUS BLOCK VERSUS CLA VIPECTORAL FASCIA PLANE BLOCK COMBINED SUPERFICIAL CERVICAL FLEXUS BLOCK IN PATIENTS UNDERGOING FIXATION OF FRACTURE CLAVICLE: A RANDOMIZED CONTROLLED TRIAL

Title: A comparative efficacy of ultrasound guided interscalene brachia! plexus block

combined with superficial cervical plexus block versus clavipectoral fascia plane block  combined superficial cervical flexus block in patients undergoing fixation of fracture  clavicle: A randomized controlled trial

Need for Study / Introduction

Clavicular fracture is the most common injury in the shoulder, particularly in young men. It mainly occurs due to sports or road traffic accidents, especially in the middle of the clavicle.

Better functional results can be obtained by surgical fixation of the fracture.

Exact innervation of clavicle is debatable 1• The supraclavicular nerve of the superficial cervical  plexus is responsible for innervation of the bone and skin above the clavicle, while the brachial plexus innervates the deep muscle of the clavicle.

Regional anaesthesia carri es several advantages over general anaesthesia. lnterscalene brachial plexus block in combination with superficial cervical plexus block is commonly used anaesthetic technique for the surgical fixation of fracture clavicle. General anaesthesia is the other option but carries inherent risk of polypharmacy,airway trauma and neuroendocrine stress response to intubation.

Clavipectoral fascia! plane block(CPB) is a new regional nerve block proposed by Valdes in 2017 where in local anaesthetic agents are injected into clavipectoral fascia plane which can be used for anaesthesia and postoperative analgesia in patients undergoing surgery for fracture clavicle.

It provides effective pain control for procedures involving the midshaft and lateral clavicle.

This typically avoids phrenic nerve blockade, thus preserving diaphragmatic function • It also minimizes unnecessary numbness or motor block in adjacent regions. It is easily visualized with ultrasound, which enhances precision and safety of this block. This block can be performed in combination with other regional techniques (e.g., superficial cervical plexus block) for broader cove rage. There are very few studies comparing the efficacy of clavipectoral block with the commonly used inter scalene brachial plexus block in combination with superficial cervical plexus for

fixation of fracture clavicle. Hence this study is conducted to explore the comparative efficacy of this block.

Review of Literature

1. Guangmin Xu, et al. (2017)3 in a randomized controlled trial compared US guided superficial cervical plexus block with clavipectoral fascia! plane block or interscalene brachial plexus block in 50 patients who underwent elective internal fixation of fracture clavicle. The effects of the block measured at 30 min of both regional anaesthesia were very satisfactory. Compared with ultrasound-guided SCPB and ISBP, SCPB combined with CPB for clavicular operation has longer postoperative analgesia, better preserves the motor function of the upper limbs and avoids the incidence of diaphragmatic paralysis. Therefore, this technique is suitable for application in clinical practice.

2. Olofsson M., ct al (2020)4 in a matched case- controlled study done on 50 consecutive patients who underwent surgical fixation of clavicle. All patients received lnterscalene brachial plexus block for surgical repair of clavicle fracture .The study concluded that there is significant lower consumption of iv morphine in the whole cohort.

3_ Kukrc.ia P, ct al. (2020t in a case series on ultrasound-guided Clavipectoral Fascia! Plane Block for Surgery involving the Clavicle in 3 patients found that the CPB is another effective alternate anaesthesia technique while avoiding undesirable side effects of more proximal techniques such as motor blockade or phrenic nerve paralysis. Moreover, it does not carry any risk of pneumothorax. The technique is easy to perform and has an advanced safety profile, especially for patients with respiratory disease. Compared with other brachial plexus blocks which prevent pain transmission more proximally, CPB offers more distal blockade and superficially. This case series adds up to evidence supporting the utility of CPB.

4. Faramarz Mosaffa, et al (2023)6 in a randomized double-blinded, non-inferiority clinical trial on 120 patients compared interscalene block (ISB) with or without superficial cervical plexus block (SCPB) for anaesthesia in clavicle surgery. The primary outcome was defined as the conversion to GA. Various factors were recorded, including surgery duration, nerve block initiation, analgesics required in the post anaesthesia care unit (PACU), and sedation during surgery. Efficacy of ISB is the same whether or not it is combined with a SCPB. lnterscalene block is an alternative regional anaesthesia approach for clavicle fractures. Thus, ISB alone is as efficient as when used in combination with SCPB.