Ultrasound-guided superficial cervical plexus block for oral and maxillofacial surgery

The population of Americans aged 65 years and older is projected to increase from 58 million in 2022 to 82 million by 2050, marking a 42% rise. As a result, the 65-and-older age group will grow from 17% to 23% of the total U.S. population (1). This demographic shift will drive an increased demand for healthcare services, including surgical care tailored to the complex medical needs of elderly individuals. In the field of oral and maxillofacial surgery (OMFS), managing geriatric patients has become increasingly important, as this population often presents with tumors, cysts, and infections of the oral and maxillofacial region requiring surgical intervention. Previous studies also highlight the need for age-specific protocols and perioperative considerations (2). The shared airway, age-related anatomical changes that increase the likelihood of difficult intubation, and heightened susceptibility to postoperative pulmonary complications and delirium all contribute to elevated perioperative risk. In a national analysis of over 146,000 patients undergoing head and neck surgery, elderly individuals demonstrated a complication rate of 16.85% and nearly twice the odds of perioperative mortality compared with younger counterparts, with pulmonary complications being the most frequent adverse event (3). For patients with significant pre-existing cardiovascular and pulmonary conditions, these risks may preclude surgical intervention.

In this context, Zhao et al. present a case series of seven elderly patients aged 69 to 92 years, each with contraindications to general anesthesia (GA), including severe ventilatory dysfunction and cardiac disease. These patients underwent unilateral oral and maxillofacial procedures under ultrasound-guided superficial cervical plexus block (SCPB) combined with local infiltration anesthesia (LIA) (4). The authors reported no conversions to GA or sedation, and no complications were observed during the 12-month follow-up period. This case series suggests that regional anesthesia may represent a reasonable alternative to GA in carefully selected geriatric patients, potentially reducing anesthetic risk without compromising surgical needs. This commentary evaluates the evidence supporting this anesthetic approach for elderly OMFS patients and explores the potential role of regional anesthesia techniques in improving perioperative outcomes in this vulnerable population.

Sensory innervation of the mandible is traditionally understood to arise from the trigeminal nerve, specifically its third division (V3). However, this view has been challenged by a large cadaver study. Ella et al. demonstrated that branches of the superficial cervical plexus, originating from the upper cervical spinal nerves (C2–C4), reach the mandible in 97% of specimens. More specifically, the great auricular nerve (GAN) was found in contact with the mandible in 97.4% of cases, primarily at the angle of the mandible, while the transverse cervical nerve (TCN) was identified in 9.6% (5). These findings were further supported by a systematic review proposing the concept of a “craniocervical nerve plexus”. This concept suggests that the cranial nerves and cervical plexus do not function as separate systems but rather as a continuous network with overlapping sensory territories, particularly in regions such as the lower face and submandibular area (5).

This anatomical overlap helps explain accessory innervation of the mandible, which may contribute to persistent sensations despite apparently successful mandibular anesthesia. This phenomenon is particularly relevant when the TCN and GAN, both branches from the cervical plexus, are involved. It may account for the widely cited 15–20% failure rate of the inferior alveolar nerve block (IANB) reported during third molar extractions, in which patients experience pain despite seemingly adequate IANB. In such cases, additional anesthesia of the GAN has occasionally been required to achieve complete mandibular anesthesia after a failed IANB. From this perspective, SCPB is not merely a cutaneous block of the neck; rather, it targets cervical plexus fibers that contribute to sensory innervation around the mandible in most patients. However, this same anatomy defines the limits of SCPB. Deeper structures, including the tongue and floor of the mouth—primarily innervated by V3—remain beyond its reach and require supplemental nerve blocks or local infiltration to achieve adequate anesthesia.

The trajectory of SCPB in OMFS reflects a gradual evolution from an isolated rescue technique to a potentially paradigm-shifting anesthetic strategy. Early reports characterized cervical plexus blocks (CPBs) primarily as adjunctive or situational tools. Shteif et al. described their use in submandibular abscess drainage, demonstrating feasibility in infected fields where airway manipulation posed substantial risk (6). Shortly thereafter, Gupta et al. reported successful decompression of Ludwig’s angina under CPB, including pediatric and pregnant patients—populations in whom GA carries distinct hazards (7). These early experiences emphasized avoidance of airway instrumentation in anatomically compromised or medically fragile patients.

The introduction of ultrasound guidance marked a significant technical advancement. Perisanidis et al. reported the first ultrasound-guided CPBs in OMFS (intermediate and deep techniques, n=19), demonstrating favorable analgesia with improved visualization of anatomical landmarks (8). Subsequent case series by Kanthan and Hakim et al. further systematized the approach, although sample sizes remained small (n=10 each), and the evidence base continued to consist of level IV data (9,10). A conceptual shift emerged with the randomized controlled trial by Kende et al., which demonstrated that SCPB used as an adjunct to IANB improved pain control and prolonged anesthetic duration compared with local infiltration alone in cases of mandibular fracture and infection (11). This represents the strongest evidence to date; however, it supports SCPB as an adjunct technique rather than as a replacement for GA.

More recent reports, including those by Saripalli et al. and Zhao et al., advance a more ambitious proposition: SCPB, with or without LIA, as a complete alternative to GA for select unilateral maxillofacial procedures (4,12). Nevertheless, this application remains supported exclusively by small case series. Rathee et al. further refined the technique, demonstrating faster onset with a modified ultrasound-guided approach compared with traditional landmark methods, signaling ongoing technical maturation (13). Collectively, the literature demonstrates a steady expansion of indications and progressive technical refinement; however, robust comparative data supporting SCPB as a true substitute for GA remain lacking.

Jarvis et al. proposed a three-tier classification of CPB based on fascial planes: superficial (above the investing fascia), intermediate (between the investing and prevertebral fascia), and deep (below the prevertebral fascia, near the cervical nerve roots) (14). In contrast, in many U.S. practices simplify the terminology into two categories: a superficial CPB performed between the investing and prevertebral fascia—corresponding to the intermediate approach described in Jarvis et al.—and a deep CPB performed at or beneath the prevertebral fascia (14).

Currently, CPB is most commonly performed under ultrasound guidance, which enhances target identification and reduces vascular and neuraxial complications compared with landmark-based techniques (14). The patient is positioned supine with the head turned contralaterally. A high-frequency linear transducer is placed on the anterolateral neck at approximately the midpoint of the sternocleidomastoid (SCM) muscle to identify the SCM and the underlying anterior and middle scalene muscles (14). The needle is typically advanced in-plane—most commonly from lateral to medial—with continuous visualization of the needle tip to ensure accurate deposition within the intended fascial plane and to minimize the risk of vascular injury (14).

For the superficial CPB, the target is the potential space deep to the SCM and superficial to the prevertebral fascia, often visualized as the plane overlying the anterior and middle scalene muscles (14). Local anesthetic is injected to achieve clear hydrodissection and spread along this plane. In many adult patients, 5–10 mL is sufficient for cutaneous analgesia, although dosing should be individualized based on patient factors and procedural requirements (14).

Deep CPB involves deposition of local anesthetic adjacent to the transverse processes beneath the prevertebral fascia (14). This approach carries a higher risk profile, including inadvertent intravascular injection-given that the vertebral artery traverses the transverse foramina- and unintended spread to adjacent motor nerves, such as the phrenic nerve (C3–C5) (14). Importantly, deep CPB has not consistently demonstrated superior sensory analgesia compared with the superficial approach, while potentially increasing the risk of undesirable motor blockade. For these reasons, deep CPB is less commonly performed when a well-executed, ultrasound-guided superficial CPB can achieve the desired clinical effect with a more favorable safety margin (14).

From a surgeon’s perspective, the choice of anesthesia extends beyond adequate pain control; it must also create a safe and optimal operative environment. GA provides controlled hypotension, neuromuscular blockade for an immobile surgical field, and endotracheal intubation to secure and protect the airway (9). These advantages cannot be replicated with local or regional anesthesia alone. In contrast, when SCPB is combined with LIA, the surgeon operates on a conscious, spontaneously breathing patient with an unprotected airway (9). As illustrated in the case series by Zhao et al, this approach is particularly challenging during procedures such as neck dissection, where the operate field lies in close proximity to critical structures including the carotid sheath, internal jugular vein, and cranial nerves, while the patient retains the capacity to cough, swallow, or move (4). Evidence from the carotid endarterectomy literature suggests that such scenarios are manageable in high-volume centers, with conversion rates to GA ranging from 0.2% to 1% (15). However, these outcomes are derived from thousands of cases performed in specialized vascular centers. OMFS has comparatively limited experience with these techniques; therefore, such results should not be directly extrapolated to OMFS practice.

Patient and procedure selection require careful consideration. These cases reported by Zhao et al. involved unilateral neck procedures; however, midline surgeries—including operations involving the floor of mouth or tongue—as well as bilateral or extensive intraoral procedures introduce additional anatomical and anesthetic complexities, even with supplemental local anesthesia (4). Moreover, the psychological burden of awake cancer surgery in elderly patients should not be underestimated. Although Zhao et al. managed intraoperative anxiety through verbal communication, additional structured strategies may be necessary to address both preoperative and intraoperative anxiety (4). Any protocol that positions SCPB as an alternative to GA must also incorporate a clearly defined and rehearsed conversion plan. If the block fails mid-procedure in a patient deemed high-risk for GA, the surgeon may be confronted with an open surgical field, a potentially compromised airway, and a distressed patient. This critical safety consideration warrants further investigation. Robust data regarding block failure rates, rescue strategies, and airway management algorithms are essential before broader adoption of this approach can be justified.

Despite these reservations, the potential implications for geriatric patients merit emphasis. For elderly individuals previously considered suboptimal surgical candidates, regional anesthesia protocols may offer a viable pathway to operative management (3). One of the most clinically meaningful aspects of Zhao et al.’s series is the complete avoidance of both opioids and sedatives (4). None of the seven elderly patients required intraoperative opioids, aligning with a growing body of literature supporting opioid-free anesthesia (OFA) when combined with cervical plexus blockade. Liu et al. demonstrated that OFA paired with CPB reduced postoperative nausea and vomiting from 39.4% to 6.1% in thyroid surgery, representing a substantial improvement in recovery quality (16). Similarly, Gürkan et al. reported that ultrasound-guided SCPB significantly decreased postoperative morphine consumption following thyroidectomy (17). Together, these findings suggest that effective regional anesthesia can substantially reduce perioperative opioid requirements without compromising analgesia.

For geriatric patients, opioid avoidance carries particular importance. Age-related reductions in hepatic and renal clearance may prolong opioid half-life, increasing susceptibility to respiratory depression, postoperative delirium, constipation, and falls (18). These complications are not merely transient; they are strongly associated with prolonged hospitalization, loss of functional independence, and increased mortality (18). Consequently, an opioid-sparing or opioid-free pathway may represent not merely an alternative anesthetic strategy, but a preferable perioperative standard for carefully selected elderly patients (19).

Beyond pharmacologic benefits, regional anesthesia protocols may expand surgical eligibility for patients previously deemed inoperable because of the risks associated with GA (20). This paradigm shift mirrors trends observed in other surgical domains. In hip fracture surgery, regional anesthesia has been associated with reduced rates of postoperative delirium compared with GA (21). Similarly, large randomized trials in carotid endarterectomy have demonstrated comparable overall safety, with potential neurocognitive advantages when local or regional techniques are employed (22). Outcomes such as preservation of cognitive function and maintenance of functional independence are particularly relevant for elderly patients who prioritize quality of life.

Whether light sedation with agents such as dexmedetomidine could enhance patient comfort while preserving the benefits of opioid avoidance remains uncertain and warrants prospective investigation. Nonetheless, the findings reported by Zhao et al. point toward a future in which regional anesthesia may facilitate safer surgical access for medically complex geriatric patients, positioning opioid-free protocols as a potentially transformative development in OMFS (4).

The growing geriatric population will increasingly challenge surgeons and anesthesiologists to deliver safe operative care to patients with diminished physiologic reserve. Zhao et al. provide compelling preliminary evidence that ultrasound-guided SCPB combined with LIA can enable OMFS in carefully selected elderly patients with unilateral neck pathology and true contraindications to GA (4). For individuals who might otherwise be considered inoperable, this approach represents a meaningful expansion of surgical access.

Enthusiasm, however, must be balanced with scientific rigor. Before SCPB-based protocols can be adopted more broadly, the field requires multicenter prospective registries, standardized outcome reporting using validated pain and recovery metrics, and comparative studies against established anesthetic techniques. Equally important is transparent reporting of block failures, intraoperative conversions, and complications to clearly define appropriate patient selection and procedural boundaries.

Zhao et al. have provided an important proof of concept (4). The next phase must determine whether this strategy can evolve from an innovative alternative into a reproducible, evidence-based pathway capable of improving perioperative safety for one of surgery’s most vulnerable populations.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Oral and Maxillofacial Anesthesia. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0007/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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