Evaluating the extent of lumbar erector spinae plane block: an anatomical study

2020 ◽  
Vol 45 (8) ◽  
pp. 640-644 ◽  
Author(s):  
Monica W Harbell ◽  
David P Seamans ◽  
Veerandra Koyyalamudi ◽  
Molly B Kraus ◽  
Ryan C Craner ◽  
...  
Keyword(s):  
Anatomical Study ◽  
Transverse Process ◽  
Erector Spinae ◽  
Lateral Spread ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Multifidus Muscle ◽  
Erector Spinae Plane Block ◽  
Thoracic Level ◽  
Dorsal Rami

Background and objectivesThe erector spinae plane (ESP) block is a relatively new interfascial block technique. Previous cadaveric studies have shown extensive cephalocaudal spread with a single ESP injection at the thoracic level. However, little data exist for lumbar ESP block. The objective of this study was to examine the anatomical spread of dye following an ultrasound-guided lumbar ESP block in a human cadaveric model.MethodsAn ultrasound-guided ESP block was performed in unembalmed human cadavers using an in-plane approach with a curvilinear transducer oriented longitudinally. 20 mL of 0.166% methylene blue was injected into the plane between the distal end of the L4 transverse process and erector spinae muscle bilaterally in four specimens and unilaterally in one specimen (nine ESP blocks in total). The superficial and deep back muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and medial–lateral directions.ResultsThere was cephalocaudal spread from L3 to L5 in all specimens with extension to L2 in four specimens. Medial–lateral spread was documented from the multifidus muscle to the lateral edge of the thoracolumbar fascia. There was extensive dye in and around the erector spinae musculature and spread to the dorsal rami in all specimens. There was no dye spread anteriorly into the dorsal root ganglion, ventral rami, or paravertebral space.ConclusionsA lumbar ESP injection has limited craniocaudal spread compared with injection in the thoracic region. It has consistent spread to dorsal rami, but no anterior spread to ventral rami or paravertebral space.

scholarly journals The Ultrasound-guided Proximal Intercostal Block: Anatomical study and clinical correlation to analgesia for breast surgery

2019 ◽  
Author(s):  
Nantthasorn Zinbonyahgoon ◽  
Panya Luksanapruksa ◽  
Sitha Piyaselakul ◽  
Pawinee Pangthipampai ◽  
Suphalerk Lohasammakul ◽  
...  
Keyword(s):  
Breast Surgery ◽  
Anatomical Study ◽  
Opioid Consumption ◽  
Intercostal Space ◽  
Lateral Spread ◽  
Parietal Pleura ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Intercostal Block ◽  
Fascial Plane

Abstract Background: The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. Methods: Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15ml) and 4th(25ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid consumption. Results: Median contrast/dye spread was 4(2-8) and 3(2-5) vertebral segments by fluoroscopy and dissection respectively. Dissection revealed injectate spread to the adjacent paravertebral space, T3 (60%) and T5 (27%), and cranio-caudal spread along the endothoracic fascia (80%). Clinically, the median documented area of hypoesthesia was 5(4-7) dermatomes with 100% and 92% of the injections covering adjacent T3 and T5 dermatomes, respectively. The patients with PICB had significantly lower perioperative opioid consumption and trend towards lower pain scores. Conclusions: In this anatomical study, PICB at the 2nd and 4th ICS produced lateral spread along the corresponding intercostal space, medial spread to the adjacent paravertebral/epidural space and cranio-caudal spread along the endothoracic fascial plane. Clinically, combined PICBs at the same levels resulted in consistent segmental chest wall analgesia and reduction in perioperative opioid consumption after breast surgery. The incomplete overlap between paravertebral spread in the anatomical study and area of hypoesthesia in our clinical findings, suggests that additional non-paravertebral routes of injectate distribution, such as the endothoracic fascial plane, may play important clinical role in the multi-level coverage provided by this block technique. Keywords: Nerve block, paravertebral space, intercostal space, intercostal block, breast surgery.

scholarly journals The Ultrasound-guided Proximal Intercostal Block: Anatomical study and clinical correlation to analgesia for breast surgery

2019 ◽  
Author(s):  
Nantthasorn Zinbonyahgoon ◽  
Panya Luksanapruksa ◽  
Sitha Piyaselakul ◽  
Pawinee Pangthipampai ◽  
Suphalerk Lohasammakul ◽  
...  
Keyword(s):  
Breast Surgery ◽  
Anatomical Study ◽  
Opioid Consumption ◽  
Intercostal Space ◽  
Lateral Spread ◽  
Parietal Pleura ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Intercostal Block ◽  
Fascial Plane

Abstract Background: The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. Methods: Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15ml) and 4th(25ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid consumption. Results: Median contrast/dye spread was 4(2-8) and 3(2-5) vertebral segments by fluoroscopy and dissection respectively. Dissection revealed injectate spread to the adjacent paravertebral space, T3 (60%) and T5 (27%), and cranio-caudal spread along the endothoracic fascia (80%). Clinically, the median documented area of hypoesthesia was 5(4-7) dermatomes with 100% and 92% of the injections covering adjacent T3 and T5 dermatomes, respectively. The patients with PICB had significantly lower perioperative opioid consumption and trend towards lower pain scores. Conclusions: In this anatomical study, PICB at the 2nd and 4th ICS produced lateral spread along the corresponding intercostal space, medial spread to the adjacent paravertebral/epidural space and cranio-caudal spread along the endothoracic fascial plane. Clinically, combined PICBs at the same levels resulted in consistent segmental chest wall analgesia and reduction in perioperative opioid consumption after breast surgery. The incomplete overlap between paravertebral spread in the anatomical study and area of hypoesthesia in our clinical findings, suggests that additional non-paravertebral routes of injectate distribution, such as the endothoracic fascial plane, may play important clinical role in the multi-level coverage provided by this block technique.

scholarly journals The Ultrasound-guided Proximal Intercostal Block: Anatomical study and clinical correlation to analgesia for breast surgery

2019 ◽  
Author(s):  
Nantthasorn Zinbonyahgoon ◽  
Panya Luksanapruksa ◽  
Sitha Piyaselakul ◽  
Pawinee Pangthipampai ◽  
Suphalerk Lohasammakul ◽  
...  
Keyword(s):  
Breast Surgery ◽  
Anatomical Study ◽  
Opioid Consumption ◽  
Intercostal Space ◽  
Lateral Spread ◽  
Parietal Pleura ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Intercostal Block ◽  
Fascial Plane

Abstract Background: The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. Methods: Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15ml) and 4th(25ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid consumption. Results: Median contrast/dye spread was 4(2-8) and 3(2-5) vertebral segments by fluoroscopy and dissection respectively. Dissection revealed injectate spread to the adjacent paravertebral space, T3 (60%) and T5 (27%), and cranio-caudal spread along the endothoracic fascia (80%). Clinically, the median documented area of hypoesthesia was 5(4-7) dermatomes with 100% and 92% of the injections covering adjacent T3 and T5 dermatomes, respectively. The patients with PICB had significantly lower perioperative opioid consumption and trend towards lower pain scores. Conclusions: In this anatomical study, PICB at the 2nd and 4th ICS produced lateral spread along the corresponding intercostal space, medial spread to the adjacent paravertebral/epidural space and cranio-caudal spread along the endothoracic fascial plane. Clinically, combined PICBs at the same levels resulted in consistent segmental chest wall analgesia and reduction in perioperative opioid consumption after breast surgery. The incomplete overlap between paravertebral spread in the anatomical study and area of hypoesthesia in our clinical findings, suggests that additional non-paravertebral routes of injectate distribution, such as the endothoracic fascial plane, may play important clinical role in the multi-level coverage provided by this block technique.

scholarly journals Comparison of Clinical Efficacy and Anatomical Investigation between Retrolaminar Block and Erector Spinae Plane Block

2019 ◽  
Vol 2019 ◽  
pp. 1-8 ◽  
Author(s):  
Eiko Onishi ◽  
Noriko Toda ◽  
Yoshinobu Kameyama ◽  
Masanori Yamauchi
Keyword(s):  
Local Anesthetic ◽  
Clinical Studies ◽  
Transverse Process ◽  
Underlying Mechanism ◽  
Erector Spinae ◽  
Clinical Indication ◽  
Paravertebral Space ◽  
Erector Spinae Plane Block ◽  
Alternative Approaches ◽  
Local Anesthetic Injection

Retrolaminar block (RLB) and erector spinae plane block (ESPB) are alternative approaches to paravertebral block (PVB) and are advantageous in that they are easier and safer techniques compared with the traditional PVB. Many clinical reports of these blocks have described their efficacy for ipsilateral thoracic analgesia. The local anesthetic injection points of RLB and ESPB are the lamina and transverse process, respectively. Despite the similarity of the puncture sites, there have been no clinical studies comparing RLB and ESPB. In addition, the underlying mechanism of these blocks has not been clarified. Recent anatomical investigations indicated that the injectate was distributed in the paravertebral space and spread laterally into the intercostal spaces. The limited distribution into the paravertebral space indicated that compared to PVB, RLB and ESPB exert their effects via a different mechanism. In this review, we describe the features of and differences between RLB and ESPB based on current clinical and anatomical reports. We also propose the clinical indication and discuss the differences, clinical outcomes, and anatomical mechanisms of the techniques.

Comparing two posterior quadratus lumborum block approaches with low thoracic erector spinae plane block: an anatomic study

2019 ◽  
Vol 44 (5) ◽  
pp. 549-555 ◽  
Author(s):  
Hesham Elsharkawy ◽  
Gausan Ratna Bajracharya ◽  
Kariem El-Boghdadly ◽  
Richard L. Drake ◽  
Edward R. Mariano
Keyword(s):  
Erector Spinae ◽  
Posterolateral Approach ◽  
Cadaver Dissection ◽  
Anatomic Study ◽  
Paravertebral Space ◽  
Erector Spinae Plane Block ◽  
India Ink ◽  
Quadratus Lumborum ◽  
Dorsal Rami ◽  
Highly Correlated

Background and objectivesBoth posterior quadratus lumborum (QL) and erector spinae plane (ESP) blocks have been described as new truncal interfascial plane blocks. Distribution of injectate is influenced by fascial anatomy; therefore, different injection sites may produce similar spread. This anatomic study was designed to test the hypothesis that a posteromedial QL block at L2 level will more closely resemble a low thoracic ESP block when compared with the posterolateral approach at L2 level.MethodsLeft-sided ESP blocks were performed in six cadavers at T10–11. Three of these cadavers received right-sided posteromedial QL block at L2, while the other three received right-sided posterolateral QL block at L2. All injections were composed of 20 mL methylcellulose 0.5 % mixed with India ink and 10 mL of Omnipaque (Iohexol) 240 mg/mL. CT 24 hours after injection and cadaver dissection were used to evaluate injectate spread.ResultsCephalocaudal spread of injectate by CT and cadaveric dissection was highly correlated (r=0.85 [95% CI 0.51 to 0.95]). Cadaver dissection showed ESP injectate spread deep to the muscle (mean [SD]) 11.7 (2.3) levels compared with 7.3 (1.2) levels for posterolateral QL and 9.7 (1.5) for posteromedial QL (p=0.04 overall, with a statistically significant pairwise difference between ESP and posterolateral QL only). The subcostal nerve and dorsal rami were commonly involved in most blocks, but the paravertebral space and ventral rami had inconsistent involvement. The lumbocostal ligament limited cranial spread from the posterlateral QL block approach.ConclusionsThe posteromedial QL block at L2 produces more cranial spread beyond the lumbocostal ligament than the posterolateral QL block, and this spread is comparable with a low thoracic ESP block. Both posterior QL and ESP blocks show unreliable spread of injectate to the paravertebral space and ventral rami, but the dorsal rami were frequently covered.

Ultrasound-guided erector spinae plane block and dexmedetomidine cooperative sedation for non-intubated chest wall surgery

2019 ◽  
Vol 85 (12) ◽  
Author(s):  
Selene Ranocchia ◽  
Paolo Scimia ◽  
Carolina Giordano ◽  
Vinicio Danzi ◽  
Elena Bignami
Keyword(s):  
Chest Wall ◽  
Erector Spinae ◽  
Ultrasound Guided ◽  
Erector Spinae Plane Block
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