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 A prospective, randomized comparison of ultrasonographic visualization of proximal intercostal block vs paravertebral block

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Kamen Vlassakov ◽  
Avery Vafai ◽  
David Ende ◽  
Megan E. Patton ◽  
Sonia Kapoor ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Nerve Block ◽  
Opioid Consumption ◽  
Paravertebral Block ◽  
Anatomical Landmarks ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Pain Scores ◽  
Performance Times ◽  
Intercostal Block

Abstract Background Thoracic paravertebral blockade is an accepted anesthetic and analgesic technique for breast surgery. However, real-time ultrasound visualization of landmarks in the paravertebral space remains challenging. We aimed to compare ultrasound-image quality, performance times, and clinical outcomes between the traditional parasagittal ultrasound-guided paravertebral block and a modified approach, the ultrasound-guided proximal intercostal block. Methods Women with breast cancer undergoing mastectomy (n = 20) were randomized to receive either paravertebral (n = 26) or proximal intercostal blocks (n = 32) under ultrasound-guidance with 2.5 mg/kg ropivacaine prior to surgery. Block ultrasound images before and after needle placement, and anesthetic injection videoclips were saved, and these images and vidoes independently rated by separate novice and expert reviewers for quality of visualization of bony elements, pleura, relevant ligament/membrane, needle, and injectate spread. Block performance times, postoperative pain scores, and opioid consumption were also recorded. Results Composite visualization scores were superior for proximal intercostal compared to paravertebral nerve block, as rated by both expert (p = 0.008) and novice (p = 0.01) reviewers. Notably, both expert and novice rated pleural visualization superior for proximal intercostal nerve block, and expert additionally rated bony landmark and injectate spread visualization as superior for proximal intercostal block. Block performance times, needle depth, opioid consumption and postoperative pain scores were similar between groups. Conclusions Proximal intercostal block yielded superior visualization of key anatomical landmarks, possibly offering technical advantages over traditional paravertebral nerve block. Trial registration ClinicalTrials.gov, NCT02911168. Registred on the 22nd of September 2016.

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 ◽  
Vol 19 (1) ◽  
Author(s):  
Nantthasorn Zinboonyahgoon ◽  
Panya Luksanapruksa ◽  
Sitha Piyaselakul ◽  
Pawinee Pangthipampai ◽  
Suphalerk Lohasammakul ◽  
...  
Keyword(s):  
Breast Surgery ◽  
Anatomical Study ◽  
Clinical Correlation ◽  
Ultrasound Guided ◽  
Intercostal Block

Anatomical basis of fascial plane blocks

2021 ◽  
Vol 46 (7) ◽  
pp. 581-599
Author(s):  
Ki Jinn Chin ◽  
Barbara Versyck ◽  
Hesham Elsharkawy ◽  
Maria Fernanda Rojas Gomez ◽  
Xavier Sala-Blanch ◽  
...  
Keyword(s):  
Local Anesthetic ◽  
Clinical Utility ◽  
Needle Insertion ◽  
Ultrasound Guided ◽  
Internal Organs ◽  
Paravertebral Space ◽  
Anatomical Basis ◽  
Local Anesthetic Injection ◽  
Visceral Innervation ◽  
Fascial Plane

Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space (“plane”) between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.

Thoracic-paravertebral blocks: comparative anatomical study with different injection techniques and volumes

2019 ◽  
pp. rapm-2019-100896 ◽  
Author(s):  
Ronald Seidel ◽  
Andreas Wree ◽  
Marko Schulze
Keyword(s):  
Epidural Space ◽  
Anatomical Study ◽  
Sympathetic Trunk ◽  
Injection Technique ◽  
Initial Contact ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Injection Volume ◽  
Injection Techniques ◽  
Intercostal Nerves

Background and objectivesWe hypothesized that different injection techniques and volumes in thoracic-paravertebral blocks (TPVB) lead to different patterns of dye spread. In particular, we investigated whether an alternating injection technique leads to complete staining of all adjacent intercostal nerves.MethodsThis comparative anatomical investigation was performed using 10 or 20 mL of dye (Alcian Blue) in 10 unfixed donor cadavers (54 injections) that were designated for education or research purposes.ResultsIn landmark-guided TPVB, the thoracic-paravertebral space (TPVS) was either not stained at all (spread of dye in the paraspinal muscles, n=3) or the dye was predominantly found in the epidural space (n=3). In ultrasound-guided TPVB, the TPVS was correctly identified in all cases (n=48). The sympathetic trunk was stained in 84.6% of injections (multi-injection technique: 100%), independent of injection technique and volume. The epidural space was stained more frequently (p≤0.001) if both the puncture site (sagittal transducer position) and guidance of the needle were more medial (77.8%). Finally, a higher injection volume (20 vs 10 mL) resulted in a higher number of stained intercostal nerves (p=0.04).ConclusionFor ultrasound-guided techniques, a higher injection volume resulted in a larger number of stained intercostal nerves. Staining of the sympathetic trunk was independent of the injection technique. Epidural spread was observed significantly less frequently if the injection was lateral (transducer transversal) or with a strictly cranial injection direction (transducer sagittal). Landmark-guided injections reliably achieved the TPVS (and the epidural space) only after a needle advance of 2.5 cm after initial contact with the transverse process.

Real-time view of anesthetic solution spread during an ultrasound-guided thoracic paravertebral block

2018 ◽  
Vol 104 (6) ◽  
pp. NP50-NP52 ◽  
Author(s):  
Domenico P Santonastaso ◽  
Annabella de Chiara ◽  
Marco Rispoli ◽  
Giovanni Musetti ◽  
Vanni Agnoletti
Keyword(s):  
Real Time ◽  
Ultrasound Guidance ◽  
Breast Surgery ◽  
Paravertebral Block ◽  
Ultrasound Guided ◽  
Accurate Identification ◽  
Paravertebral Space ◽  
Thoracic Paravertebral Block ◽  
Perioperative Analgesia ◽  
Consequent Reduction

Background: Thoracic paravertebral block is a technique for perioperative analgesia in patients undergoing thoracic, chest wall, or breast surgery, or for pain management with rib fractures, which can be performed with or without ultrasound guidance. The ultrasound guidance technique can be used to identify the thoracic paravertebral space, guide needle placement, monitor the spread of local anesthetic (LA) solution, and reduce complications such as pleural puncture and pneumothorax. The possibility of assessing anesthetic spread in real time using ultrasound guidance during paravertebral block offers numerous advantages, including the immediate and accurate identification of the extent of nervous block, with a consequent reduction of LA dose. The real-time visualization of spread may be used to achieve good anesthetic cover by administering the block at a single level, thus reducing complications normally associated with the technique. Case summary: This case report describes the use of ultrasound-guided thoracic paravertebral block, at thoracic (T) 4 and 5 levels, in a patient undergoing breast surgery for perioperative analgesia. The authors were able to witness cranial diffusion of LA at T3-T4 in real time, and measure the increase in space between the costotransverse ligament and pleura, as an indication of anesthetic spread, at T2-T3 and T6-T7 levels. Conclusions: This is the first known case in the literature of direct viewing of LA diffusion in a paravertebral space other than the one in which the block is administered and may open important scenarios for the improvement of anesthesia technique.

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