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.

A Novel Introducer for Ultrasound-Guided Cryoneurolysis Administration to Improve Patient Safety an d Functionality

2020 ◽  
pp. 217-220
Author(s):  
JOhn J. Finneran IV
Keyword(s):  
Peripheral Nerve ◽  
Postoperative Analgesia ◽  
Local Anesthetic ◽  
Improve Patient Safety ◽  
Femoral Nerve ◽  
Needle Insertion ◽  
Ultrasound Guided ◽  
Needle Pass ◽  
Time Required ◽  
Local Anesthetic Injection

Background: Percutaneous cryoneurolysis provides prolonged postoperative analgesia by placing a probe adjacent to a peripheral nerve and cooling the probe tip, inducing a reversible block that lasts weeks to months. Unfortunately, freezing the nerve can produce significant pain. Consequently, local anesthetic is generally applied to the nerve prior to cryoneurolysis, which, until now, required an additional needle insertion increasing both the risks and duration of the procedure. Case Presentation: Three patients underwent ultrasound-guided percutaneous cryoneurolysis of either the sciatic and saphenous nerves or the femoral nerve. In all patients, the local anesthetic injection and cryoneurolysis were accomplished with a single needle pass using the novel probe introducer. Conclusion: This introducer allows perineural local anesthetic injection followed immediately by cryoneurolysis, thereby sparing patients a second skin puncture, lowering the risks of the procedure, and decreasing the overall time required for cryoneurolysis. Key words: Cryoablation, cryoanalgesia, peripheral nerve block, postoperative analgesia, ultrasound

scholarly journals Ultrasound Guided Thoracic Paravertebral Block as an Analgesic Technique for Tracheoesophageal Fistula repair : A Case Report

2021 ◽  
Vol 6 (1) ◽  
pp. 1422-1425
Author(s):  
Rupesh Kumar Yadav ◽  
Sadichhya Shah Malla ◽  
Anupama Thapa
Keyword(s):  
Thoracic Surgery ◽  
Local Anesthetic ◽  
Local Anesthetics ◽  
Tracheoesophageal Fistula ◽  
Single Shot ◽  
Ultrasound Guided ◽  
Paravertebral Space ◽  
Thoracic Paravertebral Block ◽  
Local Anesthetic Agent ◽  
Analgesic Technique

Ultrasound has now become an eye of anaesthesiologist and has encouraged for its pervasive use. Its considerable use in the perioperative period for various invasive purposes has added an extra caution to prevent unforeseen complications over blind blocks. The ultrasound-guided thoracic paravertebral block provides excellent perioperative analgesia following thoracic surgery. It can be given as a single shot or a continuous infusion technique placing a catheter. Here the local anesthetic agent is deposited in the paravertebral space from where the spinal nerve emerges which are devoid of coverings and are sensitive to local anesthetics. Even a single-shot block provides analgesia of 4-6 dermatomal levels. The use of local anesthetics using ultrasound not only adds safety measures to minimize procedural complications but also reduces the perioperative requirement of opioids. It also helps in the reduction of postoperative pulmonary complications and early extubation following thoracic surgery. We report a case series where single-shot ultrasound-guided unilateral paravertebral blocks were used as an analgesic technique for the repair of tracheoesophageal fistula in neonates. After delivering anesthesia and confirming the correct placement of the endotracheal tube the neonate was kept on the left lateral position to undergo right thoracotomy and repair of fistula. Scanning at T4 level with a linear probe was done to identify the transverse process, pleura, costotransverse ligament, intercostal muscle, and the paravertebral space where the local anesthetic agent was deposited under aseptic precautions. Tenting of pleura was the endpoint for the completion of the block. The extensive use of various regional anesthetic technique has significantly improved the postoperative outcome of the patients along with adequate perioperative pain management.

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.

Confirmation of Caudal Needle Placement Using Nerve Stimulation 

1999 ◽  
Vol 91 (2) ◽  
pp. 374-378 ◽  
Author(s):  
Ban C. H. Tsui ◽  
Pekka Tarkkila ◽  
Sunil Gupta ◽  
Ramona Kearney
Keyword(s):  
Local Anesthetic ◽  
Nerve Stimulation ◽  
Pediatric Patients ◽  
Needle Insertion ◽  
Stimulation Test ◽  
Needle Placement ◽  
Caudal Block ◽  
Stimulation Tests ◽  
Local Anesthetic Injection ◽  
To Receive

Background The study was designed to examine a new method of confirming proper caudal needle placement using nerve stimulation. Methods Thirty-two pediatric patients were studied. A 22-gauge insulated needle was inserted into the caudal canal via the sacral notch until a "pop" was felt. The needle placement was classified as correct or incorrect depending upon the presence or absence of anal sphincter contraction (S2-S4) to electrical simulation (1 to 10 mA). Results Three patients were excluded, two because they inadvertently received neuromuscular blockers and one because the patient's anatomy precluded any attempt at a caudal block. The sensitivity and specificity of the test were both 100% in predicting clinical outcomes of the caudal block. Six patients had a negative stimulation test after the first attempt to place the needle. Four of these went on to receive a second attempt of needle insertion after a subcutaneous bulge or resistance to local anesthetic injection were observed. Following needle reinsertion, positive stimulation tests were elicited. These patients received the local anesthetic injection with ease and had good analgesia postoperatively. No attempt was made to reinsert the needle in the remaining two patients with a negative stimulation test, as they did not show subcutaneous bulge or resistance upon injection. These patients had poor analgesia postoperatively. The positive predictive value of the test was greater than the presence of a "pop" alone (P < 0.05) but not significantly different (P = 0.492) over the presence of "pop" and easy injection. Conclusion This test may be used as a teaching and adjuvant tool in performing caudal block.

scholarly journals Results of repeat manipulation under ultrasound-guided cervical nerve root block (MUC) with corticosteroid and local anesthetic injection for recurrence of frozen shoulder. 

2020 ◽  
Author(s):  
Tatsuki Oshiro ◽  
Masayoshi Yagi ◽  
Kazuki Harada ◽  
Kieun Park
Keyword(s):  
Local Anesthetic ◽  
Nerve Root ◽  
Frozen Shoulder ◽  
Single Group ◽  
Ultrasound Guided ◽  
Cervical Nerve Root ◽  
Cervical Nerve ◽  
One Year ◽  
Local Anesthetic Injection ◽  
Cervical Nerve Root Block

Abstract BackgroundThis study aimed to evaluate the clinical results of a repeat manipulation under ultrasound-guided cervical nerve root block (MUC) with corticosteroid and local anesthetic injection for recurrence of idiopathic frozen shoulder after MUC.MethodsA consecutive series of 42 shoulders in 39 patients with idiopathic frozen shoulder underwent MUC. All patients were assessed according to the American Shoulder Elbow Surgeon (ASES) score and shoulder range of motion (ROM) both before MUC and at one-year thereafter. If patients continued to have pain and limited ROM at 3 months after the procedure, they were offered a repeat MUC. Such patients were also assessed before the procedure and at 3 months and one-year thereafter.Results The initial MUC was successful in 31 shoulders (single group). Repeat MUC was required in 11 shoulders (repeat group). Patients in the single group showed significant improvement in ROM and ASES score at one-year after the procedure (p<0.001); similarly, patients in the repeat group had significant improvement in ROM and ASES score at 3 months and one-year after the procedure (p<0.001). Patients in the repeat group had had significantly more severely limited ROM (p<0.01) and decreased ASES score (p<0.001) before the procedure compared with those in the single group.ConclusionsA repeat MUC with corticosteroid and local anesthetic injection is a valuable option before proceeding to surgery for recurrence of idiopathic frozen shoulder. When there is severely limited ROM and decreased ASES score before the MUC, a repeat MUC may be　necessary, which would require the patient’s informed consent.Trial registration Retrospectively registered.

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.

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