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Concepts In Fascial Plane Blocks
@amit_pawa Dr Amit Pawa
What every Anaesthetist
needs to know
In the next 30mins…
My Opinions
Some Concepts
Some Evidence
Take home points
@amit_pawa
Nerve Block Evolution
@amit_pawa
Landmark-Guided Blocks
@amit_pawa
@amit_pawa
PNS-Guided Blocks
@amit_pawa
@amit_pawa
US-Guided Blocks
@amit_pawa
Are we getting too close?
@amit_pawa
With (Fascial) Plane Blocks…
@amit_pawa
Maybe this is close enough?
@amit_pawa
@amit_pawa
Have we gone too far?
@amit_pawa
Have we gone too far?
The Innovators
@amit_pawa
Fascial Plane Blocks
TAP
QLB 1/2/3
Femoral Triangle Block
PECS 1/11 Serratus
RISS
TQL
ESP BD-TAP
@amit_pawa
RLB
MTP SSPSPSPS
Shamrock
Lumbar Plexus
SPEDI
Clavipectoral
iPack
PENG
ACB
MICB
@amit_pawa
Perhaps this is part of the problem!
Too many blocks
Inconsistent NOMENCLATURE
Important Reference
@amit_pawa
Reg Anesth Pain Medicine
Volume 43, Number 4, May 2018
@kaohesham @EMARIANOMD
The
Science…
@amit_pawa
Soft collagen-containing
loose & dense fibrous connective tissue
Permeates whole body
Skin
Superficial fascia
Deep Fascia
(multilayer)
Muscle & related fasciaSuperficial adipose tissue
Deep adipose tissue
Loose connective tissue
What is Fascia?
@amit_pawa
Deep Fascia
Multiple layers
Extends through whole body
Target for Fascial plane blocks
Forms sheaths for nerves/vessels/organs
Independent of muscle below
@amit_pawa
How might fascial plane blocks work?
@amit_pawa
1. Transmission belts
LA “seeks”
decompression
planes via
potential spaces
ESP block becomes Serratus/PECS II @amit_pawa
1. Transmission belts
@amit_pawa
1. Transmission belts
@amit_pawa
Parietal pleura
Ventral ramus
Dorsal ramus
ESM
Lateral cutaneous branch of intercostal nerve
Anterior cutaneous branch of intercostal nerve
Transversus thoracis muscle
Pec. major
Pec. minor
Inn IMInt IMExt IM
Serratus anterior muscle
Latissimus dorsi muscle
Lateral and medial pectoral nerves
PEC I
PEC II
SAP Blocks
Pecto-Intercostal Fascial Block
RLBESP TPVBMTP
Pectoral branch of thoracoacromial artery
SIFB
Rhomboid
Rhomboid
Intercostal Block
Subserratus
Plane Block
RISS
Dr Ann Barron
@Ann_Barron1
PIFB: Pecto-Intercostal Fascial Block
SIFB: Serratus intercostal Fascial block
SAP: Serratus Anterior Plane
RISS: Rhomboid Intercostal & SubSerratus Plane Block
MTP: Mid-Point Transverse Process to Pleura
ESP: Erector Spinae
TPVB: Thoracic ParaVertebral Block
RLB: RetroLaminar Block
@amit_pawa
Parietal pleura
Lateral cutaneous branch of intercostal nerve
Anterior cutaneous branch of intercostal nerve
Transversus thoracis muscle
Pec. major
Pec. minor
Latissimus dorsi muscle
Lateral and medial pectoral nerves
PEC I
PEC II
SAP Blocks
Pecto-Intercostal Fascial Block
Pectoral branch of thoracoacromial artery
SIFB
2.“Back-Door” ?
@amit_pawa
“by-proxy”
SCTL
PVB
@amit_pawa
SCTL
SCTL
SCTL
SCTL
ESP
@amit_pawa
SCTL
SCTL
SCTL
SCTL
Paravertebral-by-Proxy?
@amit_pawa
3. Biomechanical properties
@amit_pawa
Fascia Is Dynamic
3. Biomechanical properties
Pumping mechanism due to muscle tendons?
Contractile elements within fascia?
-> Variable/extensive dermatomal spread?
Effect of:
Depth of Anaesthesia & Muscle Relaxation?
@amit_pawa
Nerve elements may lie within the fascia
A & C Fibres
Wide Dynamic Range neurons
Mechanoreceptors
Do these influence Fascial plane blocks?
4. Local Fascial Innervation
@amit_pawa
Not All fascias are the same
Number of layers
Pectoral region - 1
The Limbs - 2 or 3
Middle Thoracolumbar 3
Function & Mobility More mobile may
increase LA spread
Surrounding structures
Lungs/liver/spleen
IPPV vs SV
@amit_pawa
@amit_pawa
Reliability of finding the plane…
Clear Right?!
@amit_pawa
Reliability of finding the plane…
Even when you get in the correct
plane - does the LA stay there?
Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding
Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019.
doi: 10.1136/rapm-2019-100693
@amit_pawa
Even when you get in the correct
plane - does the LA stay there?
Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding
Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019.
doi: 10.1136/rapm-2019-100693
“The Fascial plane is not a closed space”
"Injectate spread into the internal oblique &
transversus abdominus muscle via the Perimysium”
Could this affect the amount of LA
available to act?
@amit_pawa
There’s a lot we DON’T know
@amit_pawa
What can we say so far?
Not all fascial plane blocks are equal
Not all fascial plane blocks work (the same way!)
Fascial plane blocks have variable efficacy
Identifying the correct plane is not always easy
(“Seeker” solution)
@amit_pawa
Evidence?…@amit_pawa
(a)
(b)
Anaesthesia, 2011, 66, pages 1023–1030
..............................................................................................
rsal extension with an anterior subcostal
ock. (b) Bilateral mid-axillary ultra-
(b)
Figure 8 (a) Bilateral ultrasound via the posterior approac
showing extension along the quadratus lumborum muscle
ORIGINAL ARTICLE
Studies on the spread of local anaesthetic solution in
transversus abdominis plane blocks*
J. Carney,1
O. Finnerty,1
J. Rauf,1
D. Bergin,4
J. G. Laffey2
and J. G. Mc Donnell3
1 Registrar, 2 Professor, 3 Senior Clinical Lecturer, Department of Anaesthesia and Intensive Care Medicine,
4 Senior Clinical Lecturer, Department of Radiology, Galway University Hospitals, Galway, Ireland
Summary
The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of
injection and pattern of spread within the plane. There are currently a number of ultrasound-
guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary
approach and a more recently proposed posterior approach. We wished to determine whether the
site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the
local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast
solution in four groups of volunteers. The first group underwent the classical landmark-based
transversus abdominis plane block whereby two different volumes of injectate were studied:
0.3 ml.kg)1
vs 0.6 ml.kg)1
. The second group underwent transversus abdominis plane block using
the anterior subcostal approach. The third group underwent transversus abdominis plane block
using the mid-axillary approach. The fourth group underwent transversus abdominis plane block
using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral
border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance
imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time.
The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches res-
ulted in a predominantly anterior spread of the contrast solution within the transversus abdominis
plane and relatively little posterior spread. There was no spread to the paravertebral space with the
anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast
ORIGINAL ARTIC
Studies on the sp
transversus abdom
1 1
Anaesthesia, 2011, 66, pages 1023–1030
..............................................................
US- Guided Posterior TAP spreads to PVS
@amit_pawa
SCIENTIFIC ARTICLE
Axillary local anesthetic spread after the thoracic
interfacial ultrasound block --- a cadaveric and
radiological evaluation
Patricia Alfaro de la Torrea
, Jerry Wayne Jones Jr.b
, Servando López Álvarezc
,
Paula Diéguez Garciac
, Francisco Javier Garcia de Migueld
, Eva Maria Monzon Rubioe
,
Federico Carol Boerisf
, Monir Kabiri Sacramentog
, Osmany Duanyh
,
Mario Fajardo Pérezi,∗
, Borja de la Quintana Gordonj
a
Tajo University Hospital, Madrid, Spain
b
University of Tennessee Health Science Center/Regional One Health, College of Medicine, Department of Anesthesiology, TN,
USA
c
Hospital Complexo Hospitalario de A Coru˜na, Coru˜na, Spain
d
Hospital General de Segovia, Departamento de Anestesia, Segovia, Spain
e
Tajo University Hospital, Departamento de Anestesia, Madrid, Spain
f
Hospital Universitario Parc Tauli Sabadell, Sabadell, Spain
g
Hospital Universitario de Guadalajara, Guadalajara, Spain
h
Primary Care and Chronic Pain Management Attending, Department of Veterans Affairs, Muskogee, OK, USA
i
Hospital Universitario de Móstoles, Madrid, Spain
j
Hospital Universitario de Móstoles, Departamento de Anestesia, Madrid, Spain
Received 23 February 2015; accepted 14 April 2015
Available online 22 June 2016
KEYWORDS
Anesthesia,
conduction;
Axilla;
Intercostal muscles;
Brachial plexus block;
Intercostal nerves;
Lymph node excision;
Ultrasonography
Abstract
Background: Oral opioid analgesics have been used for management of peri- and postoperative
analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block
and does not have a specific regional anesthesia technique published that offers its adequate
blockade.
Methods: After institutional review board approval, anatomic and radiological studies were
conducted to determine the deposition and spread of methylene blue and local anesthetic
injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance
Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery
that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy,
or supernumerary breasts, to ascertain the deposition and time course of spread of solution
within the thoracic interfascial plane in vivo.
Rev Bras Anestesiol. 2017;67(6):555---564
REVISTA
BRASILE
ANESTE
SCIENTIFIC ARTICLE
Axillary local anesthetic
cal anesthetic spread after the thoracic interfacial 559
to identify, in the surface plane, the pectoralis muscles,
the toracho-achromial artery and the cephalic vein that lie
between them. In the deep plane, the SAM is identified,
resting on the ribs. The needle is then introduced in-plane
from medial to lateral, and its tip is placed between the
SAM and the External Intercostal muscle at level of sec-
ond rib. Twenty mL of Levobupivacaine 0.25% + Epinephrine
1:200,000 were injected under direct ultrasound visualiza-
tion in real time, fragmenting the total volume, aspirating
every 3 mL to reduce the risk of intravascular injection
and minimizing the patient discomfort on hydrodissection
(Fig. 2A).
Study 1: determination of injectate spread during
SIFB using MRI
The aim of this study was to determine the axillary spread
of the injectate within the SIFB anterior approach. Our
image study consisted of a MRI done immediately after
LA injection. Our radiologist used MRI sequences to show
T2---weighed, fat-suppressed images, making axial and coro-
nal thoracic sections from the supraclavicular regions to the
inframammary crease. The same radiologist, proficient in
thoracic MRI, analyzed the images and issued a report of
the spread of the LA injectate in the interfascial thoracic
“PECS" spreads to
Intercostobrachial
Medial Brachiocutaneous
Lateral Cutaneous Branches T1-3
@amit_pawa
Injectate Spread With the TQL Block
Figure 3. Pathway. A, Visualization of spread of
dye posterior to the transversalis fascia from the
lumbar position and into the thoracic paraverte-
bral space. The 2 tweezers are placed posterior
to both arcuate ligaments. The dye spreads pos-
terior to the medial and lateral arcuate ligaments
(blue circle). The Magenta dotted line indicates
diaphragm. B, Red arrow: Green dye is visualized
posterior to endothoracic fascia within the tho-
racic cage. The magenta dotted line indicates the
diaphragm; PM, psoas major.
BACKGROUND: The spread of injectate resulting from a transmuscular quadratus lumborum
(TQL) block and a transverse oblique paramedian (TOP) TQL block has never been examined.
The aim of this cadaveric study was to investigate by which pathway the injectate spreads
cephalad into the thoracic paravertebral space and which nerves were dyed by the injectate
cephalad and caudad to the diaphragm when performing a TQL and a TOP TQL block. We also
aimed to investigate whether the thoracic and lumbar sympathetic trunks as well as the lumbar
plexus were covered by the injectate.
METHODS: Ultrasound-guided bilateral TQL and TOP TQL injections were administered in 8
cadavers. A total of 16 injections were performed. With the TQL injection, the curvilinear trans-
ducer was oriented in the transverse plane above the iliac crest at the posterior axillary line to
identify the Shamrock sign. With the TOP TQL injection, the same transducer was placed with
a TOP orientation 3 cm lateral to the L2 spinous process to identify the L2 transverse process
and the adjoining quadratus lumborum muscle. For both techniques, the needle was advanced
in-plane to the transducer, with the end point in the interfascial plane between the quadratus
lumborum and psoas major muscles. Thirty milliliters of dye solution was injected bilaterally for
each technique. The spread of the dye was evaluated by subsequent dissection.
RESULTS: In all successful injections, the dye was seen to spread into the thoracic paravertebral
space and the intercostal spaces to surround the somatic nerves and the thoracic sympathetic
trunk. The main pathway of spread of injectate was posterior to the medial and lateral arcuate liga-
ments. Caudad to the diaphragm, the injected dye surrounded the subcostal, iliohypogastric, and
ilioinguinal nerves in all cases, whereas the genitofemoral and lateral femoral cutaneous nerves
were dyed in a varying degree. No dye was seen to surround the lumbar plexus, femoral nerve, or
lumbar sympathetic trunk. The pattern of spread was similar with the TQL and TOP TQL injections.
CONCLUSIONS: The spread of injectate with the TQL and TOP TQL approaches is cephalad
from the lumbar point of administration between the quadratus lumborum and psoas major
muscles, predominantly via a pathway posterior to the arcuate ligaments and into the thoracic
paravertebral space to reach the somatic nerves and the thoracic sympathetic trunk in the
intercostal and paravertebral spaces. The lumbar plexus and lumbar sympathetic trunk are not
affected. (Anesth Analg 2017;125:303–12)
The Pathway of Injectate Spread With the
Transmuscular Quadratus Lumborum
Block: A Cadaver Study
Mette Dam, MD,* Bernhard Moriggl, MD, PhD,† Christian K. Hansen, MD,* Romed Hoermann,†
Thomas F. Bendtsen, MD, PhD,‡ and Jens Børglum, MD, PhD*
CHRONIC PAIN MEDICINEORIGIN
Section Editor: Honorio T. Benzon
Copyright © 2017 International Anesthe
July 2017 • Volume 125 • Number 1nesthesia Research Society. Unauthorized reproduction of this article is prohibited.
a.org ANESTHESIA & ANALGESIA
TQL spreads to PVS & Sympathetic trunk
Lumbar plexus was not stained
@amit_pawa
T10. As with the TQL approach, the ventral rami of the spi-
nal nerves were dyed as proximal as the cranial distribution
of dye spread. The thoracic sympathetic trunk was dyed in
100% (CI, 0.39–1.00) of the cases.
Caudad to the diaphragm, the subcostal, iliohypogastric,
and ilioinguinal nerves were dyed in 100% (CI, 0.39–1.00)
of the cases, whereas the genitofemoral and lateral femoral
cutaneous nerves were dyed to a varying degree (Table 2).
The lumbar plexus was never dyed within the psoas major
muscle; nor was the femoral nerve or the lumbar sympa-
thetic trunk. In addition, no dye was detected intraperito-
neally, and there was no dye observed spreading into the
transversus abdominis plane.
evaluate the
QLB.1,4,18,20
The main
dye to the t
posterior to
the majority
was posteri
phragmatic
to be able to
The vent
nerves) wer
the dorsal ra
dye reachin
mixture comprising 10 mL of an iodinated
hexol (Omnipaque 300; GE Healthcare,
), diluted in 85 mL of 0.9% sodium chloride
collimation, 1.2 mm. Images were reconstructed using a soft
tissue algorithm at 3 mm slice thickness at 3-mm intervals. All
images were reviewed by a consultant radiologist. Spread of
nsional CT reconstruction of injectate spread (darker area) after injection at the T5 level deep to erector spinae muscle.
caudal spread from T1 to T8. The solid arrows indicate the penetration of dye beyond the costotransverse junction
intertransverse spaces.
d Pain Medicine • Volume 41, Number 5, September-October 2016 ESP Block in Thoracic Pain
Twenty milliliters of a mixture comprising 10 mL of an iodinated
contrast material, iohexol (Omnipaque 300; GE Healthcare,
Princeton, New Jersey), diluted in 85 mL of 0.9% sodium chloride
with 5 mL of methylene blue dye was injected. Within 20 minutes
of completing the injections, cadaver 2 was transferred to a 128-slice
multidetector CT scanner (Siemens Flash CT; Siemens Healthcare)
where abdominal and thoracic imaging was performed to radio-
graphically assess the distribution of injectate. Images were
acquired using routine clinical imaging protocols with the follow-
ing parameters: kilovolt (peak), 120; effective milliampere-
second, 210; rotation time, 0.5 seconds; pitch, 0.8; and detector
collimation, 1.2 mm. Images were recon
tissue algorithm at 3 mm slice thickness
images were reviewed by a consultant r
injectate was assessed primarily upon rev
set supplemented with multiplanar images
caudal spread of injectate from C7 to T8
T8 on the left, occurring in a paraspinous
transverse processes anteriorly and the erec
teriorly (Fig. 5). Lateral spread extended t
verse processes at all levels, and slightly bey
junctions at levels T3 to T6 on the right an
FIGURE 6. Dissection of the right side of cadaver 2 after an ultrasound-guided ESP block and dye injection deep to e
Trapezius and rhomboid muscles have been removed. The longissimus thoracis portion of the erector spinae muscle
cranially and dense staining of its anterior (deep) surface is visible. The external intercostal muscle, internal intercosta
surrounding tissues are also heavily stained. Dye has penetrated deep to these layers and through the costotransvers
The Erector Spinae Plane Block
A Novel Analgesic Technique in Thoracic Neuropathic Pain
Mauricio Forero, MD, FIPP,* Sanjib D. Adhikary, MD,† Hector Lopez, MD,‡
Calvin Tsui, BMSc,§ and Ki Jinn Chin, MBBS (Hons), MMed, FRCPC||
oracic neuropathic pain is a debilitating condition that is
sponsive to oral and topical pharmacotherapy. The benefit
al nerve block procedures is unclear due to a paucity of ev-
invasiveness of the described techniques. In this report, we
el interfascial plane block, the erector spinae plane (ESP)
uccessful application in 2 cases of severe neuropathic pain
ng from metastatic disease of the ribs, and the second from
ultiple rib fractures). In both cases, the ESP block also pro-
sive multidermatomal sensory block. Anatomical and radio-
ation in fresh cadavers indicates that its likely site of action
and ventral rami of the thoracic spinal nerves. The ESP
omise as a simple and safe technique for thoracic analgesia
neuropathic pain as well as acute postsurgical or posttrau-
in Med 2016;41: 00–00)
hic pain is a common chronic pain condition with
tiologies, including surgery, trauma, and diseases
s zoster, diabetes, and cancer.1
It is notoriously diffi-
Case 1
A 67-year-old man, weight 116 kg and height 188 cm [body
mass index (BMI), 32.8 kg/m2
] with a history of heavy smoking
and paroxysmal supraventricular tachycardia controlled on ateno-
lol, was referred to the chronic pain clinic with a 4-month history
of severe left-sided chest pain. A magnetic resonance imaging
scan of his thorax at initial presentation had been reported as nor-
mal, and the working diagnosis at the time of referral was post-
herpetic neuralgia. He reported constant burning and stabbing
neuropathic pain of 10/10 severity on the numerical rating score
(NRS), radiating from his spine into the anterior chest wall, mainly
at T5 and extending several dermatomes inferiorly. There was sig-
nificant sleep disturbance and impairment of quality of life. Phys-
ical examination revealed allodynia and hyperesthesia over the
affected dermatomes with a primary trigger point over the T5 der-
matome 3 to 4 cm lateral to the neuraxial midline. Pain manage-
ment up to that point had included pregabalin (600 mg daily at
the time of consultation), nonsteroidal anti-inflammatory drugs,
baclofen, fluoxetine, and marijuana with no improvement. Several
different opioids had been tried but all had to be stopped due to
Within several minutes, the patient reporte
diminished significantly, and a full assessment
sensory block was performed 2 hours later. By
tient had obtained complete relief of pain, with
There was an area of diminished sensation to p
Hospital, McL 2-405, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8
(e‐mail: gasgenie@gmail.com).
The authors declare no conflict of interest.
Copyright © 2016 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000451
Regional Anesthesia and Pain Medicine • Volume 41, Number 5, September-October 2016
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a
ESP injection travels up & down & spreads to PVS
@amit_pawa
ESP Mechanism?
PVB spread by Proxy?
jected dyes into the back muscles after retrolaminar (RL, right) and ESP block (ESP, left).
columbar fascia covering the erector spinae muscle was revealed. (b) The muscle fibre
The spread pattern of the dyes in the vertebral laminae was seen after removal of all bac
ocostalis; Lo, longissimus thoracis).
(b)
(c)
Anaesthesia 2018, 73, 1244–1250
Original Article
Comparison of injectate spread and nerve involvement
between retrolaminar and erector spinae plane blocks in
the thoracic region: a cadaveric study
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H. Kim4
1 Assistant Professor, 2 Instructor, 3 Research Assistant, Department of Anatomy, 4 Associate Professor, Department of
Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine,
Seoul, Korea
Summary
Although different injection locations for retrolaminar and erector spinae plane blocks have been described,
the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of
dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks
and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. For
each block, 20 ml of dye solution was injected at the T5 level. The back regions were dissected and the
involvement of the thoracic spinal nerve was also investigated. Twenty blocks were successfully completed. A
consistent vertical spread, with deep staining between the posterior surface of the vertebral laminae and the
overlaying transversospinalis muscle was observed in all retrolaminar blocks. Moreover, most retrolaminar
blocks were predominantly associated with fascial spreading in the intrinsic back muscles. With an erector
spinae plane block, dye spread in a more lateral pattern than with retrolaminar block, and fascial spreading in
the back muscles was also observed. The number of stained thoracic spinal nerves was greater with erector
spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique,
the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral
space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic
spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of
Anaesthesia 2018 doi:10.1111/anae.14408
Original Article
Comparison of injectate spread and ner
between retrolaminar and erector spina
the thoracic region: a cadaveric study
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H
Anaesthesia 2018, 73, 1244–1250
“the amount of dye within the paravertebral space following both
retrolaminar and ESP injections seemed to be too small to allow for upward
or downward flow.”
@amit_pawa
Dorsal Rami Spread only?
ESP Mechanism?Downloadedfromhttps://journals.lww.com/rapmbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/Il
A Cadaveric Study Investigating the Mechanism of Action
of Erector Spinae Blockade
Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§
Background and Objectives: Erector spinae block is an ultrasound-
guided interfascial plane block first described in 2016. The objectives of
this cadaveric dye injection and dissection study were to simulate an erector
spinae block to determine if dye would spread anteriorly to the involve or-
igins of the ventral and dorsal branches of the spinal nerves.
Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy-
lene blue dye was injected bilaterally into the plane between the fifth thoracic
transverse process and erector spinae muscle. An in-plane ultrasound-guided
technique with the transducer orientated longitudinally was used. During
dissection, superficial and deep muscles were identified, and extent of
dye spread was documented in cephalocaudal and lateral directions. The
ventral and dorsal rami of spinal nerves and dorsal root ganglion at each
level were examined to determine if they were stained by dye.
Results: There was extensive cephalocaudad and lateral spread of dye
deep and superficial to the erector spinae muscles. Except for 1 injection
(from 20), the ventral rami were not stained by the dye. In only 2 injections
did the dye track posteriorly through the costotransverse foramen to the
dorsal root ganglion. In all other cases, the dorsal root ganglia were not in-
volved in the dye injection. The dye stained the dorsal rami posterior to the
costotransverse foramen.
Conclusions: There was no spread of dye anteriorly to the paravertebral
space to involve origins of the ventral and dorsal branches of the thoracic spinal
nerves. Dorsal ramus involvement was posterior to the costotransverse foramen.
(Reg Anesth Pain Med 2018;43: 567–571)
In clinical reports, ESB resulted in extensive cutaneous sen-
sory block indicating both ventral and dorsal spinal rami involve-
ment.1
Furthermore, a cadaveric dye injection and dissection in 1
cadaver reported spread of dye in the vicinity of the origins of the
ventral and dorsal rami of the spinal nerves.1
Hence, ESB has
been described as a technically simpler alternative to ultrasound-
guided paravertebral block with a similar mechanism of action.
In addition, ESB is likely to be safer than paravertebral blockade
because the injection is in a plane remote from critical structures
such as the pleura, and thus there has been significant clinical in-
terest in this block. Therefore, the objective of this current cadav-
eric experiment was to simulate an ESB to determine if dye would
spread anteriorly to the paravertebral space to involve the origins
of the ventral and dorsal branches of the thoracic spinal nerves.
The extents of craniocaudal and medial-to-lateral spread of the
dye were also documented.
METHODS
This project was approved by the Human Research Ethics
Committee, University of Melbourne (Project within Program
Ethics ID 1441811.3). Ten unembalmed human cadavers were ob-
tained through the body donor program of the Department of
Anatomy and Neuroscience. None of the specimens were frozen
before the interventions were performed. Before commencement
REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
tion. A skin incision was made along the midlin
processes from above C7 to the lower lumbar ver
reflected laterally to expose the posterior thoracic
Superficial muscles (trapezius, latissimus dorsi
were individually identified and reflected. T
muscles were identified and removed at their
the extent of dye spread deep and superficial t
explored and documented. The extent of cepha
(e‐mail: Michael.Barrington@svha.org.au).
Funding was from departmental resources only. Support was provided by the
Imaging and Posters Unit at the Department of Anatomy and Neuroscience,
University of Melbourne, and Anastasia Arsenoulis from FUJIFILM
SonoSite, Inc, which provided an ultrasound machine.
The authors declare no conflict of interest.
Copyright © 2018 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000789
Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a
@amit_pawa
Dorsal Rami Spread only?
ESP Mechanism?Downloadedfromhttps://journals.lww.com/rapmbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/Il
A Cadaveric Study Investigating the Mechanism of Action
of Erector Spinae Blockade
Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§
Background and Objectives: Erector spinae block is an ultrasound-
guided interfascial plane block first described in 2016. The objectives of
this cadaveric dye injection and dissection study were to simulate an erector
spinae block to determine if dye would spread anteriorly to the involve or-
igins of the ventral and dorsal branches of the spinal nerves.
Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy-
lene blue dye was injected bilaterally into the plane between the fifth thoracic
transverse process and erector spinae muscle. An in-plane ultrasound-guided
technique with the transducer orientated longitudinally was used. During
dissection, superficial and deep muscles were identified, and extent of
dye spread was documented in cephalocaudal and lateral directions. The
ventral and dorsal rami of spinal nerves and dorsal root ganglion at each
level were examined to determine if they were stained by dye.
Results: There was extensive cephalocaudad and lateral spread of dye
deep and superficial to the erector spinae muscles. Except for 1 injection
(from 20), the ventral rami were not stained by the dye. In only 2 injections
did the dye track posteriorly through the costotransverse foramen to the
dorsal root ganglion. In all other cases, the dorsal root ganglia were not in-
volved in the dye injection. The dye stained the dorsal rami posterior to the
costotransverse foramen.
Conclusions: There was no spread of dye anteriorly to the paravertebral
space to involve origins of the ventral and dorsal branches of the thoracic spinal
nerves. Dorsal ramus involvement was posterior to the costotransverse foramen.
(Reg Anesth Pain Med 2018;43: 567–571)
In clinical reports, ESB resulted in extensive cutaneous sen-
sory block indicating both ventral and dorsal spinal rami involve-
ment.1
Furthermore, a cadaveric dye injection and dissection in 1
cadaver reported spread of dye in the vicinity of the origins of the
ventral and dorsal rami of the spinal nerves.1
Hence, ESB has
been described as a technically simpler alternative to ultrasound-
guided paravertebral block with a similar mechanism of action.
In addition, ESB is likely to be safer than paravertebral blockade
because the injection is in a plane remote from critical structures
such as the pleura, and thus there has been significant clinical in-
terest in this block. Therefore, the objective of this current cadav-
eric experiment was to simulate an ESB to determine if dye would
spread anteriorly to the paravertebral space to involve the origins
of the ventral and dorsal branches of the thoracic spinal nerves.
The extents of craniocaudal and medial-to-lateral spread of the
dye were also documented.
METHODS
This project was approved by the Human Research Ethics
Committee, University of Melbourne (Project within Program
Ethics ID 1441811.3). Ten unembalmed human cadavers were ob-
tained through the body donor program of the Department of
Anatomy and Neuroscience. None of the specimens were frozen
before the interventions were performed. Before commencement
REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
tion. A skin incision was made along the midlin
processes from above C7 to the lower lumbar ver
reflected laterally to expose the posterior thoracic
Superficial muscles (trapezius, latissimus dorsi
were individually identified and reflected. T
muscles were identified and removed at their
the extent of dye spread deep and superficial t
explored and documented. The extent of cepha
(e‐mail: Michael.Barrington@svha.org.au).
Funding was from departmental resources only. Support was provided by the
Imaging and Posters Unit at the Department of Anatomy and Neuroscience,
University of Melbourne, and Anastasia Arsenoulis from FUJIFILM
SonoSite, Inc, which provided an ultrasound machine.
The authors declare no conflict of interest.
Copyright © 2018 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000789
Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a
nusic et al Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
@amit_pawa
Spread to Th PV Space in 4 out of 11 cadavers
(T2 injection)
Unpredictable Spread
Anesthesia & Analgesia. Publish Ahead of Print():, MAY 15, 2019 DOI: 10.1213/ANE.0000000000004187
ESP Mechanism?
@amit_pawa
ESP/MICB vs ThPVB
PV Spread in BOTH
MICB > ESP
2019 - Pub ahead of print
@amit_pawa
August 2019
Journal of Pain Research
Volume 12:2597-2613
What can we say so far?
There is limited evidence of “By-Proxy” spread
Variation exists in Cadaver studies too!
Cadaver results may not relate to “Real Life”
(Mechanical Ventilation/Movement)
@amit_pawa
What about
clinical studies?
@amit_pawa
0
50
100
150
200
250
300
350
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Publications per year
QLB TEA TPVB Serratus	Plane Pecs ESP
TEA
TPVB
QLB
SAPB
PECS
ESP
Publications per year @amit_pawa
QL Clinical Studies
Anesth Analg. 2018 Feb;126(2):559-565. doi: 10.1213/ANE.0000000000002648
@amit_pawa
Br J Anaesth. 2019 Aug;123(2):e350-e358. doi: 10.1016/j.bja.2019.04.054. Epub 2019 May 30
ESP Clinical studies
@amit_pawa
Indian J Anaesth. 2018 Jan; 62(1): 75–78 Reg Anesth Pain Med. 2017 May/Jun;42(3):372-376
ESP Clinical studies
@amit_pawa
Indian J Anaesth. 2018 Jan; 62(1): 75–78 Reg Anesth Pain Med. 2017 May/Jun;42(3):372-376
What do these say?
QL/ESP fascial plane blocks:
1. Reduce Pain Scores
2.Reduce Opioid Requirements
When compared to SYSTEMIC analgesia alone
@amit_pawa
What About Meta-analyses/SR?
@amit_pawa
What do these say?
PECS blocks (mostly PECS II)
1. Reduce Pain Scores
2. Reduce Opioid Requirements
3. May be as effective as Th PVB?…
@amit_pawa
@amit_pawa
Fascial Plane Blocks
Many unanswered questions
Unknown mechansims of action
Cadaveric studies do not reflect “real life”
Clinical studies demonstrate benefit - variable efficacy
Need more evidence
More Likely to be performed by the less experienced
@amit_pawa
Fascial Plane Blocks
Many unanswered questions
Unknown mechansims of action
Cadaveric studies do not reflect “real life”
Clinical studies demonstrate benefit - variable efficacy
Need more evidence
More Likely to be performed by the less experienced
Because, compared to TEA/PVB…
@amit_pawa
Fascial Plane Blocks
May be EASIER to site
May be SAFER to site - and may work “By Proxy”
May be QUICKER to site
SHOULD be combined with Multimodal Analgesics
Are HERE TO STAY!
@amit_pawa
Make RA
Accessible
Anatomical
Nomenclature
Ensure RA is
Evidence-based
Make RA
Simple
Make RA
Safe
Ensure RA is
Taught well
Ensure Pts
receive RA
Fascial Plane Blocks
have a role
@amit_pawa
Concepts in Fascial Plane Blocks - What Every Anaesthetist Needs to Know

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Concepts in Fascial Plane Blocks - What Every Anaesthetist Needs to Know

  • 1. Concepts In Fascial Plane Blocks @amit_pawa Dr Amit Pawa What every Anaesthetist needs to know
  • 2. In the next 30mins… My Opinions Some Concepts Some Evidence Take home points @amit_pawa
  • 9. Are we getting too close? @amit_pawa
  • 10. With (Fascial) Plane Blocks… @amit_pawa
  • 11. Maybe this is close enough? @amit_pawa
  • 13. Have we gone too far? @amit_pawa
  • 14. Have we gone too far?
  • 16. Fascial Plane Blocks TAP QLB 1/2/3 Femoral Triangle Block PECS 1/11 Serratus RISS TQL ESP BD-TAP @amit_pawa RLB MTP SSPSPSPS Shamrock Lumbar Plexus SPEDI Clavipectoral iPack PENG ACB MICB
  • 17. @amit_pawa Perhaps this is part of the problem! Too many blocks Inconsistent NOMENCLATURE
  • 18. Important Reference @amit_pawa Reg Anesth Pain Medicine Volume 43, Number 4, May 2018 @kaohesham @EMARIANOMD
  • 20. Soft collagen-containing loose & dense fibrous connective tissue Permeates whole body Skin Superficial fascia Deep Fascia (multilayer) Muscle & related fasciaSuperficial adipose tissue Deep adipose tissue Loose connective tissue What is Fascia? @amit_pawa
  • 21. Deep Fascia Multiple layers Extends through whole body Target for Fascial plane blocks Forms sheaths for nerves/vessels/organs Independent of muscle below @amit_pawa
  • 22. How might fascial plane blocks work? @amit_pawa
  • 23. 1. Transmission belts LA “seeks” decompression planes via potential spaces ESP block becomes Serratus/PECS II @amit_pawa
  • 26. Parietal pleura Ventral ramus Dorsal ramus ESM Lateral cutaneous branch of intercostal nerve Anterior cutaneous branch of intercostal nerve Transversus thoracis muscle Pec. major Pec. minor Inn IMInt IMExt IM Serratus anterior muscle Latissimus dorsi muscle Lateral and medial pectoral nerves PEC I PEC II SAP Blocks Pecto-Intercostal Fascial Block RLBESP TPVBMTP Pectoral branch of thoracoacromial artery SIFB Rhomboid Rhomboid Intercostal Block Subserratus Plane Block RISS Dr Ann Barron @Ann_Barron1 PIFB: Pecto-Intercostal Fascial Block SIFB: Serratus intercostal Fascial block SAP: Serratus Anterior Plane RISS: Rhomboid Intercostal & SubSerratus Plane Block MTP: Mid-Point Transverse Process to Pleura ESP: Erector Spinae TPVB: Thoracic ParaVertebral Block RLB: RetroLaminar Block @amit_pawa
  • 27. Parietal pleura Lateral cutaneous branch of intercostal nerve Anterior cutaneous branch of intercostal nerve Transversus thoracis muscle Pec. major Pec. minor Latissimus dorsi muscle Lateral and medial pectoral nerves PEC I PEC II SAP Blocks Pecto-Intercostal Fascial Block Pectoral branch of thoracoacromial artery SIFB
  • 33. 3. Biomechanical properties Pumping mechanism due to muscle tendons? Contractile elements within fascia? -> Variable/extensive dermatomal spread? Effect of: Depth of Anaesthesia & Muscle Relaxation? @amit_pawa
  • 34. Nerve elements may lie within the fascia A & C Fibres Wide Dynamic Range neurons Mechanoreceptors Do these influence Fascial plane blocks? 4. Local Fascial Innervation @amit_pawa
  • 35. Not All fascias are the same Number of layers Pectoral region - 1 The Limbs - 2 or 3 Middle Thoracolumbar 3 Function & Mobility More mobile may increase LA spread Surrounding structures Lungs/liver/spleen IPPV vs SV @amit_pawa
  • 38. Even when you get in the correct plane - does the LA stay there? Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019. doi: 10.1136/rapm-2019-100693 @amit_pawa
  • 39. Even when you get in the correct plane - does the LA stay there? Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019. doi: 10.1136/rapm-2019-100693 “The Fascial plane is not a closed space” "Injectate spread into the internal oblique & transversus abdominus muscle via the Perimysium” Could this affect the amount of LA available to act? @amit_pawa
  • 40. There’s a lot we DON’T know @amit_pawa
  • 41. What can we say so far? Not all fascial plane blocks are equal Not all fascial plane blocks work (the same way!) Fascial plane blocks have variable efficacy Identifying the correct plane is not always easy (“Seeker” solution) @amit_pawa
  • 43. (a) (b) Anaesthesia, 2011, 66, pages 1023–1030 .............................................................................................. rsal extension with an anterior subcostal ock. (b) Bilateral mid-axillary ultra- (b) Figure 8 (a) Bilateral ultrasound via the posterior approac showing extension along the quadratus lumborum muscle ORIGINAL ARTICLE Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks* J. Carney,1 O. Finnerty,1 J. Rauf,1 D. Bergin,4 J. G. Laffey2 and J. G. Mc Donnell3 1 Registrar, 2 Professor, 3 Senior Clinical Lecturer, Department of Anaesthesia and Intensive Care Medicine, 4 Senior Clinical Lecturer, Department of Radiology, Galway University Hospitals, Galway, Ireland Summary The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of injection and pattern of spread within the plane. There are currently a number of ultrasound- guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary approach and a more recently proposed posterior approach. We wished to determine whether the site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast solution in four groups of volunteers. The first group underwent the classical landmark-based transversus abdominis plane block whereby two different volumes of injectate were studied: 0.3 ml.kg)1 vs 0.6 ml.kg)1 . The second group underwent transversus abdominis plane block using the anterior subcostal approach. The third group underwent transversus abdominis plane block using the mid-axillary approach. The fourth group underwent transversus abdominis plane block using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time. The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches res- ulted in a predominantly anterior spread of the contrast solution within the transversus abdominis plane and relatively little posterior spread. There was no spread to the paravertebral space with the anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast ORIGINAL ARTIC Studies on the sp transversus abdom 1 1 Anaesthesia, 2011, 66, pages 1023–1030 .............................................................. US- Guided Posterior TAP spreads to PVS @amit_pawa
  • 44. SCIENTIFIC ARTICLE Axillary local anesthetic spread after the thoracic interfacial ultrasound block --- a cadaveric and radiological evaluation Patricia Alfaro de la Torrea , Jerry Wayne Jones Jr.b , Servando López Álvarezc , Paula Diéguez Garciac , Francisco Javier Garcia de Migueld , Eva Maria Monzon Rubioe , Federico Carol Boerisf , Monir Kabiri Sacramentog , Osmany Duanyh , Mario Fajardo Pérezi,∗ , Borja de la Quintana Gordonj a Tajo University Hospital, Madrid, Spain b University of Tennessee Health Science Center/Regional One Health, College of Medicine, Department of Anesthesiology, TN, USA c Hospital Complexo Hospitalario de A Coru˜na, Coru˜na, Spain d Hospital General de Segovia, Departamento de Anestesia, Segovia, Spain e Tajo University Hospital, Departamento de Anestesia, Madrid, Spain f Hospital Universitario Parc Tauli Sabadell, Sabadell, Spain g Hospital Universitario de Guadalajara, Guadalajara, Spain h Primary Care and Chronic Pain Management Attending, Department of Veterans Affairs, Muskogee, OK, USA i Hospital Universitario de Móstoles, Madrid, Spain j Hospital Universitario de Móstoles, Departamento de Anestesia, Madrid, Spain Received 23 February 2015; accepted 14 April 2015 Available online 22 June 2016 KEYWORDS Anesthesia, conduction; Axilla; Intercostal muscles; Brachial plexus block; Intercostal nerves; Lymph node excision; Ultrasonography Abstract Background: Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. Methods: After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. Rev Bras Anestesiol. 2017;67(6):555---564 REVISTA BRASILE ANESTE SCIENTIFIC ARTICLE Axillary local anesthetic cal anesthetic spread after the thoracic interfacial 559 to identify, in the surface plane, the pectoralis muscles, the toracho-achromial artery and the cephalic vein that lie between them. In the deep plane, the SAM is identified, resting on the ribs. The needle is then introduced in-plane from medial to lateral, and its tip is placed between the SAM and the External Intercostal muscle at level of sec- ond rib. Twenty mL of Levobupivacaine 0.25% + Epinephrine 1:200,000 were injected under direct ultrasound visualiza- tion in real time, fragmenting the total volume, aspirating every 3 mL to reduce the risk of intravascular injection and minimizing the patient discomfort on hydrodissection (Fig. 2A). Study 1: determination of injectate spread during SIFB using MRI The aim of this study was to determine the axillary spread of the injectate within the SIFB anterior approach. Our image study consisted of a MRI done immediately after LA injection. Our radiologist used MRI sequences to show T2---weighed, fat-suppressed images, making axial and coro- nal thoracic sections from the supraclavicular regions to the inframammary crease. The same radiologist, proficient in thoracic MRI, analyzed the images and issued a report of the spread of the LA injectate in the interfascial thoracic “PECS" spreads to Intercostobrachial Medial Brachiocutaneous Lateral Cutaneous Branches T1-3 @amit_pawa
  • 45. Injectate Spread With the TQL Block Figure 3. Pathway. A, Visualization of spread of dye posterior to the transversalis fascia from the lumbar position and into the thoracic paraverte- bral space. The 2 tweezers are placed posterior to both arcuate ligaments. The dye spreads pos- terior to the medial and lateral arcuate ligaments (blue circle). The Magenta dotted line indicates diaphragm. B, Red arrow: Green dye is visualized posterior to endothoracic fascia within the tho- racic cage. The magenta dotted line indicates the diaphragm; PM, psoas major. BACKGROUND: The spread of injectate resulting from a transmuscular quadratus lumborum (TQL) block and a transverse oblique paramedian (TOP) TQL block has never been examined. The aim of this cadaveric study was to investigate by which pathway the injectate spreads cephalad into the thoracic paravertebral space and which nerves were dyed by the injectate cephalad and caudad to the diaphragm when performing a TQL and a TOP TQL block. We also aimed to investigate whether the thoracic and lumbar sympathetic trunks as well as the lumbar plexus were covered by the injectate. METHODS: Ultrasound-guided bilateral TQL and TOP TQL injections were administered in 8 cadavers. A total of 16 injections were performed. With the TQL injection, the curvilinear trans- ducer was oriented in the transverse plane above the iliac crest at the posterior axillary line to identify the Shamrock sign. With the TOP TQL injection, the same transducer was placed with a TOP orientation 3 cm lateral to the L2 spinous process to identify the L2 transverse process and the adjoining quadratus lumborum muscle. For both techniques, the needle was advanced in-plane to the transducer, with the end point in the interfascial plane between the quadratus lumborum and psoas major muscles. Thirty milliliters of dye solution was injected bilaterally for each technique. The spread of the dye was evaluated by subsequent dissection. RESULTS: In all successful injections, the dye was seen to spread into the thoracic paravertebral space and the intercostal spaces to surround the somatic nerves and the thoracic sympathetic trunk. The main pathway of spread of injectate was posterior to the medial and lateral arcuate liga- ments. Caudad to the diaphragm, the injected dye surrounded the subcostal, iliohypogastric, and ilioinguinal nerves in all cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed in a varying degree. No dye was seen to surround the lumbar plexus, femoral nerve, or lumbar sympathetic trunk. The pattern of spread was similar with the TQL and TOP TQL injections. CONCLUSIONS: The spread of injectate with the TQL and TOP TQL approaches is cephalad from the lumbar point of administration between the quadratus lumborum and psoas major muscles, predominantly via a pathway posterior to the arcuate ligaments and into the thoracic paravertebral space to reach the somatic nerves and the thoracic sympathetic trunk in the intercostal and paravertebral spaces. The lumbar plexus and lumbar sympathetic trunk are not affected. (Anesth Analg 2017;125:303–12) The Pathway of Injectate Spread With the Transmuscular Quadratus Lumborum Block: A Cadaver Study Mette Dam, MD,* Bernhard Moriggl, MD, PhD,† Christian K. Hansen, MD,* Romed Hoermann,† Thomas F. Bendtsen, MD, PhD,‡ and Jens Børglum, MD, PhD* CHRONIC PAIN MEDICINEORIGIN Section Editor: Honorio T. Benzon Copyright © 2017 International Anesthe July 2017 • Volume 125 • Number 1nesthesia Research Society. Unauthorized reproduction of this article is prohibited. a.org ANESTHESIA & ANALGESIA TQL spreads to PVS & Sympathetic trunk Lumbar plexus was not stained @amit_pawa T10. As with the TQL approach, the ventral rami of the spi- nal nerves were dyed as proximal as the cranial distribution of dye spread. The thoracic sympathetic trunk was dyed in 100% (CI, 0.39–1.00) of the cases. Caudad to the diaphragm, the subcostal, iliohypogastric, and ilioinguinal nerves were dyed in 100% (CI, 0.39–1.00) of the cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed to a varying degree (Table 2). The lumbar plexus was never dyed within the psoas major muscle; nor was the femoral nerve or the lumbar sympa- thetic trunk. In addition, no dye was detected intraperito- neally, and there was no dye observed spreading into the transversus abdominis plane. evaluate the QLB.1,4,18,20 The main dye to the t posterior to the majority was posteri phragmatic to be able to The vent nerves) wer the dorsal ra dye reachin
  • 46. mixture comprising 10 mL of an iodinated hexol (Omnipaque 300; GE Healthcare, ), diluted in 85 mL of 0.9% sodium chloride collimation, 1.2 mm. Images were reconstructed using a soft tissue algorithm at 3 mm slice thickness at 3-mm intervals. All images were reviewed by a consultant radiologist. Spread of nsional CT reconstruction of injectate spread (darker area) after injection at the T5 level deep to erector spinae muscle. caudal spread from T1 to T8. The solid arrows indicate the penetration of dye beyond the costotransverse junction intertransverse spaces. d Pain Medicine • Volume 41, Number 5, September-October 2016 ESP Block in Thoracic Pain Twenty milliliters of a mixture comprising 10 mL of an iodinated contrast material, iohexol (Omnipaque 300; GE Healthcare, Princeton, New Jersey), diluted in 85 mL of 0.9% sodium chloride with 5 mL of methylene blue dye was injected. Within 20 minutes of completing the injections, cadaver 2 was transferred to a 128-slice multidetector CT scanner (Siemens Flash CT; Siemens Healthcare) where abdominal and thoracic imaging was performed to radio- graphically assess the distribution of injectate. Images were acquired using routine clinical imaging protocols with the follow- ing parameters: kilovolt (peak), 120; effective milliampere- second, 210; rotation time, 0.5 seconds; pitch, 0.8; and detector collimation, 1.2 mm. Images were recon tissue algorithm at 3 mm slice thickness images were reviewed by a consultant r injectate was assessed primarily upon rev set supplemented with multiplanar images caudal spread of injectate from C7 to T8 T8 on the left, occurring in a paraspinous transverse processes anteriorly and the erec teriorly (Fig. 5). Lateral spread extended t verse processes at all levels, and slightly bey junctions at levels T3 to T6 on the right an FIGURE 6. Dissection of the right side of cadaver 2 after an ultrasound-guided ESP block and dye injection deep to e Trapezius and rhomboid muscles have been removed. The longissimus thoracis portion of the erector spinae muscle cranially and dense staining of its anterior (deep) surface is visible. The external intercostal muscle, internal intercosta surrounding tissues are also heavily stained. Dye has penetrated deep to these layers and through the costotransvers The Erector Spinae Plane Block A Novel Analgesic Technique in Thoracic Neuropathic Pain Mauricio Forero, MD, FIPP,* Sanjib D. Adhikary, MD,† Hector Lopez, MD,‡ Calvin Tsui, BMSc,§ and Ki Jinn Chin, MBBS (Hons), MMed, FRCPC|| oracic neuropathic pain is a debilitating condition that is sponsive to oral and topical pharmacotherapy. The benefit al nerve block procedures is unclear due to a paucity of ev- invasiveness of the described techniques. In this report, we el interfascial plane block, the erector spinae plane (ESP) uccessful application in 2 cases of severe neuropathic pain ng from metastatic disease of the ribs, and the second from ultiple rib fractures). In both cases, the ESP block also pro- sive multidermatomal sensory block. Anatomical and radio- ation in fresh cadavers indicates that its likely site of action and ventral rami of the thoracic spinal nerves. The ESP omise as a simple and safe technique for thoracic analgesia neuropathic pain as well as acute postsurgical or posttrau- in Med 2016;41: 00–00) hic pain is a common chronic pain condition with tiologies, including surgery, trauma, and diseases s zoster, diabetes, and cancer.1 It is notoriously diffi- Case 1 A 67-year-old man, weight 116 kg and height 188 cm [body mass index (BMI), 32.8 kg/m2 ] with a history of heavy smoking and paroxysmal supraventricular tachycardia controlled on ateno- lol, was referred to the chronic pain clinic with a 4-month history of severe left-sided chest pain. A magnetic resonance imaging scan of his thorax at initial presentation had been reported as nor- mal, and the working diagnosis at the time of referral was post- herpetic neuralgia. He reported constant burning and stabbing neuropathic pain of 10/10 severity on the numerical rating score (NRS), radiating from his spine into the anterior chest wall, mainly at T5 and extending several dermatomes inferiorly. There was sig- nificant sleep disturbance and impairment of quality of life. Phys- ical examination revealed allodynia and hyperesthesia over the affected dermatomes with a primary trigger point over the T5 der- matome 3 to 4 cm lateral to the neuraxial midline. Pain manage- ment up to that point had included pregabalin (600 mg daily at the time of consultation), nonsteroidal anti-inflammatory drugs, baclofen, fluoxetine, and marijuana with no improvement. Several different opioids had been tried but all had to be stopped due to Within several minutes, the patient reporte diminished significantly, and a full assessment sensory block was performed 2 hours later. By tient had obtained complete relief of pain, with There was an area of diminished sensation to p Hospital, McL 2-405, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8 (e‐mail: gasgenie@gmail.com). The authors declare no conflict of interest. Copyright © 2016 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000451 Regional Anesthesia and Pain Medicine • Volume 41, Number 5, September-October 2016 Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a ESP injection travels up & down & spreads to PVS @amit_pawa
  • 47. ESP Mechanism? PVB spread by Proxy? jected dyes into the back muscles after retrolaminar (RL, right) and ESP block (ESP, left). columbar fascia covering the erector spinae muscle was revealed. (b) The muscle fibre The spread pattern of the dyes in the vertebral laminae was seen after removal of all bac ocostalis; Lo, longissimus thoracis). (b) (c) Anaesthesia 2018, 73, 1244–1250 Original Article Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study H.-M. Yang,1 Y. J. Choi,2 H.-J. Kwon,3 J. O,3 T. H. Cho3 and S. H. Kim4 1 Assistant Professor, 2 Instructor, 3 Research Assistant, Department of Anatomy, 4 Associate Professor, Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Summary Although different injection locations for retrolaminar and erector spinae plane blocks have been described, the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. For each block, 20 ml of dye solution was injected at the T5 level. The back regions were dissected and the involvement of the thoracic spinal nerve was also investigated. Twenty blocks were successfully completed. A consistent vertical spread, with deep staining between the posterior surface of the vertebral laminae and the overlaying transversospinalis muscle was observed in all retrolaminar blocks. Moreover, most retrolaminar blocks were predominantly associated with fascial spreading in the intrinsic back muscles. With an erector spinae plane block, dye spread in a more lateral pattern than with retrolaminar block, and fascial spreading in the back muscles was also observed. The number of stained thoracic spinal nerves was greater with erector spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique, the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of Anaesthesia 2018 doi:10.1111/anae.14408 Original Article Comparison of injectate spread and ner between retrolaminar and erector spina the thoracic region: a cadaveric study H.-M. Yang,1 Y. J. Choi,2 H.-J. Kwon,3 J. O,3 T. H. Cho3 and S. H Anaesthesia 2018, 73, 1244–1250 “the amount of dye within the paravertebral space following both retrolaminar and ESP injections seemed to be too small to allow for upward or downward flow.” @amit_pawa
  • 48. Dorsal Rami Spread only? ESP Mechanism?Downloadedfromhttps://journals.lww.com/rapmbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/Il A Cadaveric Study Investigating the Mechanism of Action of Erector Spinae Blockade Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§ Background and Objectives: Erector spinae block is an ultrasound- guided interfascial plane block first described in 2016. The objectives of this cadaveric dye injection and dissection study were to simulate an erector spinae block to determine if dye would spread anteriorly to the involve or- igins of the ventral and dorsal branches of the spinal nerves. Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy- lene blue dye was injected bilaterally into the plane between the fifth thoracic transverse process and erector spinae muscle. An in-plane ultrasound-guided technique with the transducer orientated longitudinally was used. During dissection, superficial and deep muscles were identified, and extent of dye spread was documented in cephalocaudal and lateral directions. The ventral and dorsal rami of spinal nerves and dorsal root ganglion at each level were examined to determine if they were stained by dye. Results: There was extensive cephalocaudad and lateral spread of dye deep and superficial to the erector spinae muscles. Except for 1 injection (from 20), the ventral rami were not stained by the dye. In only 2 injections did the dye track posteriorly through the costotransverse foramen to the dorsal root ganglion. In all other cases, the dorsal root ganglia were not in- volved in the dye injection. The dye stained the dorsal rami posterior to the costotransverse foramen. Conclusions: There was no spread of dye anteriorly to the paravertebral space to involve origins of the ventral and dorsal branches of the thoracic spinal nerves. Dorsal ramus involvement was posterior to the costotransverse foramen. (Reg Anesth Pain Med 2018;43: 567–571) In clinical reports, ESB resulted in extensive cutaneous sen- sory block indicating both ventral and dorsal spinal rami involve- ment.1 Furthermore, a cadaveric dye injection and dissection in 1 cadaver reported spread of dye in the vicinity of the origins of the ventral and dorsal rami of the spinal nerves.1 Hence, ESB has been described as a technically simpler alternative to ultrasound- guided paravertebral block with a similar mechanism of action. In addition, ESB is likely to be safer than paravertebral blockade because the injection is in a plane remote from critical structures such as the pleura, and thus there has been significant clinical in- terest in this block. Therefore, the objective of this current cadav- eric experiment was to simulate an ESB to determine if dye would spread anteriorly to the paravertebral space to involve the origins of the ventral and dorsal branches of the thoracic spinal nerves. The extents of craniocaudal and medial-to-lateral spread of the dye were also documented. METHODS This project was approved by the Human Research Ethics Committee, University of Melbourne (Project within Program Ethics ID 1441811.3). Ten unembalmed human cadavers were ob- tained through the body donor program of the Department of Anatomy and Neuroscience. None of the specimens were frozen before the interventions were performed. Before commencement REGIONAL ANESTHESIA AND ACUTE PAIN ORIGINAL ARTICLE tion. A skin incision was made along the midlin processes from above C7 to the lower lumbar ver reflected laterally to expose the posterior thoracic Superficial muscles (trapezius, latissimus dorsi were individually identified and reflected. T muscles were identified and removed at their the extent of dye spread deep and superficial t explored and documented. The extent of cepha (e‐mail: Michael.Barrington@svha.org.au). Funding was from departmental resources only. Support was provided by the Imaging and Posters Unit at the Department of Anatomy and Neuroscience, University of Melbourne, and Anastasia Arsenoulis from FUJIFILM SonoSite, Inc, which provided an ultrasound machine. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000789 Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018 Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a @amit_pawa
  • 49. Dorsal Rami Spread only? ESP Mechanism?Downloadedfromhttps://journals.lww.com/rapmbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/Il A Cadaveric Study Investigating the Mechanism of Action of Erector Spinae Blockade Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§ Background and Objectives: Erector spinae block is an ultrasound- guided interfascial plane block first described in 2016. The objectives of this cadaveric dye injection and dissection study were to simulate an erector spinae block to determine if dye would spread anteriorly to the involve or- igins of the ventral and dorsal branches of the spinal nerves. Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy- lene blue dye was injected bilaterally into the plane between the fifth thoracic transverse process and erector spinae muscle. An in-plane ultrasound-guided technique with the transducer orientated longitudinally was used. During dissection, superficial and deep muscles were identified, and extent of dye spread was documented in cephalocaudal and lateral directions. The ventral and dorsal rami of spinal nerves and dorsal root ganglion at each level were examined to determine if they were stained by dye. Results: There was extensive cephalocaudad and lateral spread of dye deep and superficial to the erector spinae muscles. Except for 1 injection (from 20), the ventral rami were not stained by the dye. In only 2 injections did the dye track posteriorly through the costotransverse foramen to the dorsal root ganglion. In all other cases, the dorsal root ganglia were not in- volved in the dye injection. The dye stained the dorsal rami posterior to the costotransverse foramen. Conclusions: There was no spread of dye anteriorly to the paravertebral space to involve origins of the ventral and dorsal branches of the thoracic spinal nerves. Dorsal ramus involvement was posterior to the costotransverse foramen. (Reg Anesth Pain Med 2018;43: 567–571) In clinical reports, ESB resulted in extensive cutaneous sen- sory block indicating both ventral and dorsal spinal rami involve- ment.1 Furthermore, a cadaveric dye injection and dissection in 1 cadaver reported spread of dye in the vicinity of the origins of the ventral and dorsal rami of the spinal nerves.1 Hence, ESB has been described as a technically simpler alternative to ultrasound- guided paravertebral block with a similar mechanism of action. In addition, ESB is likely to be safer than paravertebral blockade because the injection is in a plane remote from critical structures such as the pleura, and thus there has been significant clinical in- terest in this block. Therefore, the objective of this current cadav- eric experiment was to simulate an ESB to determine if dye would spread anteriorly to the paravertebral space to involve the origins of the ventral and dorsal branches of the thoracic spinal nerves. The extents of craniocaudal and medial-to-lateral spread of the dye were also documented. METHODS This project was approved by the Human Research Ethics Committee, University of Melbourne (Project within Program Ethics ID 1441811.3). Ten unembalmed human cadavers were ob- tained through the body donor program of the Department of Anatomy and Neuroscience. None of the specimens were frozen before the interventions were performed. Before commencement REGIONAL ANESTHESIA AND ACUTE PAIN ORIGINAL ARTICLE tion. A skin incision was made along the midlin processes from above C7 to the lower lumbar ver reflected laterally to expose the posterior thoracic Superficial muscles (trapezius, latissimus dorsi were individually identified and reflected. T muscles were identified and removed at their the extent of dye spread deep and superficial t explored and documented. The extent of cepha (e‐mail: Michael.Barrington@svha.org.au). Funding was from departmental resources only. Support was provided by the Imaging and Posters Unit at the Department of Anatomy and Neuroscience, University of Melbourne, and Anastasia Arsenoulis from FUJIFILM SonoSite, Inc, which provided an ultrasound machine. The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000789 Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018 Copyright © 2018 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a nusic et al Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018 @amit_pawa
  • 50. Spread to Th PV Space in 4 out of 11 cadavers (T2 injection) Unpredictable Spread Anesthesia & Analgesia. Publish Ahead of Print():, MAY 15, 2019 DOI: 10.1213/ANE.0000000000004187 ESP Mechanism? @amit_pawa
  • 51. ESP/MICB vs ThPVB PV Spread in BOTH MICB > ESP 2019 - Pub ahead of print @amit_pawa
  • 52. August 2019 Journal of Pain Research Volume 12:2597-2613
  • 53. What can we say so far? There is limited evidence of “By-Proxy” spread Variation exists in Cadaver studies too! Cadaver results may not relate to “Real Life” (Mechanical Ventilation/Movement) @amit_pawa
  • 56. QL Clinical Studies Anesth Analg. 2018 Feb;126(2):559-565. doi: 10.1213/ANE.0000000000002648 @amit_pawa Br J Anaesth. 2019 Aug;123(2):e350-e358. doi: 10.1016/j.bja.2019.04.054. Epub 2019 May 30
  • 57. ESP Clinical studies @amit_pawa Indian J Anaesth. 2018 Jan; 62(1): 75–78 Reg Anesth Pain Med. 2017 May/Jun;42(3):372-376
  • 58. ESP Clinical studies @amit_pawa Indian J Anaesth. 2018 Jan; 62(1): 75–78 Reg Anesth Pain Med. 2017 May/Jun;42(3):372-376
  • 59. What do these say? QL/ESP fascial plane blocks: 1. Reduce Pain Scores 2.Reduce Opioid Requirements When compared to SYSTEMIC analgesia alone @amit_pawa
  • 61. What do these say? PECS blocks (mostly PECS II) 1. Reduce Pain Scores 2. Reduce Opioid Requirements 3. May be as effective as Th PVB?… @amit_pawa
  • 63. Fascial Plane Blocks Many unanswered questions Unknown mechansims of action Cadaveric studies do not reflect “real life” Clinical studies demonstrate benefit - variable efficacy Need more evidence More Likely to be performed by the less experienced @amit_pawa
  • 64. Fascial Plane Blocks Many unanswered questions Unknown mechansims of action Cadaveric studies do not reflect “real life” Clinical studies demonstrate benefit - variable efficacy Need more evidence More Likely to be performed by the less experienced Because, compared to TEA/PVB… @amit_pawa
  • 65. Fascial Plane Blocks May be EASIER to site May be SAFER to site - and may work “By Proxy” May be QUICKER to site SHOULD be combined with Multimodal Analgesics Are HERE TO STAY! @amit_pawa
  • 66. Make RA Accessible Anatomical Nomenclature Ensure RA is Evidence-based Make RA Simple Make RA Safe Ensure RA is Taught well Ensure Pts receive RA Fascial Plane Blocks have a role @amit_pawa