FIGURE 2 - uploaded by Hesham A Elsharkawy
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Illustration showing a transverse cross section at the T5-T6 thoracic level showing the tissue plane deep to the ES muscle (A, B) as it is continuous laterally with the tissue plane deep to the R muscle (C) and in turn is continuous laterally with the tissue plane deep (D, E) to the SA muscle. A, Location for the retrolaminar block. B, Location for the ES block. C, Location for the rhomboid intercostal block. D and E, Location for the serratus plane block. ES, erector spinae; R, rhomboid; SA, serratus anterior; SS, subscapularis; Traps, trapezius. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2018. All Rights Reserved.
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Ultrasound-guided interfascial plane blocks are a recent development in modern regional anesthesia research and practice and represent a new route of transmission for local anesthetic to various anatomic locations, but much more research is warranted. Before becoming overtaken with enthusiasm for these new techniques, a deeper understanding of fasc...
Contexts in source publication
Context 1
... fascial planes are potential spaces and act as transmis- sion belts around the whole body across different anatomical loca- tions. Local anesthetic injected within these potential spaces will seek decompression planes (ie, "the path of least resistance"). This has been observed in cadaveric studies, even without the contribu- tion of muscle tension. To understand what happens within these tissue planes, we must look for the potential communication routes to appreciate how the anesthetic may spread locally or to more distant locations. 9 Unlike peripheral nerve or plexus blocks, interfascial plane blocks may have multiple potential points of injection, and various names have been assigned to blocks in the same tissue plane, al- beit between different muscles layers. The best examples of this are the tissue plane of the serratus plane block and Pecs II block. The tissue planes deep to the erector spinae muscle, rhomboid mus- cles, serratus anterior muscles, and deep to the latissimus dorsi mus- cle are the same. Based on the description by Blanco et al, 3,10 Forero et al, 4 and Elsharkawy et al, 11 we speculate that a paraspinal fascial plane block may potentially reach the Pecs II plane (Fig. ...
Context 2
... fascial planes are potential spaces and act as transmis- sion belts around the whole body across different anatomical loca- tions. Local anesthetic injected within these potential spaces will seek decompression planes (ie, "the path of least resistance"). This has been observed in cadaveric studies, even without the contribu- tion of muscle tension. To understand what happens within these tissue planes, we must look for the potential communication routes to appreciate how the anesthetic may spread locally or to more distant locations. 9 Unlike peripheral nerve or plexus blocks, interfascial plane blocks may have multiple potential points of injection, and various names have been assigned to blocks in the same tissue plane, al- beit between different muscles layers. The best examples of this are the tissue plane of the serratus plane block and Pecs II block. The tissue planes deep to the erector spinae muscle, rhomboid mus- cles, serratus anterior muscles, and deep to the latissimus dorsi mus- cle are the same. Based on the description by Blanco et al, 3,10 Forero et al, 4 and Elsharkawy et al, 11 we speculate that a paraspinal fascial plane block may potentially reach the Pecs II plane (Fig. ...
Similar publications
Interscalene block (ISB) is commonly performed for regional anesthesia in shoulder surgery. Ultrasound-guided ISB enables visualization of the local anesthetic spread and a reduction in local anesthetic volume. However, little is known about the appropriate local anesthetic dose for surgical anesthesia without sedation or general anesthesia. The pu...
Citations
... Fascial ultrasound-guided blocks are specialised techniques which aim to desensitise extensive anatomical areas thanks to the locoregional anaesthetic distribution allowed by superficial fascial planes [1][2][3]. The inclusion of these techniques into balanced anaesthetic protocols improves patient comfort, reduces perioperative opioid consumption and enhances recovery after surgery [4]. ...
The rectus sheath block is an ultrasound-guided anaesthetic technique which aims to provide analgesia to the abdominal midline. This study aimed to assess the distribution of 0.4 mL kg−1 of a mixture of methylene blue and iopromide injected into each hemiabdomen in the internal rectus sheath in cat cadavers. We hypothesise that this technique would be feasible and would cover the rami ventrales of the last thoracic and the first lumbar spinal nerves. The study was divided into two phases. Phase 1 aimed to study the anatomical structures of the ventral abdominal wall (four cats were dissected). Phase 2 (ten cadavers) consisted of an ultrasound-guided injection of the mixture mentioned above and the assessment of its distribution by computed tomography and anatomical dissection. The results showed the staining of the cranioventral abdominal wall with a craniocaudal spread of four (three to eight) vertebral bodies. Methylene blue stained three (one to four) rami ventrales, affecting T10 (60%), T11 (100%), T12 (90%), T13 (50%) and L1 (5%). Based on these results, it could be stated that this technique could supply anaesthesia to the midline of the abdominal midline cranial to the umbilicus in clinical patients, but it may not be able to provide anaesthesia to the middle and caudal midline abdominal region.
... The application of local anesthetics as an analgesic measure in deep planes has proven to be a much more effective intervention than the superficial release of myofascial points [13]. Like other interfacial blocks, the space between the trapezius and rhomboid muscles has the possibility of being decompressed with the application of medication and because it has a low resistance it facilitates the diffusion of medication [14]. We should consider in the specific case of myofascial pain syndrome that up to 30 % of the muscle force will be transmitted to this space, which in case of a painful pathology in the application of local anesthesia may decrease, in addition to forming a contractile apparatus that will diffuse the medication over the entire surface of these two muscles [14]. ...
... Like other interfacial blocks, the space between the trapezius and rhomboid muscles has the possibility of being decompressed with the application of medication and because it has a low resistance it facilitates the diffusion of medication [14]. We should consider in the specific case of myofascial pain syndrome that up to 30 % of the muscle force will be transmitted to this space, which in case of a painful pathology in the application of local anesthesia may decrease, in addition to forming a contractile apparatus that will diffuse the medication over the entire surface of these two muscles [14]. Finally, it is worth mentioning that all skeletal muscles are related by their connective tissue connections, which suggests that the free nerve terminals, the arrangement of the fibers, and the contractile mechanisms have a myofascial chain that is indispensable to know in order to offer treatments focused on not only one muscle if not a structural and functional group as in this case of the trapezius-rhomboid pathology [15]. ...
Introduction: Myofascial pain syndrome is a chronic pain condition prevalent in the general population. Muscular symptoms at the level of the trapezius and rhomboid muscles are frequent and the response to therapeutic interventions established so far is variable. Methods: We present a case series of six patients who underwent a new technique of interfacial trapezius-rhomboid block (TRB) performed under ultrasonographic guidance by applying 10 cubic centimeters (cc) of analgesic solution (bupivacaine 0.25 % and methylprednisolone 40 mg) in the interfacial plane between the trapezius and rhomboid muscles at the level of the fifth and sixth ribs. Results: At a follow-up of one and eight weeks, measurements of numerical rating scale (NRS) pain intensity were carried out, finding an average decrease of NRS pain intensity by 70 %. Conclusion: This new technique may be considered for the treatment of myofascial pain syndrome of the trapezius and rhomboid muscles.
... Given this, opioids and non-steroid anti-inflammatory drugs are frequently selected for the elimination of pain, but they may cause dose-dependent side effects such as nausea, itching, kidney failure, respiratory depression, and addiction, or the analgesic efficacy may remain insufficient. In addition, an increase in the use of interfascial blocks and nerve blocks in postoperative pain has been engaged together with the spread of ultrasonography utilization 4 . Paravertebral block (PVB), per se, has been widely used in postoperative analgesia for many years and has been shown to improve pain scores, attenuate the essentiality for additional analgesia, and improve respiratory function [5][6][7] . ...
OBJECTIVE: Erector spinae plane block is an updated method than paravertebral block, possessing a lower risk of complications. This study aimed to compare erector spinae plane and paravertebral blocks to safely reach the most efficacious analgesia procedure in laparoscopic cholecystectomy cases. METHODS: The study included 90 cases, aged 18–70 years, classified as American Society of Anesthesiologists I–II, who underwent a laparoscopic cholecystectomy procedure. They were randomly separated into three groups, namely, Control, erector spinae plane, and paravertebral block. No block procedure was applied to Control, and a patient-controlled analgesia device was prepared containing tramadol at a 10 mg bolus dose and a 10-min locked period. The pain scores were recorded with a visual analog scale for 24 h postoperatively.
RESULTS: The visual analog scale values at 1, 5, 10, 20, and 60 min at rest and 60 min coughing were found to be significantly higher in Control than in paravertebral block. A significant difference was revealed between Control vs. paravertebral block and paravertebral block vs. erector spinae plane in terms of total tramadol consumption (p=0.006). Total tramadol consumption in the first postoperative 24 h was significantly reduced in the paravertebral block compared with the Control and erector spinae plane groups.
CONCLUSION: Sonography-guided-paravertebral block provides sufficient postoperative analgesia in laparoscopic cholecystectomy surgery. Erector spinae plane seems to attenuate total tramadol consumption.
... These blocks are emerging as an effective alternative to conventional techniques such as paravertebral, epidural, or spinal blocks, and involve the injection of a local anesthetic between the muscles through which the peripheral nerve travels. The nerve itself is not targeted, and the needle is not directed toward the neural axis; therefore, the risks of serious complications such as neural injury and neuraxial hematoma can be prevented or at least reduced [4]. ...
... Regarding fascial tissue anatomy in the human body, 3 fascial connective layers must be addressed [4]: ...
... Deep fascia is a continuous membrane that connects various anatomical structures, including mechanoreceptors and nervous fibers. Targeting the deep fascial layers with regional anesthesia techniques can effectively block sensory input and provide pain relief [4,5]. ...
In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.
This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.
In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures.
In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.
... Today, a new generation of regional anesthesia techniques, called "fascial plane blocks", are emerging as an effective alternative to conventional techniques such as paravertebral, epidural, or spinal blocks [6]. The primary target of fascial plane blocks is the deep fascia, a dense membrane of connective tissue that extends throughout the body. ...
Pain management in patients undergoing kidney transplantation requires careful consideration due to their altered physiology, and potential risks associated with certain analgesic options. In recent years, personalized and multimodal approaches have proven to be pivotal in perioperative pain management, as well as in children. Implementing regional analgesia methods offers a valuable solution in many pediatric surgical settings and the erector spinae plane block (ESPB) could represent a possible analgesic strategy in pediatric patients undergoing renal transplantation. Here, we report the case of a 13-year-old child who underwent living-donor kidney transplantation (LDKx) and received continuous erector spinae plane block (ESPB) for perioperative pain management. This multimodal approach with continuous ESPB resulted in optimal pain control without the need for opioids, allowing for early mobilization and for an optimal postoperative course.
... However, there are no studies that document ultrasound images, depicting the plane of the needle's tip placement, followed by local anesthetic injection, and relating this evidence to potential success or failure of peripheral nerve block. Hence, an experimental study on cadaveric porcine tissues was conducted, aiming to highlight the above ultrasound signs and their correlation with fascial plane block efficacy and provide significant information for the filling of this particular knowledge gap in the literature. 1 1 A part of this article was previously presented as a meeting abstract at the 21 st Panhellenic Congress on Regional Anesthesia, Pain Management, and Palliative Care on September [16][17][18][19]2021. ...
... On the contrary, the accumulation of the blue dye into two spaces, between the two fasciae and between the fascia and epimysium, divided by the hyperechogenic fascia layer of the plane of interest, led to the corresponding ultrasound image of an intermediate-edge sign. Except for the surgical verification of the above findings, the understanding of these ultrasound signs and their negative prediction for block efficacy necessitates the comprehension of dispersion patterns of local anesthetics and fascial framework [14,16]. ...
... The above mechanisms of medication distribution may explain the partial failure of peripheral nerve block when accompanied by the ultrasound image of the intermediate-edge sign, as only a part of the administered local anesthetic's volume can reach the nerves inside the target fascial plane. Contrarily, the infusion of local anesthetic between the fascia and high-density tissue of epimysium, which corresponds to the single-edge sign, indicates total block failure because the main volume of liquid is injected distally to the target plane, with unknown clinical impact, caused by intramuscular dispersion [16,18]. Furthermore, we should bear in mind the differences between the fasciae of the human body, regarding their location, anatomy, mobility, and adjacency with organs and tissues and how these factors influence local anesthetic's spread, which requires more investigation [16]. ...
Introduction
Ultrasound-guided fascial plane blocks are nowadays the gold standard technique for regional anesthesia and postoperative analgesia. Despite their high success rate, cases of partial or total failure of this method have been reported. This experimental study aims to address the corresponding ultrasound signs and their association with fascial plane block efficacy.
Methods
After capturing the appropriate sonographic image that included muscle layers and their fasciae, an 18-gauge epidural needle penetrated the cadaveric porcine tissue and was forwarded until the tip of the needle reached the target fascial plane. The infusion of methylthioninium chloride or methylene blue dye was performed, causing tissue hydro dissection. The documentation of the generated ultrasound images was followed by surgical exposure of the tip of the needle.
Results
The distribution of the dye into the plane of interest (double-edge sign) was equivalent to block success, whereas the single-edge sign (accumulation of the dye between fascia and epimysium) indicated total block failure. The intermediate-edge sign, a combination of the previous ultrasound signs, is related to partial failure of block performance.
Conclusion
The identification of the three novel sonographic signs is an accurate predictive factor of peripheral nerve block efficacy. The respective data are expected to aid the rapid improvement of interfascial plane block accuracy and techniques, leading to their more effective execution and simultaneously eliminating the failure rates. Thereby, the amelioration of intra and postoperative analgesia will be accomplished, expediting the patient's hospital discharge and reducing or even avoiding opioid consumption.
... In addition, ultrasound-guided techniques have improved the efficacy and safety of the nerve blocks compared to blind or nerve stimulation techniques [5]. Fascial plane blocks consist of the administration of local anesthetics within different interfascial planes to target nerves traveling inside them [6]. Ultrasound-guided interfascial plane blocks are a safe and useful alternative for providing analgesia to large body areas [7]. ...
Simple Summary
The quadratus lumborum (QL) block is an ultrasound-guided locoregional anesthetic technique which aims to provide analgesia to the abdomen. Previous studies in dog cadavers have shown that a dorsal injection point, between the psoas minor muscle and the vertebral body of L1, is able to stain the truncus sympathicus and the T13–L3 rami ventrales, potentially providing analgesia to the abdominal wall and viscera. This dorsal approach could be feasible in cats and is probably able to offer similar results to those in canine cadavers. To assess this objective, 10 cat cadavers were used, and a mixture of methylene blue and iopromide (0.4 mL kg⁻¹) was injected dorsal to the QL muscle in the abovementioned location. Computerized tomography and anatomical dissection were employed to evaluate the injectate spread. Our results showed the feasibility of this approach in cat cadavers as a consistent staining of the truncus sympathicus (T13–L3) and the rami ventrales of the spinal nerves (T13–L3) was observed. These results are compatible with the induction of somatic and visceral analgesia of the abdomen, although the cranial abdominal wall may not be covered.
Abstract
The quadratus lumborum (QL) block is an ultrasound-guided locoregional anesthesia technique which aims to provide analgesia to the abdomen. The main objective of this study was to assess a modified ultrasound-guided dorsal QL block in cat cadavers. For this purpose, a volume of 0.4 mL kg⁻¹ of a mixture of iopromide and methylene blue was administered between the psoas minor muscle and the vertebral body (VB) of the first lumbar vertebra, and its distribution was assessed in thirteen cat cadavers. We hypothesized that this injection point would be feasible, offering a more cranial distribution of the injectate and a more consistent staining of the truncus sympathicus. The study was divided into two phases. Phase 1 consisted of an anatomical study (three cadavers were dissected). Phase 2 consisted of the ultrasound-guided administration of the injectate and the assessment of its distribution by computed tomography and anatomical dissection. The results showed a consistent distribution of contrast media within five (4–8) VBs from T10 to L5. Methylene blue stained three (2–6) rami ventrales, affecting T11 (10%), T12 (20%), T13 (60%), L1 (85%), L2 (95%) and L3 (65%). The truncus sympathicus was dyed in all cadavers with a spread of five (3–7) VBs. Finally, the splanchnicus major nerve was stained in all cadavers (100%). These results suggest that this technique could provide analgesia to the abdominal viscera and the abdominal wall, probably with the exception of the cranial aspects of the abdominal wall.
... 4 When we look at the facial plane blocks that start with Transversus Abdominis Plane (TAP) and become popular with erector spinae plane (ESP), we see many blocks defined differently for each plane and various nomenclatures. [5][6][7] The answer to the question of whether facial planes used to deliver local anesthetics (LAs) to target nerves can provide anesthesia/analgesia or provide some perks beyond anesthesia/analgesia is still unknown. Contrary to traditional peripheral nerve blocks, the targeted nerve or structure within interfacial plane blocks is not fully defined, and the indications have not been revealed yet. ...
... Thanks to the use of ultrasound novel plane blocks have been described recently. 7 In this section, our aim is to refer to fascial plane blocks that can be used for postoperative analgesia management following orthopedic surgeries. ...
... Or inside fascial layers? Or between the fascia, as described by et Elsharkawy et al. [20]. With multiple potential injection points, a clearer understanding of the anatomy is paramount for a successful block [22] (Figures 2, 3). ...
Among the various surgical procedures, breast surgeries rank as a frequently conducted procedure. Interfacial blocks such as the Pectoral (PECS) block became possible with the currently available knowledge on innervations and ultrasound. Interfacial blocks target the deep fascial planes, which are potential spaces for injecting local anesthetics. The Pectoral I (PECS I) consists of the injection of local anesthetics in the plane between the pectoralis major and minor muscles. The PECS II block, a modified version of the block, is achieved by adding another, deeper injection in the plane between the pectoralis minor and the serratus anterior muscle. We conducted a scoping review using Arkesy and O’Malley's framework, as described by Levac. We identified our research question as the uses of the PECS regional block technique with the choice of local anesthetics, including adjuncts, and its effectiveness in intraoperative and postoperative analgesia in the first 24 hours and incidence of postoperative nausea and vomiting. Subsequently, we identified the relevant studies that met our inclusion criteria and charted the data. Lastly, we summarized and reported the results. The PECS block was used in various breast surgeries, among which radical mastectomies with/without lymph node dissection were the most common. It was found that the PECS block reduced intraoperative opioid consumption in 60% and 24-hour postoperative opioid consumption in 93.3% of the included papers. Various local anesthetics were used such as ropivacaine, bupivacaine, and levobupivacaine. Ultrasound-guided interfacial plane blocks, such as the PECS block, are a recent development in regional anesthesia that offers analgesia for patients undergoing breast surgeries. The authors conclude that PECS block can provide a decrease in intraoperative and postoperative opioid consumption, a decrease in the incidence of nausea and vomiting, and can lead to overall patient satisfaction in terms of lower pain scores compared to systemic analgesia.
... Since the three pathways of the cervical plexus block are the superficial cervical fascia and investing fascia (superficial layer of the deep cervical fascia), the investing fascia and prevertebral fascia (deep layer of the deep cervical fascia), and the prevertebral fascia and scalenus fascia, it is also considered an IFPB [7]. Moreover, due to the uneven distribution of low-pressure areas within the fascia and susceptibility to multiple factors, such as muscle tension, position, and respiratory movements, diffusion of local anesthetics in IFPBs requires the operator's experience to determine whether multi-site injections are necessary [8]. In areas with fascial fusion bands or physical barriers of fascia, a multi-site block may result in widespread diffusion. ...
... Moreover, real-time ultrasound guidance can avoid puncturing the vital nerves, blood vessels, and organs and reduce complications related to puncture [9]. Elsharkawy et al. suggested that the biomechanical properties of the fascia could play an important role in the diffusion of local anesthetics [8]. Ultrasound can detect changes in the interfascial space following movement and monitor the local anesthetic diffusion. ...
