Part V

Nerve Block for Regional Anesthesia and Pain

Therapy in Chest, Abdomen and Pelvis
422 R. K. Sivakumar and M. K. Karmakar

briefly outlines the basic principles of TPVB, sonoanatomy Table 30.1 Indications of thoracic paravertebral block
of the TPVS and the technique of ultrasound-guided (USG) A. Surgical anaesthesia
TPVB.  1. Breast surgery
 2. Herniorrhaphy
 3. Percutaneous radiofrequency ablation of liver tumours
Indications B. Perioperative analgesia
 1. Breast surgery
 2. Thoracic surgery—Open thoracotomy, video-assisted
TPVB is indicated for anaesthesia and analgesia for surgical thoracoscopic surgery
procedures where the afferent nociception is predominantly  3. Minimally invasive cardiac surgery
unilateral in origin from the thorax and abdomen. It has also  4. Inguinal herniorrhaphy
been used for chronic pain management. Some of the com-  5. Cholecystectomy
monly reported indications for a TPVB are listed in Table 30.1.  6. Appendicectomy
 7. Renal and ureteric surgeries
 8. Liver resection
C. Acute and chronic pain management
Functional Anatomy
 1. Acute postherpetic neuralgia
 2. Fracture ribs
The TPVS is a wedge-shaped space located on either side of  3. Pain due to stretching of liver capsule (trauma or liver mass)
the thoracic vertebral column and behind the parietal pleura  4. Benign and malignant neuralgia
(retropleural) (Fig. 30.1). The TPVS is wider on the left than  5. Complex regional pain syndrome
on the right. The base of the TPVS is formed by the vertebral D. Miscellaneous
body, the intervertebral disc and the intervertebral foramen  1. Therapeutic control of hyperhidrosis
with its contents (Fig. 30.1). The parietal pleura forms the  2. Liver capsule pain after blunt abdominal trauma

Fig. 30.1 Transverse anatomy of the thoracic paravertebral space. (The figure is reproduced with kind permission from www.aic.cuhk.edu.hk/
usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 423

anterolateral boundary while the superior costotransverse (Figs. 30.2, 30.3, and 30.4). The inter-transverse ligament,
ligament (SCTL), which extends from the lower border of which is much thinner than the SCTL, also extends between
the transverse process (TP) above to the upper border of the the adjacent transverse processes (Figs. 30.3 and 30.4). The
rib below, forms the posterior boundary of the TPVS SCTL is continuous laterally with the internal intercostal

Fig. 30.2 Sagittal anatomy

of the thoracic paravertebral
space. (The figure is
reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

Fig. 30.3 Ligaments attached to the transverse process of the thoracic vertebra. (The figure is reproduced with kind permission from www.aic.
cuhk.edu.hk/usgraweb)
424 R. K. Sivakumar and M. K. Karmakar

Fig. 30.4 Anatomy of the

thoracic paravertebral region
showing the various
paravertebral ligaments and
their anatomical relationship
to the thoracic paravertebral
space. (The figure is
reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

Fig. 30.5 Paravertebral

sagittal section of the thorax
showing how the endothoracic
fascia, represented by the
broken purple line, lines the
internal aspect of the thoracic
cage. Note the location of the
neurovascular bundle in
relation to the endothoracic
fascia and its continuity with
the psoas fascia inferiorly.
(The figure is reproduced with
kind permission from www.
aic.cuhk.edu.hk/usgraweb)

membrane (IICM) (Fig. 30.4), which is the medial extension the thorax and lines the internal aspect of the thoracic cage
of the internal intercostal muscle, and the apex of the TPVS (Figs. 30.5 and 30.6). At the TPVS, the endothoracic fascia is
is continuous with the posterior intercostal space (PICS) lat- loosely attached to the ribs (Fig. 30.6) and the TP and fuses
eral to the tip of the TP (Fig. 30.4). medially with the periosteum of the vertebral body close to
Interposed between the parietal pleura anteriorly and the its mid-point (Fig. 30.6). There is an intervening layer of
SCTL posteriorly is a fibroelastic structure of the ‘endotho- loose areolar connective tissue, ‘the subserous fascia’,
racic fascia’ (Figs. 30.1 and 30.2), which is the deep fascia of between the parietal pleura and the endothoracic fascia
30 Ultrasound-Guided Thoracic Paravertebral Block 425

Fig. 30.6 The endothoracic

fascia and its anatomical
relationship to the thoracic
paravertebral space. Note the
fascial compartments and the
location of the neurovascular
structures in relation to the
endothoracic fascia. (The
figure is reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

(Figs. 30.1 and 30.2). The ‘endothoracic fascia’ thus divides prevertebral space (Fig. 30.1). The cranial extension of the
the TPVS into two potential fascial compartments, the ante- TPVS is still not defined, but we have observed direct para-
rior ‘extrapleural paravertebral compartment’ and the poste- vertebral spread of radio-opaque contrast medium from the
rior ‘subendothoracic paravertebral compartment’ (Figs. 30.1 thoracic to the cervical region, indicating that there may be
and 30.2). The TPVS contains fatty tissue within which lie a direct anatomical continuity between the thoracic and cer-
the intercostal (spinal) nerve, the dorsal ramus, intercostal vical paravertebral regions. In clinical practice, ipsilateral
vessels, rami communicantes and anteriorly the sympathetic Horner syndrome after thoracic paravertebral injections is
chain (Fig. 30.1). The spinal nerves in the TPVS divide into also not uncommon. Nevertheless, the anatomical pathway
multiple small bundles that lie freely among the fatty tissue. for the spread of LA from the thoracic to the cervical para-
They are also devoid of a fascial sheath, which make them vertebral space is still not clear. The endothoracic fascia is
vulnerable to the effects of the injected LA during a TPVB. continuous superiorly with the scalene or Sibson’s fascia
The intercostal nerve and vessels are located behind the and attached to the medial border of the first rib anteriorly
endothoracic fascia, while the sympathetic trunk is located and the TP of the seventh cervical vertebra posteriorly.
anterior to it in the TPVS (Figs. 30.4 and 30.6). Therefore, an injection posterior to the endothoracic fascia
The TPVS is continuous with the epidural space medi- in the subendothoracic paravertebral compartment of the
ally via the intervertebral foramen, the intercostal space lat- upper thoracic region is unlikely to spread cranially via the
erally; and the contralateral TPVS via the epidural and paravertebral space because of the attachment of the
426 R. K. Sivakumar and M. K. Karmakar

endothoracic fascia to the TP. However, we believe that an  onoanatomy Relevant for Thoracic
S
injection anterior to the endothoracic fascia in the extrapleu- Paravertebral Block
ral paravertebral compartment may spread to the cervical
paravertebral region via the subserous layer of connective Basic Considerations
tissue. The latter also provides the connective tissue support
for the mediastinal structures and is continuous with the An ultrasound scan for TPVB can be performed in the trans-
connective tissue investing the neurovascular structures at verse (axial scan) or sagittal (longitudinal scan) axis and with
the root of the neck. the patient in the sitting, lateral decubitus or prone position.
There is controversy about the caudal boundary of the The prone position is preferred in patients undergoing USG
TPVS. Caudal spread of a thoracic paravertebral injection TPVB for chronic pain procedure because it also allows the
is considered implausible as the TPVS is limited caudally concurrent use of fluoroscopy. Currently, there are no data
by the origin of the psoas major muscle. However, ipsilat- demonstrating an optimal axis for the ultrasound scan or the
eral lumbar spinal nerves are occasionally involved after a intervention. It is often a matter of individual choice or expe-
lower thoracic paravertebral injection. Saito and colleagues rience of the proceduralist. The transducer of choice for the
have also demonstrated ipsilateral thoracolumbar spread of ultrasound scan also depends on the body habitus of the
coloured dye in cadavers. We have also observed radiologi- patient. A review of the literature indicates that high-­frequency
cal spread of contrast below the diaphragm and ipsilateral ultrasound (12–5 MHz) is more frequently used for USG
thoracolumbar anaesthesia after a TPVB. These observa- TPVB than low-frequency ultrasound. This may be because
tions challenge the concept of lumbar nerve root sparing the relevant anatomical structures (TP, SCTL and pleura) are
following a TPVB. The exact mechanism for the ipsilateral relatively shallow in location, and high-frequency ultrasound,
thoracolumbar spread of LA or the contrast medium is still despite its limited penetration, provides higher resolution of
not clear, but it is suggested that it occurs either due to epi- these structures than low-frequency ultrasound. However, in
dural spread or extended subendothoracic fascial spread patients with large body habitus or when one has to scan at a
(Fig. 30.7) to the retroperitoneal space, posterior to the depth, then a low-frequency ultrasound transducer (5–2 MHz)
facia transversalis, where the ilioinguinal and iliohypogas- with a divergent beam and a wide field of view may be prefer-
tric nerves are located. able. Published data using low-frequency ultrasound for

Fig. 30.7 Sagittal section of

the thoracolumbar region
showing the fascial relations
of the lower thoracic
paravertebral space and the
retroperitoneal space. The
pathway for the direct spread
of local anaesthetic from the
thoracic to the lumbar
paravertebral region, along
the subendothoracic
paravertebral compartment, is
shown using red arrows. (The
figure is reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 427

TPVB in clinical practice is sparse, but contrary to common space. The latter is the anatomic basis for the intercostal
understanding (poor resolution), we have been using low- approach for USG TPVB where the needle is inserted in the
frequency ultrasound (2–5 MHz) to perform a transverse scan plane of the ultrasound beam from a lateral to medial direc-
of the thoracic paravertebral region and guide the block nee- tion (see below). The SCTL which forms the posterior border
dle in real-time with great success (details below). of the TPVS is also visible, and it blends laterally with the
IICM, which forms the posterior border of the posterior
intercostal space (Fig. 30.4). The communication between
 ransverse Scan of the Thoracic Paravertebral
T the TPVS and the PICS can also be visualized laterally
Region (Fig. 30.9).
We have recently evaluated the use of a low-frequency
For a transverse scan of the thoracic paravertebral region, a (5–2 MHz) curved array transducer to perform a transverse
high-frequency linear array transducer is positioned lateral scan of the thoracic paravertebral region and USG
to the thoracic spinous process, at the target vertebral level, TPVB. To the best of our knowledge, there are limited pub-
with the orientation marker directed laterally (Fig. 30.8). On lished data describing the use of a low-frequency ultra-
a transverse sonogram, the paraspinal muscles are clearly sound for USG TPVB. Our preliminary experience is that
delineated and lie superficial to the TP. The TP is seen as a excellent ultrasound images of the paravertebral region are
rounded hyperechoic structure, anterior to which there is a obtained using a low frequency transducer (Fig. 30.10).
dark acoustic shadow which completely obscures the TPVS Also the wide field of view, produced by the divergent
(Fig. 30.8). Lateral to the TP, the hyperechoic pleura that ultrasound beam, is an added advantage when compared to
moves with respiration and exhibits the typical ‘lung sliding the narrow rectangular field of view produced by a linear
sign’ is seen. Comet tail artefacts, which are reverberation array transducer during the USG TPVB. Using a curved
artefacts, may also be visualized deep to the pleura and array transducer, the transverse scan is performed sequen-
within the lung tissue and are often synchronous with respi- tially over three contiguous osseous anatomical sites at the
ration. A hypoechoic space is also seen between the parietal target vertebral level (Fig. 30.11) for consistency and to
pleura and the IICM laterally, which represents the medial better define the relevant sonoanatomy; (1) Position 1: at
limit of the PICS or the apex of the TPVS (Fig. 30.8), and the the level of the transverse process-rib complex (Fig. 30.11a,
two communicate with each other (Fig. 30.4). Therefore, LA green box), (2) Position 2: at the level of the transverse pro-
injected medially into the TPVS can often be seen to spread cess (Fig. 30.11a, yellow box) and (3) Position 3: at the
laterally to distend this space or vice versa. LA injected later- level of the articular process (Fig. 30.11a, b, red box).
ally into this space can spread medially to the paravertebral Based on the underlying osseous and musculoskeletal

Fig. 30.8 Transverse

sonogram of the right thoracic
paravertebral region using a
high-frequency linear
transducer with the ultrasound
beam being insonated over
the transverse process (TP).
Note how the acoustic shadow
of the TP obscures the
thoracic paravertebral space
(TPVS). The hypoechoic
space posterior to the parietal
pleura and anterolateral to the
TP is the apex of the TPVS or
the medial limit of the
posterior intercostal space.
Inset image (top left) is
showing the position and
orientation of the ultrasound
transducer with the patient in
the sitting position. (The
figure is reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)
428 R. K. Sivakumar and M. K. Karmakar

Fig. 30.9 A multiplanar 3D

ultrasound view of the
thoracic paravertebral region
with the reference marker or
‘marker dot’ placed over the
transverse process (TP). Note
how the three slice planes
(red—transverse, green—
sagittal and blue—coronal)
have been obtained and how
the superior costotransverse
ligament (SCTL) is
continuous with the internal
intercostal membrane (IICM)
laterally in the coronal plane.
TPVS thoracic paravertebral
space, PICS posterior
intercostal space, CTJ
costotransverse junction. (The
figure is reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

Fig. 30.10 Paramedian

transverse sonograms of the
thoracic paravertebral region
with the ultrasound beam being
insonated (a) at the level of the
rib and transverse process
(position 1 in Fig. 30.11), (b) at
the level of the transverse
process (position 2 in
Fig. 30.11), and (c) at the level a
of the inferior articular process
(position 3 in Fig. 30.11). SP
spinous process, TP transverse
process, CTJ costotransverse
junction, PSM paraspinal
muscles, TPVS thoracic
paravertebral space, IICM
internal intercostal membrane,
PICS posterior intercostal
space, SC spinal canal, AC
anterior complex, IAP inferior
articular process, SCTL superior
costotransverse ligament, IVF
intervertebral foramen. (The
figure is reproduced with kind
permission from www.aic.cuhk. b c
edu.hk/usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 429

a b

Fig. 30.11 (a) Posterior view: Figure illustrating the various positions process. (b) Lateral view: Note the relationship of the inferior articular
of the ultrasound transducer, relative to the osseous structures of the process to the inferior vertebral notch and the intervertebral foramen.
thoracic spine, during the ultrasound scan sequence described. Position (The figure is reproduced with kind permission from www.aic.cuhk.
1: at the level of the rib and transverse process; position 2: at the level edu.hk/usgraweb)
of the transverse process; position 3: at the level of the inferior articular

anatomy, each of these three ultrasound scan windows pro- Therefore, it is used more as a starting point for the subsequent
duce three distinct sonograms (Fig. 30.10). Correlative steps in the transverse scan sequence.
cadaver anatomical-CT-MRI and ultrasound images for Step 2: Transverse scan at the level of the transverse pro-
positions 2 and 3 of the transverse scan sequence described cess. From position 1, one can gently slide the transducer cau-
above are presented in Figs. 30.12 and 30.13. dally until the acoustic shadow of the rib is no longer visualized
Step 1: Transverse scan at the level of the transverse (Fig. 30.11, position 2, yellow box), and the hyperechogenic
process-rib complex. The transducer is positioned 2–3 cm outline of the lamina and TP with their acoustic shadow are
lateral to the midline, at the target vertebral level, in the trans- visualized (Fig. 30.10b). Lateral to the TP, one can define the
verse plane and over the rib and costotransverse articulation IICM posteriorly and the hyperechogenic pleura and lung ante-
(position 1, green box). The hyperechogenic outlines of the riorly. Interposed between the two is the hypoechoic apical part
spinous process, lamina, TP, costo-transverse junction and the of the TPVS (Fig. 30.10b). The PICS may also be visualized in
rib with their corresponding acoustic shadows are clearly continuity with the apex of the TPVS laterally (Fig. 30.10b).
delineated from a medial to lateral direction (Fig. 30.10a). The Step 3: Transverse scan at the level of the articular
posterior angulation of the TP of the thoracic vertebra process: Finally, if one now slides the transducer slightly
(Fig. 30.14) is also easily recognized (Fig. 30.10a). This is in caudally from position 2 (Fig. 30.11, position 3, red box), the
contrast to the TP of the lumbar vertebra which is more or less acoustic shadow of the lamina and transverse process disap-
at right angles to the vertebral body (Fig. 30.14). This ultra- pear, and the echogenic inferior articular process (Fig. 30.10c)
sound window does not lend itself to visualizing the paraver- with its acoustic shadow is now visualized medially. This
tebral anatomy because the acoustic shadow of the TP-rib acoustic window represents the transverse-intertransverse
complex completely obscures the TPVS (Fig. 30.10a). view of the TPVS. As in the scan at the level of the TP
430 R. K. Sivakumar and M. K. Karmakar

Fig. 30.12 Correlative a b

transverse cadaver anatomic
(a), CT (b), MRI (T1
weighted, c) and ultrasound
(d) images of the thoracic
paravertebral region from the
level of the vertebral body
and transverse process
corresponding to the level at
which the transverse scan is
performed (position 2,
Fig. 30.11). Eo oesophagus,
CTJ costotransverse junction,
TPVS thoracic paravertebral c d
space, VB vertebral body,
PSM paraspinal muscle, IVF
intervertebral foramen, TP
transverse process, SCTL
superior costotransverse
ligament. (The figure is
reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

Fig. 30.13 Correlative a b

transverse cadaver anatomic
(a), CT (b), MRI (T1
weighted, c) and ultrasound
(d) images of the thoracic
paravertebral region from the
level of the vertebral body
and inferior articular process
corresponding to the level at
which the transverse scan is
performed (position 3,
Fig. 30.11). TPVS thoracic
paravertebral space, VB
vertebral body, PSM c d
paraspinal muscle, IVF
intervertebral foramen, SCTL
superior costotransverse
ligament, SP spinous process.
(The figure is reproduced with
kind permission from www.
aic.cuhk.edu.hk/usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 431

Fig. 30.14 Figure showing the difference in the size, shape and orien- nous process, AP articular process, TP transverse process, SC spinal
tation of the transverse process (TP) of a thoracic and lumbar vertebra. canal, VB vertebral body. (The figure is reproduced with kind permis-
Note how the TP of a thoracic vertebra is directed posteriorly. SP spi- sion from www.aic.cuhk.edu.hk/usgraweb)

(Position 2, Fig. 30.10b), the SCTL, parietal pleura, lung and to the paraspinal muscles (Fig. 30.15). One can also appreci-
the apical part of the paravertebral space are clearly delin- ate the acoustic window between the contiguous transverse
eated. However, the area of the acoustic shadow at the level processes produced by reflections from the SCTL, intertrans-
of the articular process is significantly less than that at the verse ligament, TPVS with its contents, hyperechoic parietal
level of the TP. As a result, one can visualize majority of the pleura and the underlying lung tissue, from a posterior to
TPVS with this view (Fig. 30.10c). Currently, there are lim- anterior direction. (Fig. 30.15). In the resultant sagittal sono-
ited published data describing the use of a transverse scan at gram, the TPVS is seen as a hypoechoic space between the
the level of the articular process for USG TPVB. SCTL and the parietal pleura (Fig. 30.15). Doppler ultra-
sound can be used to define the intercostal vessels lying cau-
dal to the transverse process (Fig. 30.16), but we have not
 agittal Scan of the Thoracic Paravertebral
S been able to delineate the intercostal nerve with current
Region ultrasound technology.
We have observed that the underlying pleura and the
For a sagittal scan of the thoracic paravertebral region, a TPVS are not clearly delineated in a true paramedian sagittal
high-frequency linear transducer (12–5 MHz) is positioned scan (Fig. 30.15). This may be due to ‘anisotropy’ because
2–3 cm lateral to the midline (paramedian), with its orienta- the ultrasound beam is not perpendicular to the anteromedial
tion marker directed cranially, at the target vertebral level reflection of the parietal pleura near the vertebra in the para-
(Fig. 30.15). This ultrasound window (paramedian sagittal) vertebral region. Loss of spatial resolution at the depth cor-
clearly delineates the transverse processes as rounded hyper- responding to the TPVS, from using high-frequency
echoic structures, with its acoustic shadow anteriorly, deep ultrasound, cannot also be excluded. Therefore, in order to
432 R. K. Sivakumar and M. K. Karmakar

Fig. 30.15 Paramedian sagittal scan of the right mid-thoracic paraver- SCTL superior costotransverse ligament, TPVS thoracic paravertebral
tebral region using a high-frequency linear transducer. Note the para- space. (The figure is reproduced with kind permission from www.aic.
vertebral structures including the parietal pleura and the paravertebral cuhk.edu.hk/usgraweb)
space are not clearly delineated in this image. TP transverse process,

Fig. 30.16 Paramedian

sagittal oblique sonogram of
the thoracic paravertebral
region showing the power
Doppler signal from the
intercostal artery at the apex
of the paravertebral space. TP
transverse process. (The
figure is reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 433

minimize ‘anisotropy’ and to better visualize the underlying is that the proceduralist may unintentionally tilt or manipu-
TP, SCTL, TPVS and the pleura, we recommend performing late the transducer too far laterally so as to insonate the rib
a ‘paramedian sagittal oblique’ scan. This is achieved by and posterior intercostal space rather than the TP and apical
gently tilting the ultrasound transducer laterally (outward) part of the TPVS (Fig. 30.18). The clinical implication is that
until the underlying parietal pleura is clearly delineated the proceduralist may unknowingly perform a posterior
(Fig. 30.17). We believe the lateral tilt directs the ultrasound intercostal injection instead of a paravertebral injection, and
beam perpendicular to the parietal pleura and thereby depending on the technique used, the potential for inadver-
­minimizes ‘anisotropy’. A pitfall of the lateral tilt manoeuvre tent pleural puncture may be greater with the intercostal

Fig. 30.17 Paramedian

sagittal oblique sonogram of
the thoracic paravertebral
region. The picture in the
inset shows how the
ultrasound transducer is tilted
slightly laterally (outwards)
during the scan. Note the
pleura, superior
costotransverse ligament and
the paravertebral space are
clearly delineated in this
sonogram. TP transverse
process. (The figure is
reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)

Fig. 30.18 Paramedian

sagittal oblique scan of the
right mid-thoracic
paravertebral region, using a
high-frequency linear
transducer, whereby the ribs
instead of the transverse
processes are being insonated.
Note the pleura is also very
clearly delineated in this
sonogram. (The figure is
reproduced with kind
permission from www.aic.
cuhk.edu.hk/usgraweb)
30 Ultrasound-Guided Thoracic Paravertebral Block 435

Fig. 30.20 Ultrasound-guided TPVB using a paramedian sagittal the inset also shows how the transducer is oriented and the direction in
oblique scan. The long white arrow represents the direction in which the which the needle is inserted. TP transverse process, SCTL/IICM supe-
needle is inserted and the picture in the inset shows how the block nee- rior costotransverse ligament-internal intercostal membrane complex.
dle is inserted in the long axis of the ultrasound plane. Visualizing the (The figure is reproduced with kind permission from www.aic.cuhk.
block needle with this approach can be very challenging. The picture in edu.hk/usgraweb)

 aramedian Sagittal Scan with In-Plane Needle

P tions, we rarely use this approach although there are
Insertion proponents of this technique. If one were to use this tech-
With this approach, a paramedian sagittal oblique scan is nique, then we recommend advancing the block needle under
performed at the target vertebral level as described above, ultrasound guidance to deliberately contact the lower border
and the block needle is inserted in-plane and in a caudo-­ of the TP after which the block needle is slightly withdrawn
cranial direction (Fig. 30.20). Although the needle is inserted and re-advanced so as to pass under the lower border of the
in-plane, visualizing and tracking the needle tip can be chal- TP. A test bolus of normal saline (2–3 ml) is then injected,
lenging with this technique. This may be because the block and sonographic evidence (pleural displacement) is sought to
needle is inserted at an acute angle, and the ultrasound beam ensure that the tip of the block needle is in the TPVS
is also insonated with a slight outward (oblique) tilt for opti- (Fig. 30.21). A calculated dose of LA is then injected in
mal ultrasound visibility of the pleura. Due to these limita- small aliquots. Following the injection, it is common to see
436 R. K. Sivakumar and M. K. Karmakar

Fig. 30.21 Paramedian sagittal oblique sonogram of the TPVS after seen to have spread to the contiguous paravertebral space form the level
local anaesthetic injection. Note the widening of the paravertebral space of injection. TP transverse process. (The figure is reproduced with kind
and displacement of the parietal pleura. The local anaesthetic is also permission from www.aic.cuhk.edu.hk/usgraweb)

anterior displacement of the parietal pleura, widening of the and at the level of the TP and the block needle inserted in the
paravertebral space and an increased echogenicity of the short axis of the ultrasound beam (Fig. 30.22). During the
pleura (Fig. 30.21) that are objective signs of a correct injec- preview scan, the depth to the TP and pleura is determined.
tion into the TPVS. Spread of the injected LA to the contigu- The direction of needle insertion with this approach mimics
ous paravertebral spaces may also be visualized in real-time that with a surface anatomic landmark-based TPVB
(Fig. 30.21), confirming that the contiguous TPVS’s com- (Fig. 30.22). Since the needle is inserted in the short axis, it
municate with each other. is visualized only as a bright spot, and needle tracking can be
challenging. The aim of this approach is to guide the needle
 ransverse Scan with Out-of-Plane Needle
T to the TP. Once the TP is contacted, the needle is withdrawn
Insertion slightly and re-advanced by a predetermined distance of
With this technique, a transverse scan of the thoracic para- 1–1.5 cm so as to pass under the TP into the
vertebral region is performed at the desired vertebral level TPVS. Alternatively, the needle can be inserted laterally into
30 Ultrasound-Guided Thoracic Paravertebral Block 437

Fig. 30.22 Ultrasound-guided TPVB using a transverse scan in which laterally. The picture in the inset shows the orientation of the transducer
the block needle is inserted in the short axis of the ultrasound plane. and the direction in which the needle is inserted. SCTL/IICM superior
Note the widening of the paravertebral space and anterior displacement costotransverse ligament. (The figure is reproduced with kind permis-
of the pleura by the local anaesthetic on the transverse sonogram. The sion from www.aic.cuhk.edu.hk/usgraweb)
local anaesthetic is also seen to spread to the posterior intercostal space

the apex of the TPVS. After negative aspiration for blood or at the level of the TP, and the block needle is inserted in-­
CSF, the calculated dose of LA is injected in aliquots. plane from a lateral to medial direction (Fig. 30.23), aiming
Following the injection, it is common to see widening of the to place the needle tip at the apical part of the TPVS. A test
apex of the TPVS and anterior displacement of the pleura by bolus of normal saline (1–2 ml) is then injected, and sono-
the LA (Fig. 30.22). The LA may also spread to the posterior graphic evidence is sought to confirm correct needle tip
intercostal space laterally. Widening of the contiguous para- placement in the TPVS. This is visualized as widening of the
vertebral spaces by the injected LA can also be visualized on TPVS and anterior displacement of the parietal pleura
a sagittal scan after the injection. (Fig. 30.23). A calculated dose of LA is then slowly injected
in aliquots. Compared to the previously described tech-
I ntercostal Approach to the TPVS niques, the block needle is best visualized with this approach
With this approach, a transverse scan is performed at the tar- because the needle is inserted in the plane of the ultrasound
get vertebral level as described above. Originally described beam. Shibata and Nishiwaki also suggest that since the
by Shibata and Nishiwaki, the transverse scan is performed block needle is advanced, tangential to the parietal pleura,
438 R. K. Sivakumar and M. K. Karmakar

Fig. 30.23 Transverse sonogram of the TPVS (at the level of the TP) inserted. The picture in the inset shows how the block needle is inserted
after the local anaesthetic injection. Note the widening of the paraverte- in the plane of the ultrasound beam from a lateral to medial direction.
bral space, anterior displacement of the parietal pleura and spread of TP transverse process, LA local anaesthetic, TPVS thoracic paraverte-
local anaesthetic (LA) to the posterior intercostal space laterally. The bral space. (The figure is reproduced with kind permission from www.
long white arrow represents the direction in which the block needle is aic.cuhk.edu.hk/usgraweb)

this approach may have a lower potential for pleural punc- greater part of the TPVS and also offers little bony obstruc-
ture. However, since the block needle is inserted from a lat- tion to needle advancement (Fig. 30.24). Therefore, the tip of
eral to medial direction and towards the intervertebral the nerve block needle can be seen passing through the
foramen and the acoustic shadow of the transverse process SCTL/IICM complex to enter the apical part of the TPVS
obscures ultrasound visualization of the needle beyond the (Fig. 30.25). After the LA injection, there is widening of the
tip of the transverse process (Fig. 30.23), this approach may TPVS, anterior displacement of the parietal pleura and
predispose to epidural injection or central neuraxial increased echogenicity of the parietal pleura (Fig. 30.26).
complications. However, with the block needle being inserted from a lateral
We have modified the intercostal approach, and instead of to medial direction and towards the intervertebral foramen,
performing the ultrasound scan and injection at the level of the technique may also predispose to epidural spread or cen-
the transverse process, as described above, the procedure is tral neuraxial complications. Since the intervertebral fora-
performed at the level of the articular process (Fig. 30.10). men is located immediately anterior to the inferior articular
Without the transverse process in the path of the ultrasound process (Figs. 30.11 and 30.13), one must avoid inserting the
beam, we believe this approach allows visualization of a block needle too deep or perform the LA injection adjacent
30 Ultrasound-Guided Thoracic Paravertebral Block 441

Practical Tips TPVB. We believe this conclusion is valid when the single-­
injection USG TPVB is used for postoperative analgesia
1. During a paramedian sagittal scan of the TPVS, a slight after primary breast cancer surgery, the outcome evaluated
outward (lateral) tilt of the ultrasound transducer improves by Uppal and colleagues, but its efficacy as the sole anaes-
ultrasound visualization of the parietal pleura. thetic technique for the same surgery will require future
2. When using a paramedian sagittal oblique scan for the research validation.
TPVB, it is important to have a clear understanding of the Patnaik and colleagues compared anatomical landmark-­
subtle transition in sonoanatomy from the level of the ribs based and USG multi-level TPVB (T1-T6, 5 ml of LA at each
to the lamina. level) for surgical anaesthesia during a variety of breast sur-
3. The transverse ultrasound scan at the level of the inferior gery in 72 female patients. The paramedian sagittal oblique
articular process (inter-transverse view) provides mini- ultrasound window with in-plane needle insertion technique
mal acoustic shadowing from the osseous structures and was used for the USG multi-level TPVB. They observed that
thus clear visualization of the TPVS. significantly more dermatomes were blocked in the USG
4. The transverse scan should be performed in a sequential group when compared to the anatomical landmark group
manner (as described above) to consistently and accu- (median [range]; USG group 5[1–5] vs. landmark group 4
rately identify the sonoanatomy of the TPVS at the level [2–5], p = 0.0001). More patients in the USG group also had
of the transverse process and inferior articular process of successful block of the T2 (p = 0.003) and T3 (p = 0.006)
the vertebra. dermatomes than the landmark group. Furthermore, more
5. If needle visualization proves difficult during an USG patient (p = 0.024) in the USG group (94%) had successful
TPVB, then hydrodissection with 1–2 ml of normal saline block for the breast surgery when compared to the anatomical
may help improve visualization of the needle tip. group (72%). While these are encouraging results, the readers
6. It is imperative to sonographically confirm correct needle should note that a significant number of patients in both study
tip position within the TPVS (saline test bolus) before the groups still required supplementary analgesia (USG group
LA injection in small aliquots. The same may also reduce 82% vs. anatomical landmark group 58%) at various stages of
the potential for accidental intravascular injection. the breast surgery, indicating that a multi-level TPVB (T1–
7. Sonographic signs that confirm correct needle tip position T6) in conjunction with light sedation is inadequate for surgi-
within the TPVS after the saline test bolus injection cal anaesthesia during major breast surgery (discussion
include turbulence within the TPVS, anterior displace- beyond the scope of this chapter).
ment of the parietal pleura, widening of the TPVS and Fujii and colleagues aimed to determine the best approach
increased echogenicity of the pleura. for USG TPVB catheterisation and compared the transverse
8. When performing the intercostal approach for USG and parasagittal (paramedian sagittal) approach in 60 patients
TPVB, it may be prudent to perform the LA injection at using a micro-convex transducer. Correct catheter placement
the apex of the TPVS and avoid unnecessary deep needle was possible in 77% and 80% of patients using the transverse
insertion. and paramedian sagittal approach, respectively. They con-
clude that both approaches achieved a high rate of successful
catheter placement, and there is no clinically significant
Literature Review difference between the two approaches for paravertebral
­
catheterization.
Currently there are very few studies comparing outcomes Seidal and colleagues compared the effect of different
after different techniques for USG TPVB. Uppal and col- injection techniques and volume of injection on the patterns
leagues compared dermatomal anaesthesia produced by a of dye spread after an USG TPVB in cadavers. They com-
single (T3-T4) versus multiple (5 injection, T1–T5, 5 ml per pared 10 vs. 20 ml, USG vs. landmark-based technique, and
segment) injection USG TPVB using a paramedian sagittal different approaches (transverse vs. sagittal, medial vs. lat-
approach with in-plane needle insertion and a total of 25 ml eral, and single vs. multiple injections). Seidal and col-
of 0.5% ropivacaine. There was no difference in the median leagues conclude that a higher injection volume results in a
dermatomal spread of anaesthesia with the single-injection larger number of intercostal nerves being stained. The sym-
(5 [4–6] segments) when compared to the multiple-injection pathetic trunk was stained in 84.6% (100% with multiple-­
(5 [5, 6] dermatomes) technique. Duration of analgesia was injection), and it was independent of the injection volume.
also comparable, but the single-injection took less time to Epidural spread was less likely if the injections were more
perform. Uppal and colleagues thus concluded that a single-­ lateral with the transverse approach or with a cranially
injection may be preferable to a multiple-injection for USG directed needle with the sagittal approach.
442 R. K. Sivakumar and M. K. Karmakar

Conclusion gical management of breast cancer—experience in 156 cases. Ann

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vacaine and dextran. Anaesthesia. 1981;36:685–7.
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the preview scan, one is able to define the paravertebral anat- anaesthetic toxicity from continuous thoracic paravertebral block.
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Hara K, Sakura S, Nomura T. [Use of ultrasound for thoracic paraverte-
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446 B. Versyck

a b

Fig. 31.1 Region of interest for interpectoral, pectoserratus, and serratus anterior plane blocks. (a) Anterior view; (b) lateral view. (Reproduced
with permission of Dr. Barbara Versyck BV)

requiring analgesia after breast surgery. One year later, Due to their relative simplicity, safety, and efficacy, these
Blanco et al. described a modified version of this technique three blocks have rapidly gained popularity. The blocks are
where they additionally injected local anesthetic between the generally used as an adjuvant to general anesthesia or occa-
pectoralis minor and serratus muscles (now the pectoserratus sionally with sedation.
plane block). Upon introduction of the second block, Blanco
et al. labeled the first block as the Pecs I (now the interpec-
toral plane block) and the later modified technique collec- Indications and Contraindications
tively as Pecs II (now the interpectoral-pectoserratus plane
block). The interpectoral plane block is an injection between See Tables 31.2 and 31.3.
the major and minor pectoral muscles to block the medial
and lateral pectoral nerves as well as the intercostobrachial
nerve. The pectoserratus plane block is between the pectora- Indication and Patient Selection
lis minor and serratus muscle to target at least the II–VI
intercostals and the long thoracic nerve. Lastly, in 2013, Indications for the Interpectoral Plane Block
Blanco et al. described the serratus anterior plane block
(SAPB). There are two variants of the serratus anterior plane Effect of the Blockade
block, a superficial and a deep variant, which involve an The interpectoral plane block blocks the medial and lateral
injection superficial or deep to the serratus anterior muscle, pectoral nerves as well as the intercostobrachial nerve. This
respectively, at the lateral chest wall. Both target the lateral blockade attenuates the stretch-induced pain of the pectoral
cutaneous branches of the thoracic intercostal nerves. This muscles and provides sensory analgesia of the axilla through
superficial serratus anterior plane block is comparable to the the intercostobrachial nerve. As it does not reach the inter-
pectoserratus plane block and additionally stains the thora- costal nerves, there is no sensory blockade of the thoracic
codorsal and long thoracic nerves (Table 31.1). wall.
31 Pectoral and Serratus Plane Blocks 447

Table 31.1 Technique performance of the interpectoral, pectoserratus, and serratus anterior plane blocks
Technique Technical performance
Interpectoral plane block  • Injection between pectoralis major and minor muscles
 • Level of the third rib underneath the lateral half of the clavicle
Interpectoral-pectoserratus plane block  • Interpectoral plane block and a second injection between the pectoralis major and serratus
anterior muscles
 • Level of the third rib underneath the lateral half of the clavicle
Serratus anterior plane block (SAPB):  • Injection superficial to serratus anterior muscle
superficial  • Anywhere between the anterior and posterior axillary line and the third to sixth rib
Serratus anterior plane block (SAPB): deep  • Injection deep to serratus anterior muscle and superficial to ribs and intercostal muscles
 • Anywhere between the anterior and posterior axillary line and the third to sixth ribs

Table 31.2 Targeted nerves per block

Cutaneous and subcutaneous innervation Muscle innervation
Intercostal nerves Cervical plexus Brachial plexus
Nerves Lateral Anterior Intercostobrachial Supraclavicular Lateral Medial Thoracodorsal Long
cutaneous cutaneous nerve nerves pectoral pectoral nerve nerve thoracic
branches branches nerve nerve
Innervation of Lateral Medial Axilla and medial Cranial breast Pectoralis Pectoralis Latissimus Serratus
breast breast upper arm major major and dorsi muscle anterior
muscle minor muscle
muscles
Interpectoral √ √ √
plane block
Interpectoral- √ √ √ √ √
pectoserratus
plane block
Serratus anterior √ √ √ √
plane block
(SAPB):
superficial
Serratus anterior √ √
plane block
(SAPB): deep

Acute Therapeutic anterior cutaneous branches of the intercostal nerves, which

• Minor breast surgery including subpectoral prostheses innervate the sternum, are not blocked.
and insertion of breast expanders.
• Subpectoral device insertion including pacemakers and Diagnostic
port-a-caths. • Breast biopsy.

Acute Therapeutic
I ndications for the Interpectoral-Pectoserratus • Breast cancer surgery procedures such as lumpectomy, mas-
Plane Block tectomy, axillary clearance, and sentinel node dissection.
• Reconstructive breast surgery and breast augmentation.
Effect of the Blockade • Subpectoral prostheses and devices including pacemakers
The site and volume of injection influences the effect of the and port-a-caths.
blockade, in particular the block of the intercostobrachial • Chest drains in T2–T6.
nerve. Assuming the procedure described below, the inter- • Partial first rib resection.
pectoral-pectoserratus plane block provides analgesia to the
lateral chest wall and axillary region (Fig. 31.2). There is no Chronic Pain
complete analgesia of the hemithorax as, for example, the • Persistent pain after breast cancer surgery.
 448

Table 31.3 Nerves involved in frequently performed anterolateral and axillary region surgery
Cutaneous and subcutaneous innervation Muscle innervation
Intercostal nerves Cervical plexus Brachial plexus
Nerves Lateral cutaneous Anterior Intercostobrachial Supraclavicular Lateral Medial pectoral Thoracodorsal Long thoracic
branches cutaneous nerve nerves pectoral nerve nerve nerve nerve
branches
Innervation of Lateral breast Medial breast Axilla and medial Cranial breast Pectoralis Pectoralis major Latissimus dorsi Serratus
upper arm major muscle and minor muscles muscle anterior
muscle
Tissue expander √ √ √ √ √
Lumpectomy If lateral If medial If cranial
lumpectomy lumpectomy lumpectomy
Mastectomy √ √ √
Sentinel node or axillary √ √ √
dissection
Latissimus dorsi flap √
Device implementation e.g., √ √ √
port-a-cath, pacemaker
Video-assisted thoracic √ √ √
surgery (VATS)
Trauma to lateral chest wall √
e.g., rib fracture
B. Versyck
31 Pectoral and Serratus Plane Blocks 449

Fig. 31.2 Blockade achieved by the interpectoral-pectoserratus plane

block. (Reproduced with permission of Dr. Barbara Versyck BV)

Indications for Serratus Anterior Plane Block

Effect of the Blockade

The serratus anterior plane block can be performed anywhere
between the anterior and posterior axillary lines and the third
to sixth rib. The site and volume of injection influences the
effect of this blockade, in particular in which intercostal
nerve territories will be blocked. Assuming the procedure Fig. 31.3 Blockade achieved by the serratus anterior plane block upon
described below, the serratus anterior plane block typically performing the block at the level of r4 resulting in a maximal spread of
T2–T6. (Reproduced with permission of Dr. Barbara Versyck BV)
achieves analgesia one to two levels cephalad and one to two
levels caudad from the location of injection (Fig. 31.1). For
instance, the T2–T6 blockade can be achieved by a block at thetics, a presence of abnormal anatomy or inflammation at
the level of the fourth rib (Fig. 31.3). the injection site, e.g., breast cancer.

Acute Therapeutic
• Mastectomy.  natomy of the Anterolateral Chest Wall
A
• Thoracotomy. and Axillary Region
• Rib fractures.
• Chest drain insertions. Five nerve groups are key for the sensory innervation of the
anterolateral chest and axillary region: (1) the anterior cuta-
Chronic Pain neous branches of the thoracic intercostal nerves, (2) the lat-
• Rib fractures. eral cutaneous branches of the thoracic intercostal nerves,
(3) the pectoral nerves, (4) the long thoracic nerve, and (5)
the supraclavicular nerves (Fig. 31.4). These five groups
Contraindications for Interpectoral, originate from three different regions: the neuraxis, brachial
Pectoserratus, and Serratus Anterior Plane plexus, and cervical plexus.
Blocks The anterior and lateral cutaneous branches of the tho-
racic intercostal nerves originate from the neuraxis.
These blocks are contraindicated in situation when a patient Generally, the anterior branches innervate the medial side of
refuses or has a known history of allergy to the local anes- the breast T2–T6, while the lateral branches provide innerva-
450 B. Versyck

Fig. 31.4 Innervation of the pectoral and axillary region. LPN lateral pectoral nerve, MPN medial pectoral nerve, MBCN medial brachial cutane-
ous nerve, ICBN intercostobrachial nerve, LTN long thoracic nerve. (Reproduced with permission of Dr. Barbara Versyck BV)

tion of the lateral side of the breast T3–T6. The lateral Table 31.4 Pre-procedure preparation
cutaneous branch of T2 forms the intercostobrachial nerve General Equipment
and innervates the axilla and medial upper arm. In the axilla,  • Informed discussion  • Ultrasound machine at the head
the intercostobrachial nerve may merge with the medial bra- and consent of patient with a linear high-
 • Emergency frequency probe
chial cutaneous nerve. The lateral cutaneous branches pierce equipment and drugs  • 50-mm (ultrasound) needle
the intercostal and serratus anterior muscles before dividing  • Intravenous access  • Sterile ultrasound cover and gel
into an anterior and posterior branch.  • Standard monitoring  • Long-acting local anesthetic
The pectoral nerves and the long thoracic nerve originate  • Sterile precaution (bupivacaine or ropivacaine)
from the brachial plexus. The medial and lateral pectoral
nerves innervate the pectoral muscles. The long thoracic nerve
is responsible for the innervation of the serratus muscle. Sonoanatomy for the Interpectoral-
The supraclavicular nerves provide sensory innervation Pectoserratus Plane Blocks
of the superior part of the breast region and originate from
the cervical plexus. With the patient in supine position and arm either abducted or
along the side of the body, a linear transducer is positioned in
a similar position as for an infraclavicular block as it allows
Technique the visualization of the second rib caudal to the lateral part of
the clavicle (Fig. 31.5a). The transducer is moved further cau-
While these techniques are not complex, they should only be dally to the third rib and rotated about 45 degrees inferolateral
carried out by anesthesiologists with experience in to visualize both the third and the fourth rib (Fig. 31.5b). The
ultrasound-­guided regional anesthesia or under their supervi- corresponding ultrasound image should at least visualize pec-
sion. The pre-procedure preparation is summarized in toralis major, pectoralis minor, pectoral branch of the thora-
Table 31.4. coacromial artery, and the third and fourth rib (Fig. 31.5c).
452 B. Versyck

important to avoid puncturing the pleura. The needle is and blocks the intercostobrachial nerve. The following mix-
advanced medial from the thoracoacromial artery until the tures are recommended while respecting the maximum dose
needle tip reaches the facial plane deep to the pectoralis of ropivacaine (2–3 mg/kg, not to exceed 225 mg per dose):
minor muscle. Due to the anatomic variation, this plane may
be between the pectoralis minor muscle and the serratus • Adult patients >70 kg: 20 mL of ropivacaine 1% diluted
anterior muscle or between the pectoralis minor muscle and with 20 mL of saline.
the intercostal muscle. At this level, the pectoserratus plane • Adult patients 50–70 kg: 20 mL of ropivacaine 0.75%
block is performed (Fig. 31.7, yellow arrow). Then, the nee- diluted with 20 mL of saline.
dle is retracted until the needle tip reaches the fascial plane • Adult patients <50 kg: The same mixture is used as for
between the pectoralis major muscle and the pectoralis minor adult patients 50–70 kg; however, only 15 mL per injec-
muscle where the interpectoral plane block is injected tion is used while respecting the maximum dose of
(Fig. 31.7, orange arrow). The procedure is completed after ropivacaine.
confirming the lateral spread of local anesthetic in both facial
planes. Also for the interpectoral plane block, the author prefers
Optimal volumes and concentrations of local anesthetics 15–20 mL of the same mixture rather than the initially
for use for the interpectoral-pectoserratus plane block have described 10 mL.
yet to be determined. As with all facial plane blocks, the area
of spread is related to the total volume of injectate used,  erratus Anterior Plane Block
S
rather than concentration. A balance must be found between The needle is introduced in plane from medial to lateral aim-
achieving an optimal spread of sensory anesthesia and avoid- ing toward the serratus anterior muscle and the underlying
ing toxicity as well as minimizing the impact on the surgical rib. Such orientation is important to avoid puncturing the
field. pleura. For the deep variant of the serratus anterior plane
In adult patients over 50 kg, it is the author’s practice to block (Fig. 31.8, yellow arrow), our target is separating the
use a total volume of 40 mL instead of the initially proposed serratus anterior muscle off the rib. For the superficial variant
30 mL by Blanco et al. for the interpectoral-pectoserratus of the serratus anterior plane block (Fig. 31.8, orange arrow),
plane block. Twenty mL of local anesthetic is injected in we position the needle tip in the fascial plane between latis-
each fascial plane. The higher volume of the interpectoral simus dorsi and serratus anterior muscles to inject local anes-
injection ensures that the local anesthetic reaches the axilla thetic. For both variants, the procedure is completed after

Fig. 31.7 Injection technique for the interpectoral-pectoserratus plane block, Yellow arrow pectoserratus plane block. (Reproduced with per-
block. Red pectoral branch of the thoracoacromial artery, r3 third rib, r4 mission of Dr. Barbara Versyck BV)
fourth rib, IC intercostal muscle, Orange arrow interpectoral plane
31 Pectoral and Serratus Plane Blocks 453

Fig. 31.8 Injection technique for the serratus anterior plane block at the level of r5. r4 fourth rib, r5 fifth rib, IC intercostal muscle, Orange arrow
superficial variant, Yellow arrow deep variant of serratus anterior plane block. (Reproduced with permission of Dr. Barbara Versyck BV)

confirming the lateral spread of local anesthetic in the fascial blocks can be performed pre- and post-induction, before
plane. and after surgery, and as a rescue block. As clinical intro-
Another variant is recommended by Biwas et al., which duction of such regional anesthesia techniques may be
combines a deep and superficial serratus anterior plane challenging, it is recommended to choose the time of appli-
block. Each injection contains half of a mixture of 20 mL of cation that has the least impact on the existing way of work-
ropivacaine 1% and 20 mL of saline while respecting the ing and fine-tune as soon as their benefits have been
maximum dose of ropivacaine. recognized by all stakeholders.

Complications Tools

Complications To perform the interpectoral, pectoserratus, and serratus

anterior plane blocks, it is recommended to use short-length
• Intravascular injection (thoracoacromial artery) with needle (50 mm). A shorter needle may reduce the risk of
toxic reactions when performing the Pecs blocks. pleural puncture and produces greater agility to perform the
• Hematoma formation. block.
• Pleural puncture.

Local Anesthetic
Side Effects
In general, surgery of the anterolateral chest wall and axil-
This technique may impact the surgical site by spreading lary region may result in considerable acute postoperative
local anesthetic in musculofascial planes. pain over a longer period. Therefore, it is recommended to
prefer a long-acting local anesthetic such as ropivacaine.

Practical Tips
Procedure
Application
To avoid pleural puncture, it is important to perform these
The interpectoral, pectoserratus, and serratus anterior plane techniques in plane while aiming the needle at an underly-
blocks are flexible in terms of the time of application. These ing rib.
454 B. Versyck

Literature Review invasive cardiac surgery, and traumatic thoracic injuries

including rib and clavicle fractures. For such indications,
Interpectoral Plane Block there are only limited scientific evidence.

Overall, little scientific research has been performed to study

the interpectoral plane block. This might be due to its limited Serratus Anterior Plane Block
clinical applications as well as relatively short time between
the introduction of the interpectoral plane and interpectoral- One meta-analysis examined 19 trials that compared serratus
pectoserratus plane block. One meta-­analysis on these blocks anterior plane block to non-block care or paravertebral block
for modified radical mastectomy performed an interpectoral in breast and thoracic surgery. Compared to non-block care,
plane block subgroup analysis (interpectoral plane block, the serratus anterior plane block generated a modest reduc-
n = 137; GA, n = 140) and found that the block did not confer tion in pain scores within the first 24 postoperative hours.
any benefit in terms of postoperative opioid consumption Similar magnitudes were identified in the breast versus tho-
and pain scores. racic surgery and superficial versus deep serratus injection
subgroup analyses. The serratus anterior plane block also
decreased opioid consumption in the first 24 postoperative
Interpectoral-Pectoserratus Plane Block hours, prolonged time to first analgesia, and reduced rates of
PONV and pruritus. Compared to the paravertebral block,
The interpectoral-pectoserratus plane block is most com- there was no difference in pain scores at all time points
monly used as one component of a multimodal analgesia except for the immediate postoperative period where serratus
in oncological breast surgery. For this indication, multiple anterior plane block pain scores were slightly higher. All
meta-analyses have concluded that the interpectoral-pecto- other outcomes were similar between groups.
serratus plane block significantly improves the quality of One systematic review analyzed the effectiveness of the
analgesia and reduces opioid consumption compared with serratus anterior plane block in cardiothoracic surgery and
systemic analgesia alone and may be used as an alternative trauma. The qualitative summary indicates that the block
to paravertebral block as regional analgesia technique. improves postoperative analgesia compared to systemic
A first group of meta-analyses studied the interpectoral- analgesia alone, particularly within the first 4–6 postopera-
pectoserratus plane block either with systemic analgesia tive hours.
alone or with paravertebral block in patients undergoing
breast cancer surgery in general (mastectomy or lumpec-
tomy with axillary clearance or sentinel node dissection). Suggested Reading
These studies presented similar results: compared to sys-
temic analgesia alone, interpectoral-pectoserratus plane Biswas A, Castanov V, Li Z, Perlas A, Kruisselbrink R, Agur A, et al.
Serratus plane block: a cadaveric study to evaluate optimal injectate
block significantly reduced postoperative pain scores and spread. Reg Anesth Pain Med. 2018;43(8):854–8.
opioid consumption within the first 24 postoperative hours Chong M, Berbenetz N, Kumar K, Lin C. The serratus plane block
and resulted in comparable postoperative pain scores and for postoperative analgesia in breast and thoracic surgery: a
opioid consumption within the first 24 postoperative hours as systematic review and meta-analysis. Reg Anesth Pain Med.
2019;44(12):1066–74.
the paravertebral block. Grape S, El-Boghdadly K, Albrecht E. Analgesic efficacy of PECS
A second group of meta-analyses had a similar objective vs paravertebral blocks after radical mastectomy: a systematic
while focusing only on patients undergoing mastectomy. review, meta-analysis and trial sequential analysis. J Clin Anesth.
These findings were similar to the broader breast cancer sur- 2020a;63:109745.
Grape S, Jaunin E, El-Boghdadly K, Chan V, Albrecht E. Analgesic
gery studies: interpectoral-pectoserratus plane block produced efficacy of PECS and serratus plane blocks after breast surgery: a
improved analgesic outcomes compared to systemic analgesia systematic review, meta-analysis and trial sequential analysis. J Clin
alone and comparable outcomes to the paravertebral block. Anesth. 2020b;63:109744.
Based on this evidence, the 2020 PROSPECT guidelines Hussain N, Brull R, McCartney CJL, Wong P, Kumar N, Essandoh M,
et al. Pectoralis-II myofascial block and analgesia in breast cancer
for oncological breast surgery state, with Grade A, that the surgery: a systematic review and meta-analysis. Anesthesiology.
interpectoral-pectoserratus plane block may be used as an 2019;131(3):630–48.
alternative to paravertebral block as regional analgesia Jack JM, McLellan E, Versyck B, Englesakis MF, Chin KJ. The role of
technique. serratus anterior plane and pectoral nerves blocks in cardiac ­surgery,
thoracic surgery and trauma: a qualitative systematic review.
Other indications for the interpectoral-pectoserratus plane Anaesthesia. 2020;75(10):1372–85.
block include implantation of cardiac devices, thoracotomy, Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F. PROSPECT
sternotomy, transcatheter cardiac procedures, minimally working group collaborators#. PROSPECT guideline for onco-
31 Pectoral and Serratus Plane Blocks 455

logical breast surgery: a systematic review and procedure-specific Versyck B, Groen G, Van Geffen G-J, Houwe PV, Bleys RL. The pecs
postoperative pain management recommendations. Anaesthesia. anesthetic blockade: a correlation between magnetic resonance
2020;75(5):664–73. imaging, ultrasound imaging, reconstructed cross-sectional anat-
Kunigo T, Murouchi T, Yamamoto S, Yamakage M. Spread of injec- omy and cross-sectional histology. Clin Anat. 2019a;32(3):421–9.
tate in ultrasound-guided serratus plane block: a cadaveric study. JA Versyck B, van Geffen G-J, Chin K-J. Analgesic efficacy of the pecs
Clin Rep. 2018;4(1):10. II block: a systematic review and meta-analysis. Anaesthesia.
Lovett-Carter D, Kendall MC, McCormick ZL, Suh EI, Cohen AD, 2019b;74(5):663–73.
Oliveira GSD. Pectoral nerve blocks and postoperative pain out- Zhao J, Han F, Yang Y, Li H, Li Z. Pectoral nerve block in anesthesia for
comes after mastectomy: a meta-analysis of randomized controlled modified radical mastectomy: a meta-analysis based on randomized
trials. Reg Anesth Pain Med. 2019;44(10):923–8. controlled trials. Medicine. 2019;98(18):e15423.
458 N. Cribben and J. McDonnell

Oblique Subcostal TAP Block Deposition of LA in the until two ‘pops’ are appreciated. The first positions the nee-
subcostal TAP region, along the entire costal margin. This is dle in the fascial plane between the external and internal
a dynamic technique requiring considerable skill. oblique muscles, the second in the desired position between
the internal oblique and transversus abdominis muscles.
Lateral TAP Block Block performed in the classic posi- Subsequent studies revealed significant inter-individual
tion, superior to the iliac crest, inferior to the costal margin, variability in the location of the lumbar triangle, which led to
in the region of the midaxillary line. ultrasonography being incorporated to improve the block’s
success rate. The TAP block has been studied extensively since
Posterior TAP Block The authors recommend performing its introduction, leading to widely validated use as part of mul-
the TAP block as posterior as is practicably possible. The timodal analgesia across a variety of surgical disciplines.
injection site for posterior TAP blocks is posterior to the
midaxillary line. As discussed in Carney’s radiological study,
posterior deposition may offer access to the paravertebral Functional Anatomy
space, thus providing additional sympathetic blockade which
may in turn prolong analgesia. A good understanding of the origins of the TA muscle, and
the way it interacts with the nerves of the abdominal wall, is
Bilateral Dual TAP Block Combining subcostal and lateral key to understanding the functional anatomy of this block.
TAP blocks on each side. The TA muscle is a bilateral paired muscle sheet, the
innermost of the abdominal wall muscles. Laterally, the
internal and external oblique muscles lie superficially, whilst
Background medially, the rectus abdominis and pyramidalis muscles
form the corresponding outer layers. In its lateral course, the
The original approach to the TAP block was a landmark-­ TA muscle tapers off along with the internal oblique, back
based technique, using the lumbar triangle of Petit to identify into its origin from the thoracolumbar fascia.
the insertion point (Fig. 32.1). In this method, a needle is Medially, it blends with the aponeuroses of the internal
inserted posterior to the midaxillary line within the triangle, and external oblique muscles to form the rectus sheath. The

Fig. 32.1 Original Teres major muscle

representation of the lumbar Infraspinatus
Serratus anterior fascia
triangle, McDonnell 2007.
muscle
(Illustration produced by
Theresa Sakno, with Rhombold
permission) Lateral cutaneous branch major muscle
from dorsal ramus of T7
Trapezius
muscle

Rectus abdominis muscle

Latissimus dorsi
muscle
External oblique
abdominal muscle
Thoracolumbar
fascia (posterior
layer)
Lateral cutaneous branch
of subcostal nerve
(ventral ramus of T12)
Triangle of Petit

Iliac crest

Lateral cutaneous branch

of illiohypogastric nerve (L1)
Lateral cutaneous branches
from dorsal rami of L1,2,3) Gluteus
maximus
muscle
32 Transversus Abdominis Plane Blocks 459

TA muscle also inserts into the anterior two-thirds of the iliac abdominal procedures in the T6–T9 region, such as open
crest (Fig. 32.2). cholecystectomy or supraumbilical hernia repair, a subcostal
Superiorly, the TA muscle attaches to the 7th–12th costal TAP block is appropriate. Procedures around T9–T12, such
cartilages, as well as the xiphoid process. Inferiorly, the apo- as open appendicectomy, would benefit from coverage with
neurosis of the TA inserts into the pubic crest and pectineal a classic lateral or posterior TAP block, whilst a large mid-
line via the conjoint tendon. line incision can be covered with bilateral dual TAP blocks.
The TA plane offers access to all of the nerves supplying
the anterior and lateral abdominal wall. The innervation is
derived from the anterior primary rami of the lower seven tho- Indications
racic spinal nerves (the thoracoabdominal nerves, T6–T12), as
well as the ilioinguinal and iliohypogastric nerves (L1). Approach Nerves blocked Area supplied
Lateral T10–T12 Infraumbilical anterior
Each of the thoracoabdominal nerves gives off a lateral
abdominal wall
cutaneous branch in the midaxillary line, supplying the lat- Posterior T9–T12, with potential Infraumbilical anterior
eral abdominal wall. The anterior divisions progress medi- paravertebral spread abdominal wall
ally, emerging in the costal margin between the TA and the
IO muscle to travel in the TA plane. The four uppermost of Subcostal T6–T9 Supraumbilical anterior
abdominal wall
these, T6–T9, only enter the TAP medial to the anterior axil-
Oblique T6–L1 Supraumbilical and
lary line. subcostal infraumbilical anterior
The anterior branch of T6 enters just proximal to the linea abdominal wall
alba, with the anterior branch of each subsequent lower nerve Bilateral dual T6–T12 Supraumbilical and
entering the TAP incrementally more lateral. This has impor- TAP block infraumbilical anterior
abdominal wall
tant implications for the pattern of nerve blockade seen at
different injection sites whilst performing TAP blocks.
The lower segmental nerves (T9–L1) give off multiple TAP blocks are currently employed for a wide range of
communicating branches, forming a longitudinal TAP plexus surgical procedures, primarily as part of a multimodal anal-
from which the terminal anterior divisions arise. gesia regimen (Fig. 32.3). Several case reports exist of the
Incorporating this knowledge into a given clinical sce- successful use of TAP blocks as anaesthesia for abdominal
nario allows appropriate TAP block selection. For upper wall procedures, but it must be remembered that this block

Fig. 32.3 Red areas indicate expected block coverage based on

Borglum et al. (2012) results for bilateral dual TAP block. A number of
Fig. 32.2 Muscular layers of the abdominal wall. (With permission common and uncommon surgical incisions are also shown. (With per-
from Dr. Maria Fernanda Rojas) mission from Dr. Maria Fernanda Rojas)
460 N. Cribben and J. McDonnell

will not provide abdominal visceral coverage, no matter the regional anaesthesia needle or Tuohy needle can be used to
technique employed. access the plane.
Additionally, the landmark approach may confer the addi-
General Surgery—laparoscopic surgery, cholecystectomy, tional benefit of a more posterior deposition of local anaes-
umbilical/incisional hernia repair, open appendicectomy, thetic, potentially augmenting and prolonging the analgesic
midline laparotomy procedures. efficacy of this block.
Urology—prostatectomy, nephrectomy.
Obstetrics/Gynaecology—total abdominal hysterectomy, Subcostal TAP Block
caesarean section. This approach offers more reliable coverage of the upper
Chronic Pain—diagnosis of somatosensory chronic abdomi- thoracoabdominal nerves T6–T9 and is suitable for use in
nal pain. procedures where supraumbilical analgesia is desired.
The original technique employed a 100–150-mm nee-
dle, inserted in an inferolateral direction, with a single
Technique injection opening the TAP in the area immediately inferior
and parallel to the costal margin, between the RA and TA
Landmark Approach muscles.
Although this block is now most commonly performed under Injectate spread and resultant block may vary with inser-
US guidance, the authors recognise that this adjunct is not tion site. If the injection is made lateral to the linea semiluna-
always available. There remains a large body of evidence ris (at the lateral border of the RA muscle), the block will
demonstrating the safety and efficacy of the landmark centre around the T10 and T11 dermatomes. However, if the
approach, provided due care is taken to identify the requisite desired area of blockade is T9 and above, the chosen site
landmarks. should be medial to the linea semilunaris, as close as possi-
As mentioned previously, identification of the LIP is ble to the xiphoid process (Fig. 32.5).
maybe more useful than the less specific target of the lumbar For this approach, the US probe can also be used to
triangle. The iliac crest, posterior border of external oblique manipulate the injectate under the RA, moving it in a
and anterior border of latissimus dorsi are identified (palpat- cephalad-­caudad fashion along the linea alba, thus providing
ing the iliac crest in an anteroposterior direction until the an additional rectus sheath block (Fig. 32.6).
border of LD is met is a useful technique here). Needle inser-
tion is at the point where the anterior border of LD meets the
iliac crest (Fig. 32.4).
Two separate losses of resistance are appreciated, the first
being the fascial layer of external oblique, the second being
the fascial layer of internal oblique. Performed correctly, the
needle tip should now be positioned in the TAP. A blunt

Fig. 32.4 Surface landmarks for the original approach. (With permis- Fig. 32.5 Probe positioned immediately inferior to the costal margin
sion form Dr. John McDonnell) on the block side. Contralateral costal margin outlined in red
32 Transversus Abdominis Plane Blocks 461

 blique Subcostal TAP Block

O hydro-dissection of the TAP along the entirety of oblique
The oblique subcostal line runs from the xiphoid process to subcostal line. This can be achieved from a single insertion
the anterior margin of the iliac crest. Deposition of local site (technically challenging), with the potential to site a
anaesthetic along this region has the potential to cover der- catheter in the opened TA plane. Alternatively, this technique
matomes from T6 to L1 within the TAP. This variant of TAP can be performed with dual or multiple insertions (Fig. 32.8).
block is a development on the subcostal approach and These authors do not recommend the use of the original
requires considerable technical skill and sonographic knowl- technique as described. Rather, this approach can be simpli-
edge to successfully execute (Fig. 32.7). fied by first depositing local in the TAP area desired, fol-
This approach requires a longer needle (150 mm) and lowed by the application of pressure from the US probe to
larger volumes of local anaesthetic, to achieve to goal of move the fluid laterally.

Lateral TAP Block

First described by McDonnell in 2007, for this approach, the
probe is placed on the midaxillary line, parallel to the iliac
crest and costal margin, at the midpoint between the two
(Fig. 32.9). This region allows easy identification of the three
muscle layers of the anterolateral abdominal walls
(Fig. 32.10). A 100-mm needle is suitable in most patients.
This approach will reliably block the thoracoabdominal
nerves T10, T11 and T12. Radiological studies have indi-
cated injectate spread is limited to an area from the injection
point in the midaxillary line, as far as the costal margin,
with posterior spread minimal compared to the original
landmark technique. T9 and above will not typically be
blocked, as they enter the TAP medial to the anterior axil-
lary line.
Fig. 32.6 Target area in yellow, lateral to the border of the rectus
abdominis muscle Posterior TAP Block
To overcome the limited spread of the lateral approach, the
authors recommend moving the probe posteriorly until qua-
dratus lumborum is seen and choosing an injection site as
posterior as possible (Fig. 32.11). Views of QL offer a degree
of assurance over the location of your injectate and the
potential for paravertebral access.

 ilateral Dual TAP Block

B
Where analgesia for the entire abdominal wall is required
(e.g. a large laparotomy incision), a bilateral dual TAP block
is an appropriate choice. This will involve four separate
injections, encompassing the lateral/posterior and subcostal
approaches on each side.
The theoretical benefits of this approach add the blockade
of the upper thoracoabdominal dermatomes produced by a
medial subcostal TAP, to the consistent blockade of the T10–
T12 dermatomes produced by the lateral TAP, to achieve a
total coverage of T6–T12.
However, available studies show this approach will reli-
ably block up to the T8 dermatomes, but not T6/T7 in most
cases. Injectate spread is also limited to an area between the
anterior and the midaxillary line, so lateral cutaneous
Fig. 32.7 Dynamic US probe positions, with likely subsequent views
branches will also be spared. Again, the focus should be on
shown below. Note this is subject to significant variability in different posterior placement of the lateral TAP blocks, in order to
individuals. (With permission from Dr. Maria Fernanda Rojas) achieve potential paravertebral spread.
462 N. Cribben and J. McDonnell

a b

c d

Fig. 32.8 Expected US images, with target areas for deposition of local anaesthetic highlighted in yellow. (L lateral, M medial)

Fig. 32.10 Injectate site for classic lateral TAP block. (Figures 5, 6, 8,
Fig. 32.9 Probe positioned in the midaxillary line for the lateral 9, 10 with permission from Dr. Niall Cribben)
approach. Move the probe posteriorly until QL is viewed for a posterior
TAP block
32 Transversus Abdominis Plane Blocks 463

Evidence for the use of adjuncts is mixed. A study by

Singh and colleagues in 2016 suggested the addition of
clonidine improves duration of analgesia in patients under-
going caesarean section, but other trials have failed to dem-
onstrate similar results. Other studies showed lower pain
scores in patients receiving dexmedetomidine as an additive.
A recent systematic review of the addition of dexamethasone
to TAP blocks in abdominal surgery also demonstrated
efficacy.
The authors currently make no recommendation on the
routine use of adjuncts and advise consideration on a case-­
by-­case basis.

Fig. 32.11 Image from Carney, McDonnell et al. 2011 study on injec-
Procedure and Equipment
tate spread within the TAP for a posterior TAP block. View of QL with All procedures should be conducted with usual standards of
posterior probe placement. (With permission from Dr. John McDonnell) monitoring, emergency drugs available and assistance where
required. Sterile gloves, drapes, aseptic technique and probe
cover as standard.
Continuous Techniques The authors recommend supine positioning, which can be
A major limitation of TAP blocks to date has been the dura- augmented by placing a wedge (or a 1-L bag of IV fluid)
tion of analgesia provided by the block. Current evidence under the patient’s hip on the side to be blocked. This allows
indicates reductions in pain scores and opioid consumption more posterior access.
for up to 24–48 h. However, when investigated by first For most patients, a 21-G, 50–100-mm short-bevelled
request for analgesia or offset of sensory block, TAP blocks needle will suffice. If performing a subcostal oblique
are effective on average for 6–10 h. approach, a longer needle (150 mm or more) may be required.
Catheter techniques have been employed to overcome this
but come with several practical difficulties. When sited preop-
eratively, there is the potential for disruption of the surgical Complications
field. Sited post-operatively, the procedure may become more
technically challenging owing to the placement of dressings Reports exist in the literature of abdominal visceral damage
and the disruption of the muscle layers by the surgeons. from TAP block insertion, including liver and spleen punc-
Furthermore, larger midline incisions will require the insertion ture (especially in the setting of hepatosplenomegaly), bowel
and management of four separate catheters. Evidence for using and flank haematomas and renal injury.
continuous infusions vs. intermittent boluses is also lacking. Accidental intravascular injection and plasma concentra-
tions suggesting LAST have been reported. Cases of acci-
Drugs and Dosing dental co-administration of LA by anaesthetists (to the TAP)
The long-acting local anaesthetics ropivacaine (2.5–3.5 mg/ and surgeons (to the wound) have also occurred as a result of
kg) and bupivacaine/levobupivacaine (12 mg/kg) are the suboptimal communication. Overall, complication rates
most commonly employed for TAP blocks. Available evi- from TAP blocks are very low, and it is generally considered
dence suggests volume rather than dose is the main determi- a safe and effective technique.
nant of efficacy, as injectate spread is crucial. Even so, there
appears to be little benefit of using volumes of local anaes-
thesia exceeding 15–20 mL per block. Tips to Improve Block Success
Volumes should take into account maximum dose recom-
mendations, and these in turn should be adjusted to lean • Access to the area posterior to the midaxillary line allows
body weight. In summary, in adult populations, the authors avoidance of a common pitfall in TAP block performance,
recommend 15–20 mL of 0.25–0.375% ropivacaine or depositing LA too anteriorly. Placing a fluid bag (1–3 L
15–20 mL of 0.25% bupivacaine/levobupivacaine per side, depending on the size of the patient) under the hip on the
with epinephrine added to reduce peak plasma concentra- block side offers easier access to the posterior structures.
tions. Paediatric data is limited. • Hydro-dissection is a useful technique prior to the deposi-
Liposomal bupivacaine offers a novel potential solution to tion of the full LA dose. Saline (or 1% lidocaine with epi-
the time-limited nature of single-shot TAP blocks, but fur- nephrine) may be used to open the TAP initially, improving
ther studies are required. success when the full volume is sited.
464 N. Cribben and J. McDonnell

• As has been emphasised throughout this chapter, poste- reduction in pain scores and opioid use, with benefits seen at
rior is better. Anterior TAP injections are easier to visual- up to 48 h. For laparoscopic approaches, TAP blocks have
ise and perform and are a tempting endeavour (especially consistently shown to be beneficial in reducing pain scores
when first learning this block). However, for better results, and opioid consumption, in many cases also allowing earlier
it is best to aim posterior and for the potential benefits of mobilisation and return of bowel function. A recent system-
paravertebral spread. atic review comparing thoracic epidural to TAP blocks in
laparoscopic colorectal surgery showed equivalent analgesia
between the groups but shorter time to ambulation and pass-
Literature Review ing flatus in the TAP group. As such, TAP blocks can be con-
sidered a safe and effective additive to enhanced recovery
The TAP block has been well studied since its introduction, programmes after colorectal surgery.
and a large body of evidence now exists to support its use in Open appendicectomy is amongst the procedures most
a variety of settings. amenable to successful TAP block. Typical incisions cross
the T11/T12 dermatomes, which are reliably covered by the
lateral approach. The evidence for employing TAP blocks in
Upper Abdominal Surgery laparoscopic appendicectomy is equivocal at best, possibly
owing to a larger contribution to the pain score from visceral
TAP blocks have been compared with thoracic epidurals for elements. In similar fashion to use in laparoscopic cholecys-
post-operative analgesia in several studies (including cathe- tectomy, when combined with multimodal analgesia and
ter techniques). Results indicate the TAP block is a useful port-site infiltration with local anaesthetic, there appears to
alternative where thoracic epidural insertion proves difficult be little additive benefit to a TAP block.
or contraindications exist. TAP blocks are associated with For inguinal hernia repair, the evidence is surprisingly
fewer complications in this setting, most notably hypoten- conflicting. Despite an operative site seemingly suited to the
sion. Upper abdominal surgery is associated with significant TAP block, the literature suggests benefit for the early post-­
visceral pain, in which TAP blocks will not cover. The nature operative period but not beyond. Compared with ilioinguinal
of the incisions for upper GI procedures can make TAP block and iliohypogastric blocks, the TAP approach is likely not
insertion challenging, and thoracic epidural is more likely to inferior, but again the benefits are limited to the first 24 h at
provide superior analgesia. best. A recent systematic review concluded these approaches
In the setting of laparoscopic cholecystectomy, evidence lead to similar opioid consumption, with a similar complica-
for the routine use of TAP blocks is limited. Pain control tion rate.
regimens for this procedure, incorporating multimodal anal-
gesia and port-site infiltration with local anaesthetic, have
rendered the benefit of additive TAP blocks questionable. Gynaecological Surgery
TAP blocks have recently been studied in the setting of
bariatric surgery. One systematic review indicates TAP Two recent systematic reviews concluded that TAP blocks
blocks are an effective additive to multimodal analgesia, provide early benefit in terms of pain scores and opioid con-
contributing to lower pain scores and lower opioid consump- sumption in patients undergoing total abdominal hysterec-
tion. Another recent review in this cohort revealed less post-­ tomy. However, there was marked heterogeneity in the
operative nausea and vomiting, earlier ambulation, but studies included. Many individual RCTs examining TAP
similar pain scores in the TAP group. Overall, there is low to blocks in the TAH have marked limitations. The evidence for
moderate evidence for the use of TAP blocks in bariatric use in laparoscopic approaches is lacking. As with laparo-
surgery. scopic approaches for other surgical disciplines, there
A recent systematic review and meta-analysis (limited to appears to be a marginal benefit when combined with multi-
two RCTs) concluded that TAP blocks have a role in reduc- modal analgesia and local infiltration.
ing opioid requirements in the 24-h period following liver
transplant.
Obstetric Surgery

Lower Abdominal Surgery For the obstetric population, there appears to be several dis-
tinct circumstances under which TAP blocks are beneficial.
The efficacy of TAP blocks in open and laparoscopic colorec- With most caesarean sections performed under subarachnoid
tal surgery has been well demonstrated. A high-quality early block, intrathecal morphine has become the gold standard
trial involving open procedures showed a significant for analgesia in the immediate 24 h after delivery. In this
32 Transversus Abdominis Plane Blocks 465

setting, the addition of a TAP block does not appear to confer meta-­ analysis. J Minim Invasive Gynecol. 2019;26(1):40–52.
Epub 2018 Apr 30. PMID: 29723644. https://doi.org/10.1016/j.
any benefit. jmig.2018.04.020.
For patients not receiving intrathecal morphine, early Baeriswyl M, Kirkham KR, Kern C, Albrecht E. The analgesic efficacy
benefits in pain scores and opioid consumption have been of ultrasound-guided transversus abdominis plane block in adult
demonstrated, as well as a consequential decrease in the inci- patients: a meta-analysis. Anesth Analg. 2015;121:1640–54.
Baeriswyl M, Zeiter F, Piubellini D, Kirkham KR, Albrecht
dence of PONV. Benefits appear to be limited to the early E. The analgesic efficacy of transverse abdominis plane block
post-operative period, and a recent systematic review con- versus epidural analgesia: a systematic review with meta-
cluded wound infiltration is close to equivalent. There may analysis. Medicine (Baltimore). 2018;97(26):e11261. PMID:
also be a role for TAP blocks in rescue analgesia for uncon- 29952997; PMCID: PMC6039642. https://doi.org/10.1097/
MD.0000000000011261.
trolled pain and in settings where opioids or NSAIDs are Børglum J, Maschmann C, Belhage B, Jensen K. Ultrasound-guided
contraindicated. bilateral dual transversus abdominis plane block: a new four-point
approach. Acta Anaesthesiol Scand. 2011;55:658–63.
Børglum J, Jensen K, Christensen AF, et al. Distribution patterns, der-
matomal anesthesia, and ropivacaine serum concentrations after
Urological Procedures bilateral dual transversus abdominis plane block. Reg Anesth Pain
Med. 2012;37:294–301.
TAP blocks have been studied in the setting of renal trans- Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling TM. Transversus
plantation, with little apparent benefit to routine use. Pain abdominal plane block for postoperative analgesia: a system-
atic review and meta-analysis of randomized-controlled trials.
control in the study groups was sufficient without the addi- Can J Anaesth. 2016;63(10):1184–96. Epub 2016 Jun 15. PMID:
tion of TAP blocks even in the setting of NSAID avoidance. 27307177. https://doi.org/10.1007/s12630-­016-­0679-­x.
The same can be applied to open radical prostatectomy Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The trans-
patients. Whilst there is evidence for an initial reduction in versus abdominis plane block provides effective postoperative anal-
gesia in patients undergoing total abdominal hysterectomy. Anesth
opioid use, when compared to optimal multimodal analgesia Analg. 2008;107(6):2056–60.
with wound infiltration, TAP blocks do not offer additional Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell
benefits. JG. Studies on the spread of local anaesthetic solu-
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2011;66(11):1023–30. Epub 2011 Aug 18. https://doi.
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Conclusions Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative trans-
versus abdominis plane (TAP) blocks for analgesia after abdomi-
There is now a large body of evidence studying TAP blocks, nal surgery. Cochrane Database Syst Rev. 2010;(12):CD007705.
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recommend considering TAP blocks for open procedures pub2.
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vant settings where the standard intervention is contraindi- understanding: abdominal wall blocks. Reg Anaesth Pain Med.
2017;42:133–83.
cated (i.e. as an alternative to thoracic epidural or intrathecal Favuzza J, Delaney CP. Outcomes of discharge after elective
morphine), or as a rescue technique for escalating pain laparoscopic colorectal surgery with transversus abdominis
scores. It is important to bear in mind benefits appear to be plane blocks and enhanced recovery pathway. J Am Coll Surg.
limited in laparoscopic surgery and will likely not extend 2013;217:503–6.
Ganapathy S, Sondekoppam RV, Terlecki M, et al. Comparison of
beyond the initial 24-h period post-operatively in most cases. efficacy and safety of lateral-to-medial continuous transversus
This may be improved by a more posterior deposition of abdominis plane block with thoracic epidural analgesia in patients
local anaesthetic, potentially tracking retrograde into the undergoing abdominal surgery: a randomised, open-label feasibility
paravertebral spaces. study. Eur J Anaesthesiol. 2015;32:797–804.
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Aveline C, Le Hetet H, Le Roux A, et al. Comparison between Gulyam KSM, Mukhtar K, Singh SK. A randomised controlled trial
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ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal transplantation. Anaesthesia. 2014;69:1222–6.
hernia repair. Br J Anaesth. 2011;106:380–6. Hamid HKS, Marc-Hernández A, Saber AA. Transversus abdominis
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Jankovic ZB, Pollard SG, Nachiappan MM. Continuous transversus Petersen PL, Stjernholm P, Kristiansen VB, et al. The beneficial effect
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Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, Astley B, Pollard Røjskjaer JO, Gade E, Kiel LB, et al. Analgesic effect of ultrasound-­
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468 J. Børglum et al.

injected very close to the antero-lateral part of the QL mus- The muscles of the torso are embryologically divided
cle. The mode of injection and execution did bear much into the hypaxial and epaxial muscle compartments. The
resemblance to the fascia transversalis plane block technique epaxial (or paraspinal) muscles are the components of the
described by Dr. Hebbard previously in 2009. As it were, the erector spinae muscles. In the lumbar region that is the
first QL block (QL I) was abandoned by Blanco et al. in favor iliocostalis lumborum, the longissimus lumborum, and the
of a new QL block called QL II. spinalis dorsi muscles. The hypaxial muscles in the lumbar
The USG transmuscular QL (TQL) block was first region include the QL and PM muscles, and these are in
described in 2013. The idea of the TQL block never had the fact the posterior aspect of the abdominal wall. The dis-
intention that the injected LA would spread into the tinction is relevant due to the difference in nomenclature,
TAP. Rather, the TQL block had, from the beginning, the but also because the related fasciae have different proper-
premise that if the injectate was deposited in the facial inter- ties. The transversalis fascia covers the deep side of all of
space between the QL and psoas major (PM) muscles (at the the abdominal wall (hypaxial) muscles, i.e., rectus abdom-
level of L3–L4), and posterior to the transversalis fascia, inis, transversus abdominis, as well as the QL and PM
then the injectate would spread cephalad in the plane between muscles.
the two muscles to reach the diaphragmatic openings and Various anatomists disagree on the issue of layers from
spread beyond further cranially into the thoracic paraverte- the thoracolumbar fascia (TLF). When describing the TLF
bral space to anesthetize the ventral rami of the segmental as a 2-layer structure, the anterior part is what elsewhere
nerves and the sympathetic thoracic trunk. This theory was (3-layer structure) is known as the middle part. Since the
first documented in a cadaveric study by Dam et al. transversalis fascia is a marked structure of its own, and the
embryologic origin of the two muscle compartments is
apart, many anatomists advocate a 2-layer model of the
Block Indications TLF. The posterior layer encapsulates the paraspinal mus-
cles, i.e., the erector spinae muscles. The anterior part of the
Unilateral: Unilateral herniotomy, percutaneous nephroli- TLF is attached to the transverse processes of the lumbar
thotomy, open appendicectomy, and as a rescue block in the vertebrae, where it forms the intramuscular septum and a
Post Anesthesia Care Unit (PACU). clear division between the two muscle compartments. Thus,
Bilateral: Laparoscopic procedures (nephrectomy, hemi- the anterior part of the TLF separates the paraspinal/epaxial
nephrectomy, hemicolectomy, hysterectomy, cholecystec- muscles from the hypaxial muscles in the posterior aspect of
tomy), cesarean section, mini-laparotomy, and as rescue the abdominal wall, which consists of the QL and PM
blocks in the PACU. muscles.
The discovery of a pathway from the lumbar into the tho-
racic paravertebral region is not new. Injectate flow through
Anatomy the pathway has previously been described from a thoracic
starting point, and understanding the pathway is crucial for
The quadratus lumborum muscle is a paired muscle of the accepting the pattern of injectate spread associated with the
left and right posterior abdominal wall. Each of the two mus- TQL block. The transversalis fascia covers the QL and PM
cles is irregular and quadrilateral in shape. The QL muscles muscles (anteriorly) below the diaphragm. At the level of the
derive from the wings of the ilium, where they originate from diaphragmatic openings, the transversalis fascia splits into
the iliolumbar ligaments and the internal lips of the iliac an anterior layer covering the abdominal (deep) side of the
crests. The QL muscle insertions are on the transverse pro- diaphragm, and a posterior layer that covers the most cepha-
cesses of the upper four lumbar vertebrae and additionally at lad parts of the QL and PM muscles, as they insert (QL) or
the lower posterior borders of the twelfth rib. The innerva- originate (PM) within the thoracic cage. At this level, the
tion of the QL muscles is with branches of the ventral rami transversalis fascia becomes continuous with the endotho-
of T12 to L4. The psoas major (PM) muscle lies adjacent and racic fascia. Thus, any injected volume of LA deposited
antero-medial to the QL muscle. The PM is innervated by below the diaphragm, posterior to the transversalis fascia,
direct branches of the anterior rami of the lumbar plexus at and in the fascial interspace between the QL and PM mus-
the levels of L1–L3. The superficial part of the PM muscle cles, could potentially spread cephalad and enter into the
originates from the lateral surfaces of the last (T12) thoracic thoracic paravertebral space, i.e., with the injectate now pos-
vertebra, the lumbar vertebrae (L1–L4), and from the neigh- terior to the endothoracic fascia.
boring intervertebral discs. Thus, the QL and PM muscles Why not inject directly into the (lower) thoracic para-
either insert or originate within the thoracic cage. vertebral space? The benefits of a direct thoracic paraver-
33 Quadratus Lumborum Block 469

tebral block are evidently (potentially) many. There are to get the optimal sonographic image of all relevant anatomi-
several techniques described. However, since a direct USG cal structures.
thoracic paravertebral block is by many physicians consid-
ered to be a rather advanced block and to be associated
with the potential—maybe perceived—risk of pneumotho- Block Techniques
rax due to its close proximity to the pleura, an indirect way
of reaching the thoracic paravertebral space is widely The QL I Block/The Lateral QL Block Approach
searched and research in this area has increased rapidly the
last years. With the patient in a supine position a high frequency linear
transducer is placed in a transverse position in the mid-­
axillary line at the lateral border of the anterior abdominal
Block Nomenclature wall. The transducer is then moved posteriorly until the
transversus abdominis and internal oblique aponeurosis are
During the last decade, there has been a fluctuating nomen- visualized. With a needle trajectory guided by ultrasound in
clature relative to the various QL block techniques. A sug- an anterior to posterior direction, the point of injectate is at
gestion for a common nomenclature was put forward by the antero-lateral border of the quadratus lumborum muscle,
Elsharkawy et al. in 2019. These suggestions have now been superficial to the transversalis fascia and deep to the trans-
broadly accepted with international consensus, and this has versus abdominis and internal oblique aponeurosis
resulted in a novel manuscript which has been accepted for (Figs. 33.1 and 33.2).
publication in Regional Anesthesia and Pain Medicine with
the initial title “Standardizing nomenclature in regional
anesthesia: An ASRA-ESRA Delphi consensus study of  he QL2 Block/The Posterior QL Block
T
abdominal wall, paraspinal and chest wall blocks.” This Approach
means that the QL I and QL II blocks are now called the
lateral and posterior QL blocks, respectively (Figs. 33.1 and Same position for the patient and the same transducer as
33.2). The transmuscular QL block is now called the anterior described for the QL I block, but the point of injection is pos-
QL block (Figs. 33.1 and 33.2). It is important to realize that tero-lateral to the QL muscle, deep to the latissimus dorsi
the anatomy is changing relative to which level you are able muscle and superficial to the QL muscle (Figs. 33.1 and 33.2).

Fig. 33.1 Quadratus

lumborum blocks at the level
of L3. EO external oblique
muscle, IO internal oblique
muscle, TA transversus
abdominis muscle, LD
latissimus dorsi muscle, QL
quadratus lumborum muscle,
PM psoas major muscle, ES
erector spinae muscles, L3
vertebral body of L3. White
dotted line depicts relevant
parts of the transversalis
fascia. Red arrows indicate
the posterior renal fascia
(Gerota’s fascia). White
arrows; needle trajectory with
injections for the lateral QL
block (number 1, blue circle),
the posterior QL block
(number 2, green circle), and
the anterior QL block
(number 3, red circle)
470 J. Børglum et al.

Fig. 33.2 Quadratus

lumborum blocks at the level
of L4. EO external oblique
muscle, IO internal oblique
muscle, TA transversus
abdominis muscle, LD
latissimus dorsi muscle, QL
quadratus lumborum muscle,
PM psoas major muscle, ES
erector spinae muscles, L3
vertebral body of L3. White
dotted line depicts relevant
parts of the transversalis
fascia. Red arrows indicate
the posterior renal fascia
(Gerota’s fascia). White
arrows; needle trajectory with
injections for the lateral QL
block (number 1, blue circle),
the posterior QL block
(number 2, green circle), and
the anterior QL block
(number 3, red circle)

 he Transmuscular QL Block/The Anterior QL

T
Block Approach

The patient is placed in the lateral decubitus position. A

low frequency curved array transducer is placed in the
transverse position between the iliac crest and costal rim in
the posterior axillary line. The transducer is then adjusted
to visualize the Shamrock sign (the transverse process of
L4, QL muscle, PM muscle, and erector spinae muscles).
The needle is advanced in a posterior to anterior direction
passing through the QL muscle. The point of injection is in
the fascial interspace between the QL and PM muscles,
posterior to the transversalis fascia (Figs. 33.1, 33.2, and
33.3).
Fig. 33.3 Stepwise approach to the transmuscular quadratus lumbo-
rum block. Model photo. EO external oblique muscle, IO internal
 lock Complications (All QL Block
B oblique muscle, TA transversus abdominis muscle, LD latissimus dorsi
muscle, TLF thoracolumbar fascia, QL quadratus lumborum muscle,
Approaches) PM psoas major muscle, ES erector spinae muscles, TP transverse pro-
cess of L4, L4 vertebral body of L4. Yellow dotted line depicts relevant
Local systemic toxicity, vascular injection, injection of LA parts of the transversalis fascia. Red arrows indicate the posterior renal
into the peritoneal cavity, lower limb weakness (if accidental fascia (Gerota’s fascia). Green arrow; needle trajectory with injection in
the fascial interspace between the QL and PM muscles, posterior to the
piercing of the psoas muscle), Horner’s syndrome (case rap-
transversalis fascia
port), and block failure.

1. Identification of the antero-lateral abdominal wall mus-

Practical Tips cles, i.e., transversus abdominis, internal and external
oblique muscles. Notice the aponeurosis of the transver-
The transmuscular QL block is by many considered to be an sus abdominis and internal oblique muscles, which
advanced block. To improve the block success rate we rec- merges with the posterior part of the TLF at the postero-­
ommend this stepwise approach (Fig. 33.3): lateral aspect of the QL muscle (Fig. 33.3).
33 Quadratus Lumborum Block 471

2. With real time ultrasound scanning, notice the respiratory transmuscular QL block should not be performed without a
movements of the para- and peri-renal fat compartments. satisfactory visualization of some of the necessary internal
3. Locate the posterior part of the renal fascia (Gerota’s fas- landmarks.
cia), separating the para- and peri-renal fat compartments,
attaching to the hyperechoic antero-lateral part of the
intrinsic fascia of the PM muscle. Often, the para-renal Literature Review
fat compartment can be difficult to distinguish from the
likewise hypoechoic QL muscle, i.e., thus it is important In recent years, the number of randomized studies investigat-
to observe the respiratory movements of the para-renal ing the different QL blocks have increased. However, the
fat, whereas the QL muscle will not move. common denominator of all studies is, they are single-center
4. Observe the bony landmarks of the vertebral bodies studies with inclusion of a rather small number of partici-
(L3/4) and the hypoechoic shape of the transverse pro- pants. No systematic review, where the three QL blocks are
cess, also known as the Shamrock sign. The OL muscle not pooled in the statistical analysis, has been published yet.
attaches to the apex of the transverse process.
5. The needle is advanced from the posterior side of the
curved array transducer. Endpoint for injection is in the The QL1 Block/The Lateral QL Block Approach
fascial interspace (or plane) between the QL and PM
muscles, posterior to the transversalis fascia (Fig. 33.3). Letters and articles by Blanco et al. have stipulated that the
Advancing the needle in a postero-lateral to antero-­ correct point of injection was between the transversus
medial direction through the QL muscle is key in order to abdominis and internal oblique muscle aponeurosis and
avoid piercing the transversalis fascia and to ensure a superficial to the transversalis fascia (Figs. 33.1 and 33.2).
muscular “backstop” for the needle when piercing the Mode of action has not entirely reached consensus. In a
medial intrinsic fascia of the QL muscle. small MRI study by Carney et al., utilizing healthy young
6. After (or during) injection of LA, a subsequent longitudi- volunteers (when the block was still called an USG poste-
nal orientation (Fig. 33.4) of the transducer (turning the rior approach TAP block), no spread of contrast into the
transducer 90° into the sagittal plane) enables visualiza- TAP was found. Rather, contrast was observed to be pooled
tion of intended cranial spread of LA between the QL and between the QL and PM muscles, and a resultant spread to
PM muscles. the thoracic paravertebral space was observed. A later
cadaveric study found spread of dye to the TAP but no
Long lasting immobilization with muscle atrophy, osteo- spread to the thoracic paravertebral space. Using the QL I
porosis, extensive abdominal circumference, anatomical block, clinical studies have found a reduction in pain scores
variations, and air trapped intraabdominally may hinder an and opioid consumption in patients with femoral neck frac-
adequate ultrasound image prior to block execution. The ture (vs. femoral block), in patients undergoing cesarean
section (vs. control), and also for lower abdominal surgery
(vs. TAP block).

 he QL2 Block/The Posterior QL Block

T
Approach

Dr. Blanco et al. later abandoned the QL I block approach in

favor of a more posterior approach (QL II block) (Figs. 33.1
and 33.2). The point of injectate with this technique is
explained to be between the latissimus dorsi and QL muscle.
It is stipulated that MRI (unpublished data and 3-D MRI
reconstructions) show a spread of injectate into the paraver-
tebral space, although a close examination of these 3-D
image reconstructions seems to show rather scarce contrast
spread limited to the lumbar paravertebral area reaching
cephalad to the twelfth rib. Two cadaveric studies also refuted
these findings and showed a variety of spread with dye reach-
Fig. 33.4 Sagittal orientation of the transducer depicts relevant ana-
tomical structures. Model photo. ES erector spinae muscles, QL quadra- ing the subcostal, iliohypogastric, and ilioinguinal nerves
tus lumborum muscle, PM psoas major muscle, IC iliac crest and spread into the TAP (some cadavers) in one study, and in
472 J. Børglum et al.

2a 2b 2c 2d

1a
3a 3b 4a 4b

Fig. 33.5 Posterior paravertebral muscle compartments and adjacent tus posterior inferior (3a), internal (abdominal) oblique (3b). Fourth
muscular structures. First (deepest) muscular layer (orange color); mul- muscular layer (orange color) (4a left); latissimus dorsi muscle. Notice
tifidus muscle (1a). Second muscular layers (orange color) (2a–2d)— the appearance of the internal (abdominal) oblique (orange color)
from medial to lateral; spinalis thoracis (2a), longissimus thoracis (2b), (4a right), deep to the overlying external (abdominal) oblique muscle
iliocostalis thoracis (2c), iliocostalis lumborum (2d) muscles. Third (not marked). (The figure is a modified excerpt from Complete
muscular layers (orange color) (3a–3b)—from medial to lateral; serra- Anatomy, with permission from 3D4Medical (www.3d4medical.com))

the other study spread of dye reaching into the TAP, subcuta- spread of dye reaching into the thoracic paravertebral space.
neous tissue or muscular spread. Further, spread of dye also reached the subcostal, iliohypo-
From an anatomical point of view, it is quite challenging gastric, and ilioinguinal nerves. Another two cadaveric stud-
to fully elucidate, how spread of LA deep to the latissimus ies could not reproduce these findings, but they were flawed
dorsi muscle would be able to advance cephalad and then to in the block administration technique. Clinical RCTs have
penetrate anterior into the thoracic paravertebral space from found a reduction in opioid consumption and NRS score fol-
this posterior position, i.e., given the massive muscular “bar- lowing percutaneous nephrolithotomy (PNL), elective cesar-
rier” deep to the latissimus dorsi muscle. This is clearly illus- ean section, and laparoscopic nephrectomy. In one RCT, TQL
trated in Fig. 33.5, which depicts the posterior paravertebral block also reduced length of stay in hospital, prolonged time
muscle compartments and adjacent muscular structures. to first opioid, and accelerated early ambulation, whereas
Nevertheless, it is also apparent that clinical studies inves- other trials also showed prolonged time to first opioid.
tigating the QL II block have found a reduction in opioid
consumption and NRS score following cesarean section,
laparoscopic gynecological surgery, laparoscopic colorectal Suggested Reading
surgery, laparoscopic cholecystectomy, and abdominoplasty
to name a few. Adhikary SD, El-Boghdadly K, Nasralah Z, Sarwani N, Nixon AM,
Chin KJ. A radiologic and anatomic assessment of injectate spread
following transmuscular quadratus lumborum block in cadavers.
Anaesthesia. 2017;72:73–9.
 he Transmuscular QL Block/The Anterior QL
T Bjelland TW, Yates TGR, Fagerland MW, Frøyen JK, Lysebråten KR,
Block Approach Spreng UJ. Quadratus lumborum block for postoperative analgesia
after full abdominoplasty: a randomized controlled trial. Scand J
Pain. 2019;19:671–8.
A third approach to perform a QL block was proposed in Blanco R. Tap block under ultrasound guidance: the description of a ‘no
2013. The TQL block stipulates the endpoint of the injected pops’ technique. Reg Anesth Pain Med. 2007;32:130.
LA as being in the fascial interspace between the QL and PM Blanco R, McDonnell JG. Optimal point of injection: the quadratus
lumborum type I and II blocks. 2014. http://www.respond2articles.
muscles, posterior to the transversalis fascia (Fig. 33.1). com/ANA/forums/post1550.aspx. Accessed 28 Nov 2015.
Cadaveric studies—both of them with a transmuscular Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postop-
approach—first by Dam et al. and subsequently later by erative pain after caesarean section: a randomized controlled trial.
Elsharkaway et al. (subcostal approach)—confirmed the Eur J Anaesthesiol. 2015;32:812–8.
33 Quadratus Lumborum Block 473

Blanco R, Ansari T, Riad W, Shetty N. Quadratus Lumborum block ver- Hebbard PD. Transversalis fascia plane block, a novel ultrasound-guided
sus transversus abdominis plane block for postoperative pain after abdominal wall nerve block. Can J Anaesth. 2009;56:618–20.
cesarean delivery: a randomized controlled trial. Reg Anesth Pain Ishio J, Komasawa N, Kido H, Minami T. Evaluation of ultrasound-­
Med. 2016;41:757–62. guided posterior quadratus lumborum block for postoperative
Børglum J, Moriggl B, Jensen K, Lönnqvist PA, Christensen AF, Sauter analgesia after laparoscopic gynecologic surgery. J Clin Anesth.
A, et al. Ultrasound-guided transmuscular quadratus lumborum 2017;41:1–4.
blockade. Br J Anaesth. 2013. http://bja.oxfordjournals.org/forum/ Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar anaesthesia
topic/brjana_el%3b9919. Accessed 15 Jun 2015. and paravertebral spread after low thoracic paravertebral injection.
Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of Br J Anaesth. 2001;87:312–6.
dye and nerve involvement after three different quadratus lumborum Krediet AC, Moayeri N, van Geffen GJ, Bruhn J, Renes S, Bigeleisen
blocks. Br J Anaesth. 2016;117:387–94. PE, et al. Different approaches to ultrasound-guided thoracic
Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell paravertebral block: an illustrated review. Anesthesiology.
JG. Studies on the spread of local anaesthetic solution in transversus 2015;123:459–74.
abdominis plane blocks. Anaesthesia. 2011;66:1023–30. Krohg A, Ullensvang K, Rosseland LA, Langesæter E, Sauter AR. The
Chin KJ. Thoracic wall blocks: from paravertebral to retrolaminar to analgesic effect of ultrasound-guided Quadratus Lumborum block
serratus to erector spinae and back again—a review of evidence. after cesarean delivery: a randomized clinical trial. Anesth Analg.
Best Pract Res Clin Anaesthesiol. 2019;33:67–77. 2018;126:559–65.
Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden Kumar GD, Gnanasekar N, Kurhekar P, Prasad TK. A compara-
J. Essentials of our current understanding: abdominal wall blocks. tive study of transversus abdominis plane block versus Quadratus
Reg Anesth Pain Med. 2017;42:133–83. Lumborum block for postoperative analgesia following lower
Dam M, Moriggl B, Hansen CK, Hoermann R, Bendtsen TF, abdominal surgeries: a prospective double-blinded study. Anesth
Børglum J. The pathway of injectate spread with the transmus- Essays Res. 2018;12:919–23.
cular quadratus lumborum block: a cadaver study. Anesth Analg. McDonnell JG, O’Donnell BD, Farrell T, Gough N, Tuite D, Power C,
2017;125:303–12. et al. Transversus abdominis plane block: a cadaveric and radiologi-
Dam M, Hansen CK, Poulsen TD, Azawi NH, Wolmarans M, Chan V, cal evaluation. Reg Anesth Pain Med. 2007;32:399–404.
et al. Transmuscular quadratus lumborum block for percutaneous Mieszkowski MM, Mayzner-Zawadzka E, Tuyakov B, Mieszkowska
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M, et al. Transmuscular quadratus lumborum block reduces opioid Nielsen MV, Bendtsen TF, Børglum J. Superiority of ultrasound-­
consumption and prolongs time to first opioid demand after laparo- guided shamrock lumbar plexus block. Minerva Anestesiol.
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Elsharkawy H, El-Boghdadly K, Kolli S, Esa WAS, DeGrande S, Ökmen K, Metin Ökmen B, Topal S. Ultrasound-guided posterior qua-
Soliman LM, et al. Injectate spread following anterior sub-costal dratus lumborum block for postoperative pain after laparoscopic
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Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus Lumborum Parras T, Blanco R. Randomised trial comparing the transversus
block: anatomical concepts, mechanisms, and techniques. abdominis plane block posterior approach or quadratus lumbo-
Anesthesiology. 2019;130:322–35. rum block type I with femoral block for postoperative analgesia in
Gallaudet BB. A description of the planes of fascia of the human body: femoral neck fracture, both ultrasound-guided. Rev Esp Anestesiol
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Hansen CK, Dam M, Steingrimsdottir GE, Laier GH, Lebech M, bases for paravertebral anesthetic block: fluid communication
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Hansen C, Dam M, Nielsen MV, Tanggaard KB, Poulsen TD, Bendtsen Zhu M, Qi Y, He H, Lou J, Pei Q, Mei Y. Analgesic effect of the
TF, et al. Transmuscular quadratus lumborum block for total lap- ultrasound-­guided subcostal approach to transmuscular quadratus
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476 J. F. Vargas Silva et al.

Table 34.1 Level selection for erector spinae plane block, according Anatomy and Physiology
to painful condition

Spinal Pain condition The Fascia

level Acute Chronic Volume
High Postsurgical shoulder Chronic shoulder 20– The fascia is composed of soft, collagen-containing, loose,
thoracic pain pain syndrome 30 mL and dense fibrous connective tissues and is ubiquitous in
T2 or CRPS upper
T3 extremity
the whole body. Fascia over a muscle is composed of three
Mid-­ Rib fracture (midpoint Chronic postherpetic 20– layers in the human body: superficial, more dense deep
thoracic of the level of rib neuralgia (level of 30 mL fascia, and muscle-related layers (epimysium, perimy-
T4 to T6 fracture) segment involved) sium, and endomysium) (Fig. 34.1). The deep fascia is
Open thoracotomy and Chronic post-­ composed of multiple layers and is the target for the inter-
VATS lobectomy(T5) thoracotomy pain
(level of segments
facial plane blocks. This fascia is a membrane that extends
involved) throughout the whole body under basal tension where
Rescue after TE failure Metastatic rib cancer numerous muscular expansions attach and transmit the
for thoracic (level of segments tension generated by muscle contraction to the neighbor-
surgery(T5) involved) ing areas. It forms sheaths for the nerves and vessels. The
Cardiac surgery
deep fascia is independent of the underlying muscle, sepa-
sternotomy (T5)
Breast surgery with rated from it by the epimysium and a layer of loose con-
axillary lymph node nective tissue.
dissections (T3) Deep fascial planes are potential spaces transmitting
Low Nephrectomies (T8) Chronic postherpetic 20– forces around the whole body. These fascial planes are a con-
thoracic Hysterectomies (T10) neuralgia (level of 30 mL
tinuum, with multiple potential points of injection in the
T7 to Laparoscopic ventral segment involved)
T12 hernia repair with Chronic abdominal same tissue plane at different craniocaudal anatomical levels.
mesh (T7) pain syndrome (T7 Local anesthetic injected within these potential spaces will
Laparotomies (T7) to T10) spread widely along the path of least resistance. Other fac-
Chronic pelvic pain tors also influence the spread. The movement of the muscle
syndrome (T10)
encourage the spread via a pumping mechanism to the injec-
Lumbar Vertebral surgery Postsurgical hip 20–
(L4) (midpoint of levels replacement pain 30 mL tate. The negative intrathoracic pressure during respiration
involved) management (L4) may also influence the spread (Fig. 34.2). This fascial sheath
has multiple perforations in his anterior wall and is intermit-
tently tethered to bony structures such as the spinous pro-
The ESP block can be used to deliver regional analgesia cesses and transverse processes of the vertebrae, allowing
(with a multimodal analgesic approach) for a wide variety of passage of local anesthesia (Fig. 34.3).
surgical procedures in the anterior, posterior, and lateral tho-
racic and abdominal areas, as well as for management of
acute and chronic pain syndromes (Table 34.1). Also, the The Erector Spinae Muscles
ESP block placed at the most upper thoracic segments (T1–
T2) could provide coverage up to cervical nerve roots giving The architecture of the erector spinae muscle is complex,
analgesia for shoulder pain. with three muscle bellies distributing in the lumbar, thoracic,
Usually, the level chosen for thoracic indications is between and cervical area and surrounded by fascia.
T2 and T5 and for abdominal or pelvic indications is between The thoracolumbar fascia covers the deep muscles of
T7 and T10. Despite its extensive spread, it is recommended to the back and the trunk. Medially, it is attached to the
perform an ESP block at a vertebral level congruent to the spines of the thoracic vertebrae and laterally to the angles
thoracic or abdominal surgical incision, rather than relying on of the ribs. In the lumbar region, the thoracolumbar fas-
adequate spread of the local anesthesia. cia is divided into three layers (posterior, middle, and
anterior) attached at different levels. The posterior layer
is attached to the spines of the lumbar and sacral verte-
Contraindications brae and to the supraspinous ligaments. The middle layer
is attached to the tips of the lumbar transverse processes
Infection at the site of injection in the paraspinal region or and the intertransverse ligaments. The anterior layer cov-
near the puncture site. ers quadratus lumborum and is attached to the anterior
Anticoagulation may be a relative contraindication to surfaces of the lumbar transverse processes behind the
ESP block, although there are no specific guidelines. psoas major. At its caudad portion, it is attached to the
34 The Erector Spinae Plane (ESP) Block 477

Fig. 34.1 Facial connective layers at the erector spinal plane. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

Fig. 34.2 Possible mechanism of in vivo erector spinae plane block, facilitating the spread of the injectate with muscle contraction and negative
intrathoracic pressure during inspiration. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

iliolumbar ligament and the iliac crest. The posterior and Three muscles are in the plane of the ESP block at upper
middle layers unite to form a tough raphe at the lateral thoracic levels. Trapezius is the most superficial (posterior),
margin of erector spinae (the lateral border of quadratus rhomboid major in the middle, and erector spinae anterior
lumborum) and join the anterior layer to form the apo- (deeper). They are identified superficial to the tip of the
neurotic origin of transversus abdominis. hyperechoic transverse processes (Fig. 34.4).
478 J. F. Vargas Silva et al.

Fig. 34.3 Passage of local anesthesia through intermittent perforations in the anterior wall. (Reprinted with permission from Dr. Vicente Roques
from IMEDAR.com)

Fig. 34.4 Muscular anatomy of the back. Note the different muscle planes encountered at different spinal levels when the most superficial muscles
are removed. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

The erector spinae muscles are a complex structure that It originates from the sacrum and the lumbar spinous
forms the paraspinal column, composed of three muscles, processes and extends upward as a gradually tapering col-
iliocostalis, longissimus, and spinalis, and surrounded by umn of muscle in the paravertebral groove on either side of
muscular groups at different levels in the plane of the erector the spinous processes, with insertions on the thoracic and
muscles (Fig. 34.5). They arise from and insert into various cervical vertebrae as high as C2. This muscular column is
bony components of the vertebral column (from spinous pro- encased in a retinaculum (blended aponeuroses and fasciae)
cess to spinous process, rib to rib, and transverse process to that extends from the sacrum to the skull base. In the lower
transverse process). back, this retinaculum is referred to as the thoracolumbar
34 The Erector Spinae Plane (ESP) Block 479

Fig. 34.5 Cross-sectional anatomy of paraspinal muscles. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

fascia. This thoracolumbar fascia, extending from the poste- the ESP block consistently anesthetizes the dorsal ramus
rior thorax and abdomen in continuity with the nuchal fas- (posterior hemi-body analgesia). Regarding the ESP block
cia, facilitates the spread of the injectate or multiple thoracic anterior spread (anterior hemi-body analgesia), the cadaveric
and lumbosacral levels during ESP blocks at lower thoracic data is less homogeneous. In fact, about 50% of cadaveric
levels. studies did not demonstrate paravertebral/intercostal/ or epi-
The target of the ESP block is to place the local anesthetic dural spread, but 50% did. In contrast, imaging studies in live
between the deepest layer (most anterior) of the erector spi- subjects (MRI-CT dye spread studies) found consistent ante-
nae muscle and the tip of the transverse process. This place rior spread (anterior hemi-body analgesia) reaching the tho-
allows cranial-caudal spread in multiple spinal segments racic paravertebral space, the intercostal space, and in some
(Fig. 34.3). The injectate is placed in close relation to the cases also the epidural space. However, the extent of the cra-
intertransverse connective soft tissue, which allows the nial to caudal spread is inconsistent.
spread of the local anesthetic to the paravertebral or epidural It is theorized that the volume (mass) of local anesthetic
space. This multilevel spread blocks the dorsal and ventral that reaches the nerves is small to be seen, but enough to
rami of the thoracic and abdominal spinal nerves allowing a produce analgesia, blocking preferentially unmyelinated C
multi-dermatomal sensory block. This multi-dermatomal fibers over the larger A-δ and A-γ fibers, giving it the charac-
sensory block is thought to be due to the cranial and caudal teristic differential blockade (analgesia without motor
spread of the injected local anesthetic through the thoraco- block). If there is a passage of local anesthetic through the
lumbar fascia, aided by muscle tone and contraction. The paravertebral space with ipsilateral and contralateral (bilat-
cranial to caudal spread in the posterior wall is quite consis- eral) epidural spread, it provides abdominal visceral analge-
tent in the spread study, but the extent in the anterior wall is sia in the lower thoracic levels.
quite variable as shown in multiple cadaver models and lim- The craniocaudal spread has been found variable in both
ited human studies. cadaveric and live subject imaging studies. However, most
ESP block case studies described that 20 mL of local
­anesthetic produces clinical sensory blockade from 4 to 8
Mechanism of Action dermatomes in both anterior and posterior hemi-bodies. The
authors advise performing the block at the level of the surgi-
The mechanism of action has been examined through clini- cal incision to cover two dermatomes up and two derma-
cal and cadaveric studies. There is substantial evidence that tomes down consistently from the injection site when using
480 J. F. Vargas Silva et al.

20 mL and inserting a perineural catheter to prolong dard prep, the use of sterile gloves, surgical cap, mask, and
analgesia. sterile ultrasound probe cover for imaging. Linear probe
At the lumbar level, an ESP block has different consider- (7–12 MHz) is usually sufficient. For high BMI, a curvilin-
ations. The spread is partial to the anterior area of the para- ear (2–6 MHz) is recommended. The typical needle is
vertebral space, surrounding the psoas muscle and lumbar 22-gauge 50–100-mm needle (depending on body habitus).
plexus, leading to blockage of the nerves L2–L5, with differ- When catheter insertion is considered, perineural (catheter
ent patterns of spread depending on volume, and therefore through needle or needle over catheter) or regular epidural
varying anesthetic effects. catheter can be considered.

Technique Procedure

The ESP block can be performed using a single-injection Position the patient in sitting or prone position, depending on
technique or via catheter placement for continuous infusion. the operator and patient’s comfort. A lateral decubitus could
be an alternative when performing the block after general
anesthetic induction or when the patient is unable to tolerate
Preparation sitting or prone position.
The ultrasound probe is placed at the selected level of the
After informed consent and peri-procedural “time-out,” stan- spine using a longitudinal parasagittal approach, approxi-
dard patient monitoring should be placed. Intravenous access mately 3 cm lateral to the spinous process. The level is iden-
should be obtained, and resuscitation equipment, including tified by counting from cephalad to caudad, starting from the
vasopressors and medications for local anesthetic toxicity, first rib and descending caudally to the desired level
should be available. The procedure is performed with stan- (Fig. 34.6). This level is followed medially to identify the

Fig. 34.6 Process for the recognition of the level before the realization of the erector spinae plane block. (Reprinted with permission from Dr.
Vicente Roques from IMEDAR.com)
34 The Erector Spinae Plane (ESP) Block 481

corresponding transverse process. The location could be verse processes, so the optimal plane for injection must be
established using the transverse process counting cephalad within the hyperechoic investing sheath, rather than deep to
from the 12th rib. it. The injection superficial to this fascial layer, inside the
The transverse process requires differentiation from the muscle fibers, produces an erroneous image similar to that
rib at that level. The transverse process will be more superfi- seen with an interfacial injection, known as lamination
cial, wider, and square-shaped, while the rib will be thinner (Fig. 34.10).
and semicircular-shaped (Fig. 34.7a, b). Alternatively, the A total of 20 to 30 mL of local anesthesia is injected in
transverse process can be visualized by a transverse approach 5-mL aliquots through the needle with frequent aspiration to
over the spinous process in the midline, and the lamina, prevent intravascular injection. If a continuous technique is
transverse process, and rib are seen laterally (Fig. 34.8). desired, insert the catheter trough the needle under direct
After all the structures are seen, the probe is rotated in a para- vision 3 to maximum 5 cm beyond the needle tip keeping
sagittal orientation with the tip of the transverse process as always in mind to leave the tip of the catheter at the surgical
the target. indicated level (Fig. 34.11). After the catheter is secured in
The trapezius, rhomboid major, and erector spinae mus- place, a patient-controlled local anesthetic infusion regimen
cles are identified superficial to the tip of the transverse pro- is started with a background infusion of at least 8 mL/h of
cess in the upper/mid-thoracic area (Fig. 34.7b). Following 0.2% ropivacaine and 5 mL bolus with a lockout interval of
skin infiltration with lidocaine, insert the needle using an in-­ 30 to 60 minutes.
plane superior-to-inferior approach to place the tip into the
fascial plane on the deep (anterior) aspect of erector spinae
muscle. The location of the needle tip is confirmed by visible Complications
fluid lifting the erector spinae muscle off the bony shadow of
the transverse process (Fig. 34.9). Any injection deeper to Complications like pneumothorax, spinal cord injury, or spi-
the anterior sheath wall does not permit craniocaudal spread nal hematoma are unlikely as the injection target is away
of local anesthesia beyond that single intertransverse space, from the pleura, major blood vessels, and spinal cord. Local
because of tight junctions between the sheath to the trans- anesthetic toxicity has been reported when performing

Fig. 34.7 (a) Sonographic appearance of the rib. The rib is smaller, square-shaped. The structures in the sonogram are indicated in the
thinner, and semicircular in shape and deepens toward the posterome- schematic diagram. (Reprinted with permission from Dr. Vicente
dial planes. (b) The transverse process is more superficial, wider, and Roques from IMEDAR.com)
482 J. F. Vargas Silva et al.

Fig. 34.7 (continued)

Fig. 34.8 Transverse view of the spine. This approach can help to bet- verse process is identified, the transducer can be rotated 90° in a sagittal
ter characterize the structures and differentiate the transverse process orientation to perform the block. (Reprinted with permission from Dr.
from adjacent structures, such as the lamina and rib. Once the trans- Vicente Roques from IMEDAR.com)
34 The Erector Spinae Plane (ESP) Block 483

Fig. 34.9 Correct location of the injection during the erector plane block. Note the injection between the anterior fascia of the erector muscle and
the intertransverse ligament. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

Fig. 34.10 In a parasagittal approach, lamination mimics an interfa- results in circumferential spread, which is less likely to be confused
cial spread, but the injectate is inside the muscle and needs needle repo- with interfacial spread, but need needle repositioning. (Reprinted with
sitioning. With a transverse approach, the needle placed intramuscularly permission from Dr. Vicente Roques from IMEDAR.com)
484 J. F. Vargas Silva et al.

Fig. 34.11 Catheter in place of the erector spine plane. (Reprinted with permission from Dr. Vicente Roques from IMEDAR.com)

ESPB, and precaution must be taken as any other interfacial The authors advise repositioning the needle to a less steep
block using large volumes to avoid local anesthetic toxicity. angle and hydrodissection using a non-active solution to
It is advised to use lower doses than maximum recommended assure the correct spread before injection of local
and add epinephrine 2.5–5.0 μg/mL to the local anesthetic as anesthetic.
an intravascular marker and reduce the plasmatic concentra- ESP block in pediatric patients is feasible, with volumes
tion of the local anesthetic. from 0.2 cc to 0.4 cc per kg. The clinician should avoid
So far 65 RCTs have been published reporting no compli- exceeding the maximum recommended dose of local
cations linked to the ESP block although more investigations anesthesia.
are needed to reinforce the safety and complications rates of There is no evidence that the needle orientation impacts
the ESP block. the clinical outcome. It can be performed either from cranial
to caudal or vice versa.
Although there is extensive craniocaudal spread with
Clinical Pearls multiple dermatomes involved, it is recommended to target
the tip of the needle or catheter to the most painful or surgi-
Intramuscular injection should be avoided. The injectate cal incisional dermatome.
spread must be in the interfacial plane between two distinct Consider bilateral blocks for incisions crossing the mid-
hyperechoic layers, the most anterior layer of the erector spi- line. Use with extreme caution in high thoracic ESP blocks
nae muscles (ESM) and the transverse process, rather than due to the potential risk of hypotension or bilateral phrenic
purely in the erector spine muscle. nerve palsy.
The transverse process can be used as a target for ease and ESP block becomes an attractive alternative in anticoagu-
safety of the procedure. However, the endpoint that should lated patients, due to its extra-axial position without invasion
always be sought is a clear linear spread lifting the ESM of the neuraxis. However, other bleeding complications can
from the transverse process in both cranial and caudal direc- ensue. Studies are required to evaluate safety in anticoagu-
tions from the needle tip. lated patients.
The ESP block target is the transverse process. The needle
must avoid piercing the intertransverse ligament or deeper
structures. Keeping the needle between the most anterior Literature Reviews
hyperechoic layer of the ESM and the hyperechoic trans-
verse process will assure the ESP block spread target lifting Since the publication of the first report in 2016, a growing
the ESM from the transverse process in several segments evidence of ESP block developed, starting with case reports
after a single injection. Sometimes, despite being in contact and anecdotal experience, followed by several RCTs that led
with the transverse process, there is intramuscular injection to the possibility of systematic reviews. To date, there are 65
into the erector muscle (lamination) and requires reposition- RCTs and 8 systematic reviews in different clinical scenar-
ing of the needle. ios, showing the versatility of the ESP block.
34 The Erector Spinae Plane (ESP) Block 485

The efficacy of ESP block in breast surgery had been and analgesic drug consumption, without operation-­related
examined in four systematic reviews. The most recent two adverse events. With the small number of RCT, the authors
systematic reviews by Leong et al. and Hussain et al. covered concluded that the effectiveness and safety of ESP block for
13 and 12 RCTs, respectively, and conveyed a number of lumbar spine surgery are still controversial because the evi-
important messages. dence is insufficient. However, there are three more RCTs
First, compared with no block, the literature consistently published since this review, all demonstrating the analgesic
supported the superior analgesic efficacy of ESP block with efficacy of ESPB for lumbar spine surgery vs. no blocks.
decrease in pain scores and opioid consumption in the first In conclusion, there is moderate quality evidence that
postoperative 24 h. erector spinae plane block is an effective strategy to improve
Second, the clinical implication of the difference had postsurgical analgesia in adults in different surgical models.
been under scrutiny. For instance, the review by Hussain This conclusion needs to be interpreted with caution due to
et al. showed that the mean differences in pain score (0–10) insufficient evidence. It will need large-scale RCTs to con-
were −1.17, −1.17, −0.85, and −0.72 in recovery room and firm this statement.
at 6-h, 12-h, and 24-h time points, respectively. The reduc-
tion in oral morphine equivalent consumption is 17.6 mg.
The reduction in pain intensity represented 34–42% over the
first 24-h postoperative period. Another review by Leong Suggested Reading
et al. represented with similar result. Hussian’s group sug-
Aponte A, Sala-Blanch X, Prats-Galino A, Masdeu J, Moreno LA,
gested a minimal reduction of 2 points in pain score as clini- Sermeus LA. Anatomical evaluation of the extent of spread in
cally meaningful. However, the mean pain scores of the the erector spinae plane block: a cadaveric study. Can J Anesth.
control group were less than 3 in all time points in the first 2019;66(8):886–93.
Barrios A, Camelo J, Gomez J, Forero M, Peng PWH, Visbal K,
24-h period.
Cadavid A. Evaluation of sensory mapping of erector spinae plane
Third, paravertebral used to be the standard regional anes- block. Pain Physician. 2020;23:E289–95.
thesia for breast surgery. The popularity faded with the Cai Q, Liu GQ, Huang LS, Yang ZX, Gao ML, Jing R, Liu Z, Pan
advent of the newer interfascial plane block: pectoral nerve LH. Effects of erector spinae plane block on postoperative pain
and side-effects in adult patients underwent surgery: a systematic
block and ESP block. Review of paravertebral block in breast
review and meta-analysis of randomized controlled trials. Int J Surg.
surgery by Schnabel et al. in 2020 showed an impressive 2020;80:107–16.
reduction in pain intensity: approximately 2.0–2.5 reduction Chin KJ, Adhikary S, Forero M. Is the erector spinae plane (ESP) block
in pain score when the control group pain score ranged a sheath block? A reply. Anaesthesia. 2017;72(7):916–7.
Chin KJ, Adhikary SD, Forero M. Understanding ESP and fascial
between 4.0 and 7.0; but all studies were conducted at least
plane blocks: a challenge to omniscience. Reg Anesth Pain Med.
14 years ago. Hussain’s review showed that all the mean pain 2018;43(7):807–8.
scores in the control group (the group with no regional anes- Cornish PB. Erector spinae plane block: the “happily accidental” para-
thesia block) were less than 3. Comparative studies between vertebral block. Reg Anesth Pain Med. 2018;43(6):644–5.
Daghmouri MA, Akremi S, Chaouch MA, Mesbahi M, Amouri N,
ESP block and paravertebral block did not find any differ-
Jaoua H, Ben Fadhel K. Bilateral erector spinae plane block for
ence in opioid consumption but the presence of four cases of postoperative analgesia in laparoscopic cholecystectomy: a system-
pneumothorax in paravertebral group (none in ESP block atic review and meta-analysis of randomized controlled trials. Pain
group). The choice of regional anesthesia is a balance Pract. 2020;21(3):357–65.
De Cassai A, Andreatta G, Bonvicini D, Boscolo A, Munari M, Navalesi
between the risk and benefit.
P. Injectate spread in ESP block: a review of anatomical investiga-
For analgesia in laparoscopic cholecystectomy, tions. J Clin Anesth. 2020;61:109669.
Daghmouri performed a systematic review and meta-­analysis ElHawary H, Abdelhamid K, Meng F, Janis JE. Erector spinae plane
with five RCTs analyzed. Bilateral ESP block showed a block decreases pain and opioid consumption in breast surgery: sys-
tematic review. Plast Reconstr Surg Glob Open. 2019;7(11):e2525.
lower postoperative pain score, a significant reduction of
Elsharkawy H, Pawa A, Mariano ER. Interfascial plane blocks: back to
postoperative intravenous opioid consumption reported up to basics. Reg Anesth Pain Med. 2018;43(4):341–6.
24 h after surgery, and a longer time to first rescue analgesic. Elsharkawy H, Bajracharya GR, El-Boghdadly K, Drake RL,
However, the opioid-sparing effect did not translate to reduc- Mariano ER. Comparing two posterior quadratus lumborum block
approaches with low thoracic erector spinae plane block: an ana-
tion in postoperative nausea and vomiting.
tomic study. Reg Anesth Pain Med. 2019;44(5):549–55.
In lumbar spinal surgery, Qui summarized the use of ESPB Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae
in a systematic review including all types of articles (case plane block: a novel analgesic technique in thoracic neuropathic
report, case series, retrospective cohort study, and random- pain. Reg Anesth Pain Med. 2016;41(5):621–7.
Forero M, Rajarathinam M, Adhikary SD, Chin KJ. Erector spinae
ized controlled trials). They included 171 participants from
plane block for the management of chronic shoulder pain: a case
11 publications (2 RCTs). The two RCTs found that ESP report. Can J Anesth. 2018;65(3):288–93.
block significantly reduced lumbar postoperative pain scores Hamilton DL. Pneumothorax following erector spinae plane block. J
Clin Anesth. 2019;52:17.
486 J. F. Vargas Silva et al.

Hamilton DL, Manickam BP. Is the erector spinae plane (ESP) block a Qiu Y, Zhang TJ, Hua Z. Erector spinae plane block for lumbar spinal
sheath block? Anaesthesia. 2017;72(7):915–6. surgery: a systematic review. J Pain Res. 2020;13:1611.
Huang J, Liu JC. Ultrasound-guided erector spinae plane block for Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn
postoperative analgesia: a meta-analysis of randomized controlled PK. Efficacy and safety of paravertebral blocks in breast sur-
trials. BMC Anesthesiol. 2020;20:1–8. gery: a meta-analysis of randomized controlled trials. Br J
Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane block Anaesth. 2010;105:842–52.
for postoperative analgesia in breast and thoracic surgery: a sys- Schnabel A, Weibel S, Meißner M, Reichl SU, Kranke P, Meyer-
tematic review and meta-analysis. J Clin Anesth. 2020;66:109900. Frießem CH, Zahn PK, Pogatzki-Zahn E. Erector spinae plane
Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating block for postoperative pain. Cochrane Database Syst Rev.
the mechanism of action of erector spinae blockade. Reg Anesth 2020;(10):CD013763.
Pain Med. 2018;43(6):567–71. Schwartzmann A, Peng P, Maciel MA, Forero M. Mechanism of the
Jacobs A, et al. PROSPECT guideline for oncological breast surgery: erector spinae plane block: insights from a magnetic resonance
a systematic review and procedure-specific postoperative pain man- imaging study. Can J Anesth. 2018;65(10):1165–6.
agement recommendations. Anaesthesia. 2020;75(5):664–73. Schwartzmann A, Peng P, Maciel MA, Alcarraz P, Gonzalez X, Forero
Klingler W, Velders M, Hoppe K, Pedro M, Schleip R. Clinical rel- M. A magnetic resonance imaging study of local anesthetic spread
evance of fascial tissue and dysfunctions. Curr Pain Headache Rep. in patients receiving an erector spinae plane block. Can J Anaesth.
2014;18(8):439. 2020;67(8):942–8. https://doi.org/10.1007/s12630-­020-­01613-­8.
Kose HC, Kose SG, Thomas DT. Lumbar versus thoracic erector spinae Susan S. Gray’s anatomy: the anatomical basis of clinical practice. 41th
plane block: similar nomenclature, different mechanism of action. J ed. Amsterdam: Elsevier Health Sciences; 2015.
Clin Anesth. 2018;48:1. Tulgar S, Selvi O, Ozer Z. Clinical experience of ultrasound-guided
Leong RW, Tan ESJ, Wong SN, Tan KH, Liu CW. Efficacy of erec- single and bi-level erector spinae plane block for postopera-
tor spinae plane block for analgesia in breast surgery: a systematic tive analgesia in patients undergoing thoracotomy. J Clin Anesth.
review and meta-analysis. Anaesthesia. 2020;76(3):404–13. 2018;50:22–3.
López MB, Cadórniga ÁG, González JML, Suárez ED, Carballo CL, Tulgar S, Ahiskalioglu A, De Cassai A, Gurkan Y. Efficacy of bilat-
Sobrino FP. Erector spinae block. A narrative review. Cent Eur J eral erector spinae plane block in the management of pain: current
Clin Res. 2018;1(1):28–39. insights. J Pain Res. 2019;12:2597.
Macintosh JE, Bogduk N. 1987 Volvo award in basic science: the mor- Tulgar S, Aydin ME, Ahiskalioglu A, De Cassai A, Gurkan Y. Anesthetic
phology of the lumbar erector spinae. Spine. 1987;12(7):658–68. techniques: focus on lumbar erector spinae plane block. Local Reg
Nair AS, Seelam S. The risks associated with erector spinae plane block Anesth. 2020;13:121.
in patients with abnormalities of coagulation. Korean J Anesthesiol. Ueshima H. Pneumothorax after the erector spinae plane block. J Clin
2019;72(3):275. Anesth. 2018;48:12.
Narayanan M, Venkataraju A. Transverse approach to the erector spinae Vidal E, Giménez H, Forero M, Fajardo M. Erector spinae plane block:
block: is there more? Reg Anesth Pain Med. 2019;44:529–30. a cadaver study to determine its mechanism of action. Revista
Papa P, Antunez-Maciel M, Asenjo JF. Cancer shoulder pain treated Española de Anestesiología y Reanimación. 2018;65(9):514–9.
with a neurolytic erector spinae plane block. Can J Anesth. Yang HM, Choi YJ, Kwon HJ, O J, Cho TH, Kim SH. Comparison of
2020;67:1262–3. injectate spread and nerve involvement between retrolaminar and
Pourkashanian A, Narayanan M, Venkataraju A. The erector spinae erector spinae plane blocks in the thoracic region: a cadaveric study.
plane block: a review of current evidence. Education for anaesthesia Anaesthesia. 2018;73(10):1244–50.
providers worldwide; 2019. p. 27.
488 R. Sahoo and P. Peng

c­oagulopathy. Because of the risk of pneumothorax, it is The 11 upper nerves are (relative to the thoracic ribs) genu-
relatively contraindicated in patients with poor lung reserve, inely intercostal because the nerves at least partially run in the
single lung, or unknown anatomic changes on the side of intercostal space. The 12th, however, lies caudal to the 12th rib
injection. Clinician should exercise discretion of the inter- and is known as the subcostal nerve. The six upper intercostal
costal block in patients with bleeding diathesis (from disease nerves run entirely in the intercostal spaces, as far as the edge
or drugs), previous nerve injury, and systemic infection, and of the sternum; the six lower ones reach the area of the linea
they are relatively contraindicated. alba. All the intercostal nerves, with the exception of the 12th,
run in the relevant intercostal space in front of the superior
costotransverse ligament and on the inner surface of the inter-
Functional Anatomy nal intercostal muscles. The internal intercostal muscles are
absent from the spine as far as the costal angle and replaced by
There are 12 pairs of thoracic spinal nerves. With the excep- internal intercostal membrane (Fig. 35.3). Over this area, the
tion of the first two, these spinal nerves are smaller in size intercostal nerves lie over the endothoracic fascia and costal or
compared with the lower half of the cervical spinal nerves. parietal pleura. Approaching the angle of the rib, the nerves lie
These spinal nerves emerge from the spinal cord with two between the internal and innermost intercostal muscles, and
roots—the sensory dorsal root (posterior) and the motor they are accompanied by the intercostal vessels (the intercos-
ventral root (anterior) (Fig. 35.1). After leaving the dural tal artery and vein). They lie caudal to the vessels (Fig. 35.4).
sac, the two roots are surrounded by a dural sheath. The Special care needs to be taken during procedures, as due to the
sensory root expands to accommodate the sensory neurons proximity of blood vessels to the nerves, toxic concentrations
and forms the dorsal root ganglion. Beyond the ganglion, of local anesthetic can easily be reached.
the roots form a common mixed spinal nerve trunk, which The intercostal nerves give out various branches: muscu-
divides into four branches after exiting through the inter- lar branches for various chest wall muscles such as serratus
vertebral foramen: the dorsal primary rami, the ventral pri- posterior and rectus abdominis muscles; lateral cutaneous
mary rami, the meningeal branches which supply the spinal branches supplying the skin of lateral sides of the thorax and
canal and the meninges, and the white and gray communi- abdomen, as well as skin of the axilla (first intercostal nerve);
cating branches, which anastomose with each neighboring anterior cutaneous branches supplying the anterior side of
ganglion of the sympathetic trunk and thus extend to the the thorax; and pleural and peritoneal branches supplying the
viscera and vessels, mediating and involving the sympa- pleura and thoracic wall and the peritoneum of the lateral
thetic nervous system. They also carry sympathetic fibers to and anterior abdominal wall, as well as the pleural and peri-
the spine. toneal covering at the origin of the diaphragm (Fig. 35.5).
The dorsal rami of the thoracic nerves pass between the
two transverse processes to their area of distribution and
divide into two typical branches, the medial and lateral 6 7 1
branches; they give off muscular branches (back muscles)
and cutaneous branches (spinous processes, posterior wall of
the thorax, and lumbar region). The ventral rami of the tho-
racic nerves are also termed intercostal nerves, and they are
distributed segmentally (Fig. 35.2).
5 8
4
5 9
5 10
1 3 12
2

11 2
4

3
6

Fig. 35.2 Intercostal nerves (1). Ventral branches (intercostal nerves),

(2) lateral cutaneous branch, (3) anterior cutaneous branch, (4) poste-
Fig. 35.1 Anatomy of the thoracic spinal nerves. (1) spinal ganglion, rior intercostal artery, (5) posterior intercostal vein, (6) spinal cord, (7)
(2) spinal nerve, (3) ganglion of the sympathetic trunk, (4) dorsal and spinal nerve, (8) sympathetic trunk, (9) thoracic aorta, (10) azygos vein,
ventral branch, (5) dorsal and ventral root, (6) white and gray commu- (11) external intercostal muscles, (12) internal intercostal muscles.
nicating branches. (Reprinted with permission from Danilo Jankovic) (Reprinted with permission from Danilo Jankovic)
35 Intercostal Nerve Block 489

Fig. 35.3 Intercostal muscles

in the chest wall. (Reprinted
with permission from Philip
Peng Educational Series)

The index and middle fingers of the left hand palpate the
Technique rib being blocked and press the skin around the contours of
the ribs. The index finger locates the lower edge of the rib. A
Landmark Technique 3.5-cm 25-G-long needle is advanced at an angle of 80° to
the skin surface until bone contact (costal periosteum) is
The patient is placed in prone (preferred position for bilateral made. Upon contact with bone, the needle is withdrawn
block) or lateral recumbent position (Fig. 35.6). When the slightly, and the skin and needle are then simultaneously
procedure is performed in prone position, a pillow is placed pushed caudally until the needle slides under the lower edge
under the mid-abdomen, between the arch of the ribs and the of the rib (Fig. 35.7). After loss of bone contact, the needle
iliac crest line, with the patient’s arms hanging (Fig. 35.6). must not be introduced beyond 2–3 mm deeper. The hub of
The first four intercostal nerves are blocked paravertebrally, the needle is fixed between the thumb and the index finger as
3.5–4 cm or two fingerbreadths lateral to the spinous pro- this is done; the middle finger fixes the shaft and directs the
cesses. For the other level, the target is the caudal boundary needle. The side of the left hand (left hypothenar eminence)
of the rib at costal angle (7–8 cm or four fingerbreadths lat- rests on the patient’s back; initially, it serves as a brake, and
eral to the midline and lateral to the musculature of the erec- then during the injection, it serves as fixation. After aspira-
tor muscle of the spine). The rib level is counted from 12th tion at various levels, the local anesthetic is injected on an
rib onward cranially. incremental basis.
490 R. Sahoo and P. Peng

Fig. 35.4 Cross section of

the chest wall showing
intercostal muscles and
neurovascular bundles.
(Reprinted with permission
from Philip Peng Educational
Series)

Fig. 35.5 Branches of the

typical intercostal nerves.
(Reprinted with permission
from Philip Peng Educational
Series)
35 Intercostal Nerve Block 491

Fig. 35.6 Left: prone position. The red line indicates the midline and blue indicates line joining the angle of ribs. The ultrasound probe position
is indicated on the right side. Right: lateral position. (Reprinted with permission from Danilo Jankovic)

Fig. 35.7 Left: the needle position with landmark technique. Right: schematic diagram to show how the needle is moved. The skin and the needle
are simultaneously pushed caudally, and the needle is then introduced a further 2–3 mm. (Reprinted with permission from Danilo Jankovic)
492 R. Sahoo and P. Peng

During the injection, the following points must be

observed:

1. The person carrying out the injection must stand on the

side being blocked.
2. The intercostal nerve runs dorsocaudal to the vessels in
the inferior costal groove.
3. Start with the lowest rib.
4. The injection must only be carried out after definite iden-
tification of the rib being blocked.
5. Targeted paresthesias are not elicited.
6. If the patient coughs, it indicates pleural irritation. The
procedure should be stopped.
7. Injection should be carried out on an incremental basis,
with frequent aspiration. Fig. 35.8 Ultrasonographic image showing the intercostal muscles
and pleura at the angle of the rib. EI, external intercostal muscle; II,
Due to overlap, at least three nerves have to be blocked in internal intercostal muscle; *, intercostal neurovascular bundle; arrows,
pleura, appears as a hyperechoic line. (Reproduced with permission
order to achieve a complete segmental block. A volume of from Philip Peng Educational Series)
3–5-mL local anesthetic is injected per segment, e.g., 0.5–
0.75% ropivacaine and 0.25–0.5% bupivacaine (0.25–0.5%
levobupivacaine). As intercostal block is the procedure in dle to be visualized, as well as the confirmation of the spread
which the highest blood levels of local anesthetic per milli- of injectate, avoiding inadvertent vascular injection.
gram injected are achieved (due to very fast absorption),
there is a risk of overdose. The individual maximum dose Needle Insertion
must be carefully calculated and must never be exceeded. With out-of-plane technique, the ultrasound probe is placed
in short axis to the two ribs of the intercostal space. The tar-
get is the intercostal nerve deep to the internal intercostal
Ultrasound-Guided Injection muscle just caudal to the cranial rib and is usually less than
5 mm from the pleura. The ultrasound probe should be posi-
Sonoanatomy tioned so that this target is in the center of view in the ultra-
The ideal location for ultrasound-guided injection is at the sound screen. A 25-G 1.5-in. needle is inserted out of plane
level of angle of the rib because the internal intercostal mus- in an angle almost parallel to the midpoint of the ultrasound
cle is formed from this point onward and the lateral cutane- probe. The hand holding the ultrasound probe should adjust
ous branch is still incorporated in the intercostal nerve. the tilting of the probe constantly to follow the needle tip.
The patient lies on the contralateral side or in prone posi- When the needle is in the external intercostal muscle
tion with the arm abducted to bring the scapula away from (Fig. 35.9), the position of the needle tip should be confirmed
midline. A high-frequency ultrasound probe is used. The key with hydrolocation technique by injecting a small amount of
landmarks are the upper and lower rib of each intercostal local anesthetic (0.1–0.2 mL). The needle is then carefully
space, the intercostal muscles, and the pleura. The probe is advanced to the target. If the tip is in the right location, the
placed 90° to the course of the ribs so that upper and lower pleura is seen pushed down by the spread of injectate
ribs, intercostal muscles, and pleura can be visualized. The (Fig. 35.9). A volume of 1–2 mL is sufficient, contrast to the
target is the intercostal nerve deep to the internal intercostal landmark-guided technique. Alternatively, an in-plane tech-
muscle just caudal to the cranial rib and is usually less than nique can be performed with the block needle inserted from
5 mm from the pleura (Fig. 35.8). To enhance the visualiza- caudad to cephalad targeting the caudal part of the costal
tion of the internal intercostal muscle, the cranial end of the margin (Fig. 35.10).
ultrasound probe is tilted laterally to align with the muscle. Following the injection of various levels, it is advisable to
The preferred position for ultrasound-guided technique is perform a scan of the pleura to document the absence of
prone position for two reasons: it is easier to count the level pneumothorax. It is important to scan the lung at the site
of ribs in this position, and it is the preferred position to diag- when the needle is inserted. The feature to look for is the
nose the presence of pneumothorax as air tends to stay in the pleura which is a thin but densely hyperechoic structure glid-
nondependent position. These two are also the advantages of ing freely with B lines, which are bright, hyperechoic rever-
the use of ultrasound over the landmark-guided technique. In beration artifacts originating from the pleura and travelling
addition, ultrasound guidance allows the target and the nee- all the way to the edge of the screen (Fig. 35.11). Absence of
35 Intercostal Nerve Block 493

Fig. 35.9 Left: the arrows indicate the needle position inserted with result in the appearance of pooling of local anesthetic (bold arrows),
out-of-plane technique. It indicates the needle tip is in external intercos- which pushes the pleura deeper. (Reproduced with permission from
tal muscle. Right: further insertion of the needle results in the tip just Philip Peng Educational Series)
deep to the internal intercostal muscle. Injection of local anesthetic will

Fig. 35.10 Alternative probe position in a more oblique alignment to

allow in-plane insertion of the needle (arrow). EI external intercostal Fig. 35.11 Ultrasound image showing the B line (line arrows). The
muscle, II internal intercostal muscle, arrows pleura, appears as a pleura is indicated by the bold arrows. (Reproduced with permission
hyperechoic line. (Reproduced with permission from Philip Peng from Philip Peng Educational Series)
Educational Series)

lung gliding, B lines, and conversion of “seashore sign” to 4. Infection.

“barcode sign” in M mode are diagnostic for the presence of 5. Hematoma.
pneumothorax (Fig. 35.12). The concept of lung point is
important and is 100% diagnostic of pneumothorax. It repre-
sents a transition point where there is absence of the normal Practical Tips
lung signs to the point when lung gliding reappears.
1. Patient positioning is important. Intercostal nerve blocks
can be performed with patient in prone, lateral decubitus,
Complications or sitting position, but it is best performed in prone
position.
1. Pneumothorax. 2. The target is the intercostal nerve deep to the internal
2. Local anesthetic systemic toxicity due to high systemic intercostal muscle. Regardless of the body build, the tip
absorption and overdosage. of the needle is <5 mm to the pleura, and a successful
3. Intravascular injection. injection will result in pushing the pleura. Therefore,
494 R. Sahoo and P. Peng

Fig. 35.12 Left: M mode showing the sea (soft tissue superficial to the appearance of barcode sign. (Reproduced with permission from Philip
pleura) shore sign. Right: with pneumothorax, the region deep the Peng Educational Series)
pleura will appear as the same as superficial to the pleura and gives the

when a clinician is using out-of-plane technique, a couple opioid requirement, or inspiratory effect as measured by
of caveats, have the needle 0.5 to 1 cm away from the spirometry.
probe, but insert at a steep angle (this allows early visual- In addition, the fear of pneumothorax decreased the popu-
ization of the needle and avoids the tip to advance to the larity of this block, and paravertebral block can provide the
other side of the probe); pay attention to the fascia joining same type of analgesic benefit. A recent systematic review
the superficial surface of both adjoining ribs as movement and meta-analysis compared the safety and efficacy of para-
of it signifying the needle is about to enter into the inter- vertebral block with intercostal nerve block in the setting of
costal muscle. Then use hydrodissection to confirm the thoracotomy, thoracoscopic surgery, and breast surgery. The
tip location from that point onward. primary outcome was visual analog scale (VAS) at rest
3. Intercostal blocks are best performed near the angle of the recorded at 1, 2, 12, and 24 h after surgery. The secondary
ribs. In the upper chest, the ipsilateral arm can be put on outcomes included the rate of postoperative nausea and vom-
the contralateral shoulder to move the scapula away. iting (PONV), rate of additional analgesia, and postoperative
4. Postprocedure evaluation for pneumothorax is warranted. consumption of morphine. They included a total of 9 trials
The scanning of the lung should be in the same position including 440 patients (paravertebral block, 222 patients;
as injection. intercostal nerve block, 218 patients) and found that paraver-
tebral block provided better analgesia and resulted in lower
consumption of morphine after thoracic surgery and breast
Literature Review surgery.
The use of intercostal nerve block and subsequent thermal
In perioperative setting, intercostal nerve block provided radiofrequency ablation (RFA) has been successfully
superior pain control at rest and with movement (cough) described in chronic pain settings. Applying RFA to inter-
after major surgery such as esophagectomy through thora- costal nerves showed promising result in palliative setting in
cotomy when compared with opioids alone in early postop- either metastatic disease of the rib (nociceptive pain) or chest
erative period. When added as part of multimodal analgesia wall neuralgia (neuropathic pain). In one study, RFA of the
technique, intercostal nerve block reduced opioid consump- intercostal nerve was used to treat 25 patients with uncon-
tion and hospital stay in breast implant surgery. However, the trollable breakthrough pain (BTP) arising out of the rib
effect size and analgesic duration are limited. In a random- metastasis. Following the RFA treatment, there was more
ized study, investigators evaluated the added benefit of inter- than 50% decrease in both intensity and frequency of BTP in
costal nerve block to thoracic epidural analgesia performed more than 50% of patients for 3 months, and there was more
by the surgeon at the end of the surgery (at the level of the than 50% decrease in BTP opioid dose in more than 50% of
thoracotomy and two levels up and down). The authors con- patients throughout the study period. There was also signifi-
cluded that addition of intercostal block to epidural analgesia cant improvement in the background pain, functional status,
does not confer any benefit in terms of postoperative pain, and quality of life after the RFA. This group of investigators
35 Intercostal Nerve Block 495

noted that the pain relief, opioid reduction, and functional Byas-Smith MG, Gulati A. Ultrasound-guided intercostal nerve cryoab-
lation. Anesth Analg. 2006;103(4):1033–5.
status improvement were found mostly in patients with inter- Curatolo M. Intercostal nerve block. In: Peng PW, editor. Ultrasound for
costal nerve involvement, i.e., neuropathic pain or mixed pain medicine intervention: a practical guide. Peripheral structures.
neuropathic and nociceptive pain. Similarly, thermal RFA Philip Peng educational series. iBook, vol. 1. 1st ed. Cupertino, CA:
has been reported providing long-lasting pain relief in patient Apple; 2013. p. 65–8.
Curatolo M, Bogduk N. Diagnostic and therapeutic nerve blocks. In:
with cancer-related refractory chest wall neuralgia. Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica’s man-
Persistent chest wall neuralgic pain is not uncommon in agement of pain. Philadelphia: Lippincott William & Wilkins;
the contact sports athletes and can limit their activity and 2010a. p. 1401–23.
participation in the sports. In a case series involving 18 Curatolo M, Bogduk N. Diagnostic blocks for chronic pain. Scand J
Pain. 2010b;1:186–92.
patients with sports-related persistent intercostal neuralgic Gulati A, Shah R, Puttanniah V, Hung JC, Malhotra V. A retrospec-
pain who underwent pulsed radiofrequency (PRF) neuro- tive review and treatment paradigm of interventional therapies for
modulation, 16 of 18 (88%) patients had effective pain relief patients suffering from intractable thoracic Chest Wall pain in the
(NRS <3) following the PRF therapy from the baseline oncologic population. Pain Med. 2015;16:802–10.
Hashemi M, Mohseni G, Ataei MH, Zafari A, Keyhani S, Jazayeri
numeric pain score 8.5 ± 1.9 up to the 4-week follow-up. The SM. Intercostal nerves pulsed radiofrequency for intractable neural-
PRF provides adequate and quick pain relief, enabling them gia treatment in athletes with sport trauma of the chest: a case-series
to resume their sports activities. In addition, cryoanalgesia study. Arch Trauma Res. 2017;6:37–40.
has been successfully used in the treatment of post-­ Haskins SC, Tsui BC, Nejim JA, et al. Lung ultrasound for the regional
anesthesiologist and acute pain specialist. Reg Anesth Pain Med.
thoracotomy pain syndrome. Traditionally, it used to be done 2017;42:289–98.
with landmark-guided technique but in recent times under Huan S, Deng Y, Wang J, Ji Y, Yin G. Efficacy and safety of para-
ultrasound guidance which significantly reduces the possi- vertebral block versus intercostal nerve block in thoracic surgery
bility of pneumothorax and provides effective long-term pain and breast surgery: a systematic review and meta-analysis. PLoS
One. 2020;15(10):e0237363. https://doi.org/10.1371/journal.
relief. pone.0237363.
In patient with refractory chest wall pain from tumor Jankovic D. Thoracic spinal nerve blocks. In: Jankovic D, editor.
spread, another option is chemical neurolysis of the intercos- Regional nerve. Blocks & infiltration therapy. 3rd ed. Oxford:
tal nerves. In a retrospective analysis of 146 patients who Blackwell; 2004. p. 171–85.
Jemal B, Woldeyohanes M, Shitemaw T, Ayalew N, Awoke Z, Abiy
underwent intercostal nerve block, intercostal nerve chemi- S. Effectiveness of thoracic paravertebral and intercostal nerve
cal ablation provided pain relief in 62% of patient after a blocks as a part of postoperative analgesia in patients undergoing
successful diagnostic blockade. Authors chose alcohol over open cholecystectomy under general anesthesia in Addis Ababa,
phenol as the neurolytic agent due to a perceived decreased Ethiopia: a prospective cohort study. Int J Surg Open. 2019;18:1–8.
Moorjani N, Zhao F, Tian Y, Liang C, Kaluba J, Maiwand MO. Effects
risk in deafferentation pain, whereas phenol may lead to of cryoanalgesia on post-thoracotomy pain and on the structure of
nerve arborization and neuroma formation. Both local anes- intercostal nerves: a human prospective randomized trial and a his-
thetic and neurolytic agents have been described to enter the tological study. Eur J Cardiothorac Surg. 2001;20(3):502–7.
intrathecal space and cause anesthesia and paralysis, respec- Peng P, Narouze S. Ultrasound-guided interventional procedures in
pain medicine: a review of anatomy, sonoanatomy and procedures.
tively. Hence, it is prudent that small amount of neurolytic Part I: non-axial structures. Reg Anesth Pain Med. 2009;34:458–74.
solution (<1 mL) is used for neurolysis and ultrasound guid- Ranganathan P, Tadvi A, Jiwnani S, Karimundackal G, Pramesh
ance allows the precise location of the target. CS. A randomised evaluation of intercostal block as an adjunct to
epidural analgesia for post-thoracotomy pain. Indian J Anaesth.
2020;64:280–5.
Shah A, Rowlands M, Krishnan N, Patel A, Ott-Young A. Thoracic
References intercostal nerve blocks reduce opioid consumption and length of
stay in patients undergoing implant-based breast reconstruction.
Abd-Elsayed A, Lee S, Jackson M. Radiofrequency ablation for treat- Plast Reconstr Surg. 2015;136:584e–91e.
ing resistant intercostal neuralgia. Ochsner J. 2018;18(1):91–3. Shankar H, Eastwood D. Retrospective comparison of ultrasound and
Ahmed A, Bhatnagar S, Khurana D, Joshi S, Thulkar S. Ultrasound-­ fluoroscopic image guidance for intercostal steroid injections. Pain
guided radiofrequency treatment of intercostal nerves for the pre- Pract. 2010;10:312–7.
vention of incidental pain arising due to rib metastasis: a prospective Vlassakov KV, Narang S, Kissin I. Local anesthetic blockade of periph-
study. Am J Hosp Palliat Med. 2017;34(2):115–24. eral nerves for treatment of neuralgias: systematic analysis. Anesth
Bhatia A, Gofeld M, Ganapathy S, Hanlon J, Johnson M. Comparison Analg. 2011;112:1487–93.
of anatomic landmarks and ultrasound guidance for intercostal Zhu M, Gu Y, Sun X, et al. Ultrasound-guided intercostal nerve block
nerve injections in cadavers. Reg Anesth Pain Med. 2013;38:503–7. following esophagectomy for acute postoperative pain relief in the
Brown DL. Intercostal block. In: Brown DL, editor. Atlas of regional postanesthesia care unit. Pain Pract. 2018;18:879–83.
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498 A. Thottungal and P. Peng

Fig. 36.1 Sensory

innervation from the lumbar
plexus. (Reprinted with
permission from Philip Peng
Educational Series)

Indications Cancer Pain

Acute Pain In patient with cancer pain originating from inguinal region
or external genitalia region, blockade of GFN with or
Local anesthetic block of these nerves provides analgesia for without IIN/IHN can be considered.
operations or trauma involving the lower part of the abdo-
men and anterior pelvic region.
Surgeries: Inguinal hernia repair, pelvic open and laparo- Functional Anatomy
scopic surgeries, trocar trauma from laparoscopic or robotic
surgery, appendicectomy, hysterectomy, abdominoplasty, The II and IH nerves originate from the anterior rami of L1
Pfannenstiel incision, orchiectomy, surgery of female or nerve roots with contributions from T12 or L2, emerging
male external genitalia. near the lateral border of the psoas major muscle. These two
Trauma: Blunt abdominal trauma, femoral catheter place- nerves extend diagonally toward the crest of the ilium. The
ment, tearing of the lower external oblique aponeurosis in GFN tends to originate predominantly from L1 and L2, and
hockey or other sports players, stretch injury as in pregnancy after the intrapelvic course, it enters the abdominal wall at
or during lower segment Cesarean section, entrapment near the level of the deep inguinal ring.
the rectus border (anterior cutaneous nerve entrapment syn- The IHN pierces the transversus abdominis muscle above
drome) and near the ilium or around psoas/quadratus lumbo- the iliac crest, midway between the iliac crest and the 12th
rum muscles. rib. The IIN runs caudally and parallel to the IHN. Here, both
nerves can be found consistently (90%) between the trans-
versus abdominis and internal oblique muscles. Terminal
Chronic Pain branches of the IH nerve perforate the external oblique mus-
cle aponeurosis approximately 4 cm lateral to the midline to
The nerve blockade of these nerves can be used to provide supply the skin over the lower portion of the rectus abdomi-
analgesia for persistent postsurgical pain following any of nis. The IH nerve also provides sensory innervation to the
the above surgeries, neuropathic pain, or psoas spasm. skin above the tensor fasciae latae through a lateral ­cutaneous
36 Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Blocks 499

Fig. 36.2 The anterior abdominal wall muscles showing the relationship of “border nerves” and GFN. (Reprinted with permission from Philip
Peng Educational Series)

branch. Terminal branches of the II nerve enter the inguinal However, the main concept to remind when dealing with
canal through the deep inguinal ring; it may lie upon the cre- the “border nerves” is the high rate of variability they are
master muscle and fascial layer of the spermatic cord in men associated with. Anatomic studies highlight this variability,
or the round ligament in women. Here, the II nerve is often which have been reported with respect to their origin and
accompanied by the genital branch of the GF nerve, and spinal contribution, communication between nerves, pene-
wide variations in the course of these nerves within the tration of fascial layers, branching patterns, and dominance
inguinal canal have been documented. The terminal sensory patterns; in some cases, one of the nerves may be entirely
branches may innervate the skin of the mons pubis, inner absent. Although the general anatomy of the IH and II nerves
thigh, inguinal crease, and anterior surface of the scrotum or has been well documented in standard anatomy textbooks,
anterior one-third of the labia (Fig. 36.1). recent studies related to nerve injury during surgery or based
500 A. Thottungal and P. Peng

on cadaver dissections were able to identify multiple and dif- is a sensory branch passes laterally over the external iliac
ferent spinal nerves contributing to the formation of these artery and then penetrates the fascia latae to enter the femoral
nerves. The II and IH nerves mainly originate from the T12 sheath and supplies the triangular dermatomal part over the
and L1 nerve roots, but a contribution from T11 to L3 exists femoral triangle. The genital branch crosses the inferior epi-
in a minority of patients. gastric artery (IEA) at its lower end lateral to the junction
The most consistent anatomical location for the II and IH between the external iliac artery (EIA) and the IEA to enter
nerves to perforate the abdominal muscular layers is lateral the inguinal canal through the deep inguinal ring. It travels
and superior to the anterior superior iliac spine, where they along with other contents of the inguinal canal along with the
run between the transversus abdominis and internal oblique spermatic cord in men and the round ligament of the uterus
muscular layers, even though the distance from the ASIS to in women. The canal also contains inguinal branch of the
the point the nerves enter the fascial layer can widely vary. ilioinguinal nerve and testicular vessels in men or vessels
Also, communication between the GF, IH, or II nerves (as following the round ligament of the uterus in females
well as the lateral femoral cutaneous nerve) is common and (Fig. 36.3). Anatomical studies describe this branch running
results in sensory overlap. Finally, the sites at which the II between the cremaster and internal spermatic fascia, incor-
and IH nerves pierce the abdominal wall muscle layers are porating with the cremasteric fascia, or lying outside of the
significantly variable. spermatic cord. Terminal sensory branches may innervate
Special considerations are needed for pediatric patients. the scrotum and possibly the upper, inner, medial thigh.
Anatomically, pediatric patients have varying II and IH
nerves compared with adults; anatomical results from adults
cannot be downscaled to infants and children, in whom the Nerve Block Techniques
iliohypogastric and ilioinguinal nerves lie closer to the ASIS
than originally thought, and differences have been noted  xisting Landmark Techniques for Nerve
E
according to different age groups. Blockade
The GFN originates from the L1 and L2 nerve roots
(Figs. 36.1 and 36.2). It emerges on the anterior surface of IIN/IHN
the psoas muscle either as a single trunk or separate genital As discussed above, there is a high degree of anatomic vari-
and femoral branches and crosses the ureter on its descent. ability in not only the course of the nerves but also their
The division could happen anywhere during its course above branching patterns, areas of penetration of the fascial layers,
the inguinal ligament. It mainly carries sensory fibers except and dominance patterns. By far, the most consistent location
motor fibers to cremaster muscle. The femoral branch which of the II and IH nerves is lateral and superior to the ASIS,

Fig. 36.3 The schematic

diagram showing the
relationship of the genital
branch (GB) of the GFN to
the external iliac artery (EIA)
and inferior epigastric artery
(IEA). (Reprinted with
permission from Philip Peng
Educational Series)
36 Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Blocks 501

clear, the needle is likely directed toward the spermatic cord,

and important structures of the spermatic cord (testicular
artery and vas deferens) or the peritoneum are at risk. It is
also worth remembering that the common site of nerve injury
is proximal to the site of injection in these techniques which
leads to high failure rate with these techniques (Fig. 36.4).

Ultrasound-Guided Block Techniques

Advantages of ultrasound guidance include the identification

of muscular and fascial layers (including structures lying
deeper to the peritoneum), the visualization of needle’s
­trajectory and spread of injectate, and the detection of vascu-
lar structures. Ultrasound helps physicians to overcome the
wide anatomical variability associated with the structures in
this area, helping to identify the nerves themselves or the
plane they lie within. Ultrasound guidance has demonstrated
to improve accuracy in the injection of local anesthetics,
with less risk of inadvertent injections in the wrong fascial
Fig. 36.4 Landmark points for ilioinguinal and iliohypogastric nerves plane, reduced amount of local anesthetics used for anesthe-
(IIN/IHN) block (asterisk mark) and genitofemoral nerve (GFN) block
(star mark). ASIS anterior superior iliac spine. (Reprinted with permis- sia, and lower consumption of systemic pain medications
sion from Dr. Athmaja Thottungal) compared to landmark techniques. The identification of indi-
vidual nerves is important for the success of blocks in chronic
pain treatment modalities like pulsed radiofrequency dener-
where the nerves are found between the transverses abdomi- vation, cryotherapy, neuromodulation, or neurolysis.
nis and internal oblique muscular layers in nearly 90% of
cases. While most of the anatomical variations occur medial IIN/IHN Block Technique
to the ASIS, virtually all landmark-guided injection tech- The IHN and IIN are very superficial nerves and best viewed
niques described in the literature are performed in the ante- with a linear probe of high frequency (6–13 MHz). In very obese
rior abdominal wall (Fig. 36.4). Because the existing patient, a curved medium-frequency probe may be useful.
landmark-based techniques rely on blind infiltration of local The patient is usually placed in supine; in situations of
anesthetic through different layers, the risk of complications high BMI or pendulous abdomen, the patient can be placed
are well understandable: these include inadvertent femoral in lateral position with the affected side up to improve the
nerve block, colonic puncture, and vascular injury. visibility.
Nevertheless, block failure is still an important matter of Most of clinical studies or reports used ASIS as landmark,
concern, and failure rate of the blind technique lies in the and the position of the probe was above ASIS and moved
range of 10% to 40%. This is attributed to the potential for along the line joining the ASIS and umbilicus. This approach
injecting local anesthetics into the wrong abdominal plane, carries some limitation: when the probe is placed too near to
and in some situation, it leads to injection inside the perito- ASIS, the external oblique muscle layer may be missed;
neum. This is more common in pediatric population. when the probe is too far away from the ASIS (the “bone
shadow of the iliac crest” not in the scan), the nerve seen in
GFN between the transversus abdominis and internal oblique
The conventional description of the blockade of genital muscular layers is likely to be the 12th intercostal nerve or
branch of GF nerve is mainly a “blind” technique and relies subcostal nerve instead.
on the pubic tubercle, inguinal ligament, inguinal crease, and The recommended area for ultrasound scanning of II and
femoral artery as landmarks. One involves infiltration of IH nerves is lateral and superior to the anterior superior iliac
local anesthetic immediately lateral to the pubic tubercle spine (Fig. 36.5), because the two nerves are detectable in
caudal to the inguinal ligament. In another method, a needle this area in 90% of cases. When the probe is placed cranial
is inserted into the inguinal canal to block the genital branch. and three fingerbreadths lateral to the ASIS with the
The blind techniques described are essentially infiltration ­transducer perpendicular to the inguinal ligament and its lat-
techniques and rely on high volumes of local anesthetic for eral end in contact with the iliac crest, three layers of the
consistent results. Although the basis of this landmark is not abdominal wall muscle can be seen. Below the transversus
502 A. Thottungal and P. Peng

abdominis, peristaltic movements of the bowel may be nis muscle layers. Both nerves should be within 1.5 cm of the
detected. The IIN and IHN will be found in the split fascial iliac crest at this site, located on the “upsloping” split fascia
plane between the internal oblique and transversus abdomi- close to the iliac crest, with the IIN closer to the iliac crest. In
some cases, the nerves may run approximately 1 cm apart,
and in many cases, they are so close together so that it is
visualized as single neurovascular bundle. The deep circum-
flex iliac artery which is close to the two nerves in the same
fascial layer can be revealed with the use of color Doppler
(Fig. 36.6).
In some patients (those with previous surgery, multiple
childbirth) or when the procedure is performed by inexperi-
enced practitioners, either the IIN and IHN or the fascia split
Anterio is difficult to visualize; in these cases, the target will be the
A superior fascial plane between the internal oblique and transverse
iliac
spine abdominal muscles. Neurostimulation to locate the nerves
External under the ultrasound can be used to locate the nerves which
iliac are essential for the chronic pain procedures.
artery
Femoral Injection can be performed with either out-of-plane or in-­
artery plane (Fig. 36.7) techniques with a 50-mm echogenic needle.
As the two nerves run very closely within the fascial plane
(sometimes as a common trunk) and frequently overlap in
sensory innervation, a selective block of one of the two
Fig. 36.5 The probe position for the ilioinguinal and iliohypogastric
nerves. (Reprinted with permission from Philip Peng Educational nerves has recently been demonstrated to be impractical. In
Series) chronic pain settings, the out-of-plane technique helps to

Fig. 36.6 Left figure. Sonoanatomy of the ilioinguinal and iliohypo- fascia layer where the ilioinguinal and iliohypogastric nerves are
gastric nerves in the fascia plane (indicated by arrows) between internal located. EO external oblique. (Reprinted with permission from Philip
oblique (IO) and transverse abdominis (TA) muscles. RIght figure. Peng Educational Series)
Sonogram showing the deep circumflex iliac artery (bold arrow) in the
36 Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Blocks 503

a b

c d

Fig. 36.7 (a) Ilioinguinal and iliohypogastric nerves (arrowheads) needle next to the nerve. (c) Out-of-plane (OP) approach. The needle is
between the IO and TA (internal oblique and transversus abdominis inserted perpendicular to the nerve (arrow); (d) local anesthetic (**)
muscles), EO external oblique; (b) in-plane needle insertion to within the fascia expansion. (Reprinted with permission from Dr.
Ilioinguinal and iliohypogastric nerves (arrowhead). Arrow shows the Athmaja Thottungal)

keep the tip of radiofrequency cannula and neurostimulator Method 1: GFN Blockade Proximal to Deep
catheters parallel to the nerves from cranial to caudal direc- Inguinal Ring
tion. The injectate that the author usually used is 2–4 mL of This is from the author’s clinical experience. The initial
0.25–0.5% levo or plain bupivacaine. In chronic pain, this scanning starts at the rectus abdominis muscle at the lower
can be mixed with 1-mL (3.8 mg) dexamethasone or 40-mg abdomen in transverse plane to identify inferior epigastric
depomedrone. In addition to the injection, straight or curved artery (IEA) (Fig. 36.8). The probe is further moved caudally
radiofrequency needle with 5-mm active tip, cryoprobe, or till the junction of the IEA with the external iliac artery (EIA)
stimulating catheter can be used appropriately. is identified. The lateral part of the probe is tilted cranially to
align the probe position parallel to the inguinal ligament
GFN Block Technique (Fig. 36.9). The deep inguinal ring area is visible lateral to
There are three different methods to scan and identify the the IEA and the GFN and spermatic cord or round ligament
genitofemoral nerve (GFN). No validated standardized tech- of the uterus entering into the inguinal canal. Once the GFN
nique has been described yet. Two methods are already is located, a 20-G or 22-G 50-mm echogenic needle is
described in the literature, and the third one is from author’s inserted in plane in lateral to medial direction (Fig. 36.10).
clinical experience especially from scanning female patients. The injectate is 2–4 mL of 0.25–0.5% levo or plain bupiva-
In all situations, the patient is put in supine position, and a caine. In chronic pain, this can be mixed with 1-mL (3.8 mg)
high-frequency probe is used. dexamethasone or 40-mg depomedrone.
504 A. Thottungal and P. Peng

Fig. 36.8 Position of ultrasound probe (blue rectangle) with corre- IEA with the external iliac artery (EIA). GFN genitofemoral nerve, GB
sponding sonography. Upper panel: inferior epigastric artery (IEA) is genital branch, EIV external iliac vein. (Reprinted with permission from
seen deep to the rectus abdominis (RA) muscle. Lower panel: sonogra- Philip Peng Educational Series)
phy when the ultrasound probe is moved lower to the junction of the

Fig. 36.9 Sonography when the ultrasound probe is aligned to the inguinal canal. The genital branch of the genitofemoral nerve (GFN) is indi-
cated by arrows. (Reprinted with permission from Philip Peng Educational Series)
36 Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Blocks 505

Method 2: Using Femoral Artery to Identify

the Inguinal Canal
The initial scan of this method is similar to that of the femo-
ral nerve block. The probe is placed in transverse plane just
below the inguinal ligament to identify femoral artery (FA),
which is then kept in the middle of the screen (Fig. 36.11).
The probe is then rotated to sagittal plane to visualize FA
longitudinally, and the FA is traced cranially until it becomes
EIA diving deep into the abdomen (Fig. 36.12). At this point,
the inguinal canal is seen as an oval structure superficial to
the FA with the spermatic cord or round ligament of the
uterus inside (Fig. 36.13). The inguinal canal can be traced in
medial direction for maximal visibility. Because of the
Fig. 36.10 Needle insertion in-plane approach from lateral to medial superficial nature of the inguinal canal, the needle can be
direction. The genital branch of genitofemoral nerve is indicated by the easily advanced with out-of-plane approach. The medication
arrowheads and the local anesthetic by the *. (Reprinted with permis-
sion from Dr. Athmaja Thottungal)
used is the same as above, but 2–4 mL of injectate is admin-

c
Anterio
a superior
iliac
spine
External
b iliac
artery
1 Femoral
artery

Pubic
symphysis

Fig. 36.11 Sonography of the femoral artery (FA) in short axis when the ultrasound probe is placed below the inguinal ligament (position 1). *
femoral nerve. (Reprinted with permission from Philip Peng Educational Series)

c
a Anterio
superior
iliac
spine
External FA
iliac
b artery EIA
2
Femoral
artery

Pubic
symphysis Cephalad

Fig. 36.12 Sonography of the femoral artery (FA) in long axis when the ultrasound probe is placed below the inguinal ligament (position 2). EIA
external iliac artery, arrows inguinal canal, bold arrows pubic ramus. (Reprinted with permission from Philip Peng Educational Series)
506 A. Thottungal and P. Peng

Fig. 36.13 Left: inguinal canal (bold arrows) in a female patient with a round ligament of the uterus. Right: inguinal canal (bold arrows) in a male
patient with spermatic cord inside. (Reprinted with permission from Dr. Athmaja Thottungal)

Fig. 36.14 Inguinal canal with the effect of injectate. Left: local anes- (arrows) but outside the spermatic cord. (Reprinted with permission
thetic (**) is sent spread inside the spermatic cord (outlined by arrow- from Philip Peng Educational Series)
heads). Right: local anesthetic is seen spread inside the spermatic cord

istered inside the inguinal canal and another 2–4 mL inside Absence of any observed spread is indicative of intravascular
the spermatic cord. This is because the GFN may travel out- injection or loss of needle tip visualization. Given the ana-
side or within the spermatic cord (Fig. 36.14). tomic variability of the genital branch of the GF nerve, local
anesthetic is injected within and outside of the spermatic
Method 3: Placing the Ultrasound Probe Right over cord in men; in women, local anesthetic is injected around
the Spermatic Cord the round ligament only. In males, the local anesthetic should
This method applies to male patient since the spermatic cord not contain epinephrine so as to avoid vasoconstriction of the
can be seen next to superficial inguinal ring in surface anat- testicular arteries. Steroid can be added for the management
omy. The initial probe is placed lateral and superior to the of chronic pain syndromes.
pubic tubercle and moved laterally till EIA is identified
(Fig. 36.15). This is also known as “spermatic cord block” or
“inguinal canal block.” Complications of IIN, IHN, and GFN Blocks
Both in-plane and out-of-plane techniques may be used.
Hydrodissection with saline should be utilized to confirm Vascular injury, nerve injury, perforation of the gut, sper-
adequate spread within the inguinal canal or within the cord. matic cord injury, and infection.
36 Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Blocks 507

Fig. 36.15 Upper panel: probe position at pubic tubercle (PT) and corresponding sonography. Lower panel: lateral movement of the ultrasound
probe revealed the spermatic cord outlined by arrows. (Reprinted with permission from Philip Peng Educational Series)

Practical Tips 3. Put patients to lateral position with the affected side up
for patients with high BMI and pendulous abdomen
II/IH Nerve Blocks which will help to move tissue away from the ilium and
visibility of the nerve and needling much easier.
1. Make sure the probe is above ASIS enough so that all 4. Out-of-plane technique is much easier if patients have
three layers of the abdomen, ilium, and iliacus muscle are a high BMI and also for certain chronic pain
visible all the time. procedures.
2. Apply pressure to the medial end of the probe which is 5. Using color Doppler to identify deep circumflex iliac
pointing toward the umbilicus to “cave in” so that the artery is helpful if the facial planes are fibrosed after sur-
ultrasound beam is falling on and reflecting from the ilia- gery to locate the plane.
cus muscle inside of the ilium which will make visibility
of nerves much easier.
508 A. Thottungal and P. Peng

GF Nerve Blocks Suggested Reading

1. Method 1 is useful for both male and female patients, Alfieri S, Amid PK, Campanelli G, et al. International guidelines for
prevention and management of post-operative chronic pain follow-
any age group, and size. If methods 2 and 3 are used in ing inguinal hernia surgery. Hernia. 2011;15(3):239–49.
elderly women or women with high BMI, identifying the Bellingham G, Peng P. Ultrasound-guided interventional proce-
round ligament of the uterus can be technically difficult. dures for chronic pelvic pain. Tech Reg Anesth Pain Manag.
In men, it is easier as the spermatic cord is easy to 2009a;13(3):171–8.
Bellingham GA, Peng PWH. Ultrasound guided interventional pro-
identify. cedures for chronic pelvic pain. Tech Reg Anesth Pain Manang.
2. Method 1 is also a preferred position for neuromodula- 2009b;13:171–8.
tory techniques like pulsed radiofrequency denervation Campos NA, Chiles JH, Plunkett AR. Ultrasound-guided cryoablation
and peripheral nerve stimulation. for genitofemoral nerve for chronic inguinal pain. Pain Physician.
2009;12(6):997–1000.
3. In-plane needling is preferred as EIA and FA are closed Chan CW, Peng PWH. Ultrasound guided blocks for pelvic pain. In:
by and can avoid bleeding. Nauroze S, editor. Atlas of ultrasound guided procedures in inter-
4. Always use color Doppler prior to injection to identify ventional pain management. 1st ed. Berlin: Springer. p. 207–26.
testicular vessels and IEA pulsations. Deer T. Interventional and neuromodulatory techniques for pain man-
agement. Philadelphia: Elsevier/Saunders; 2012.
5. GFN is a nerve of huge anatomical variation. It could also Ducic I, Dellon A. Testicular pain after inguinal hernia repair: an
be originating from T12 or L3. L2 contribution tends to approach to resection of the genital branch of genitofemoral nerve.
be more consistent. J Am Coll Surg. 2004;198(2):181–4.
6. The division of genital and femoral branch is very vari- Huang Z, Xia W, Peng X, Ke J, Wang W. Evaluation of ultrasound-­
guided genitofemoral nerve block combined with Ilioinguinal/ilio-
able and can happen anywhere during the course of the hypogastric nerve block during inguinal hernia repair in the elderly.
nerve. Curr Med Sci. 2019;39(5):794–9.
7. There is overlap between dermatomal supplies of the Liu W, Chen T, Shyu J, Chen C, Shih C, Wang J, et al. Applied anatomy
ilioinguinal nerve (IIN) and GFN. So, checking the of the genital branch of the genitofemoral nerve in open inguinal
herniorrhaphy. Eur J Surg. 2002a;168(3):145–9.
IIN is also important when GFN pathology is Liu WC, Chen TH, Shyu JF, et al. Applied anatomy of the genital
suspected. branch of genitofemoral nerve in open inguinal herniorraphy. Eur J
8. Do not use local anesthetic with epinephrine for this Surg. 2002b;168(3):145–9.
block if injected around the spermatic cord. Narouze S. Atlas of ultrasound-guided procedures in interventional
pain management. Berlin: Springer.
Oelrich T, Moosman D. The aberrant course of the cutaneous compo-
nent of the ilioinguinal nerve. Anat Rec. 1977;189(2):233–6.
Pandav D. Ultrasound guided ilioinguinal & iliohypogastric nerve
Literature Review blocks combined with genital branch of genitofemoral nerve block
for open inguinal hernia repair. J Med Sci Clin Res. 2020;8(7).
Peng PWH, Tumber PS. Ultrasound-guided interventional procedures
The IIN/IHN and GFN blocks are used for both anesthesia for patients with chronic pelvic pain—a description of techniques
and analgesia purposes. In chronic pain situations, these are and review of the literature. Pain Physician. 2008;11:215–24.
used for diagnostic and therapeutic purposes. There is a huge Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal
and genitofemoral nerve: implications for the treatment of groin
variability in the anatomical origin, course, location of pen- pain. Last Reconstr Surg. 2001;108(6):1618–23.
etration of various abdominal wall muscles, and dermatomal Rosendal F, Moir L, de Pennington N, Green A, Aziz T. Successful
distribution. This leads to high failure rate and complications treatment of testicular pain with peripheral nerve stimulation of the
when blind techniques are used where ASIS is the only reli- cutaneous branch of the Ilioinguinal and genital branch of the geni-
tofemoral nerves. Neuromodulation. 2012;16(2):121–4.
able landmark that can be used. When using ultrasound-­ Seib R, Peng P. Ultrasound-guided peripheral nerve block in chronic
guided technique for IIN/IHN, these nerves are found pain management. Tech Reg Anesth Pain Manag. 2009;13(3):110–6.
superior and lateral to ASIS between internal oblique and Soneji N, Peng P. Ultrasound-guided pain interventions—a review of
transverse abdominis muscles and are validated by a cadaver techniques for peripheral nerves. Kor J Pain. 2013;26(2):111.
Terkawi AS, Romdhane K. Ultrasound-guided pulsed radiofrequency
study with 95% accuracy. The genitofemoral nerve branches ablation of the genital branch of the genitofemoral nerve for treat-
to genital and femoral branches. If distal branch blocking ment of intractable orchalgia. Saudi J Anaesth. 2014;8(2):294–8.
techniques are used, it blocks only the genital branch, not the https://doi.org/10.4103/1658-­354X.130755.
entire GFN. The femoral branch of the GFN is spared. The Thottungal AR, Peng P. Genitofemoral nerve. In: Peng P, editor.
Ultrasound for interventional pain management—an illustrated pro-
inguinal canal contains both genital branch of the GFN and cedural guide. Springer: Cham; 2019. p. 83–92.
inguinal branch of the IIN. This makes it difficult to isolate Waldman SD. Atlas of pain management injection techniques. 3rd ed.
the nerve for persistent postsurgical pain following hernia Philadelphia: Elsevier Saunders; 2013. p. 340–1.
repair.
510 P. Peng and D. Jankovic

the piriformis passes through the greater sciatic foramen and

9
inserts on the upper edge of the greater trochanter. The piri-
formis is the only muscle that courses transversely through
3
the greater sciatic notch, and it is the key landmark to all the
4 important nerves and vessels that pass from the pelvis to the
7 6 gluteal region, such as sciatic nerve, the pudendal nerve and
artery, and the superior and inferior gluteal arteries and
2 nerves (Figs. 37.1 and 37.3). It receives innervation from S1
and S2.
1
The function of the piriformis in the non-weight-bearing
10
limb is external rotation of the thigh with the hip extended
11 and abduction when the hip is fixed at 90°. In weight-bear-
ing activities, the piriformis restrains vigorous or excessive
5 medial rotation of the thigh. The other short lateral rotators
8
of the thigh at the hip (the superior gemellus, obturator
internus, inferior gemellus, and quadratus femoris muscle
lying distal to the piriformis) may cause symptoms in piri-
formis syndrome, especially the obturator internus muscle,
which is partly an intrapelvic muscle and partly a hip mus-
cle. The sciatic nerve arises from the ventral branches of
the spinal nerves, from L4 to S3. Exiting from pelvic cavity
at the lower edge of the piriformis, the sciatic nerve runs
Fig. 37.1 The piriformis muscle (1) and neighboring muscles, nerves, between the ischial tuberosity and the greater trochanter;
and vessels: (2) gluteus minimus, (3) gluteus medius, (4) gluteus maxi- turns downward over the gemelli, the obturator internus
mus, (5) quadratus femoris, (6) superior gluteal nerve, (7) inferior glu- tendon, and the quadratus femoris muscle, which separate
teal nerve, (8) posterior cutaneous femoral nerve, (9) superior gluteal
artery, (10) inferior gluteal artery and vein, (11) internal pudendal it from the hip joint; and leaves the buttock to enter the
artery. The black dotted line outlined the deep gluteal space. thigh beneath the lower border of the gluteus maximus.
(Reproduced with permission from Danilo Jankovic) This is the region where the course of sciatic nerve is inti-
mately related to the piriformis and short rotators of the
Indication and Patient Selection hip. There are six routes by which portions of the sciatic
nerve may exit the pelvis, and these are illustrated in a
According to a recent review of the symptomatology of schematic diagram (Fig. 37.4).
piriformis syndrome, the most common clinical features
are buttock pain, pain aggravated on sitting, tenderness
near the greater sciatic notch, pain on any maneuver that Technique
increases piriformis muscle tension, and limitation of
straight leg raising. Different specific physical maneuvers Various modalities have been described to help localize the
have been developed, and the philosophy of those examina- piriformis or obturator internus muscle. These include imag-
tions is either to stretch the piriformis muscle or to enhance ing techniques such as ultrasound, CT, and fluoroscopy to
active contraction of the muscle (Fig. 37.2). Obturator guide the needle to the vicinity of the muscle and electro-
internus muscle dysfunction may present with similar clini- physiologic techniques such as electromyography and nerve
cal pictures. stimulation to confirm activation of the piriformis muscle or
sciatic nerve. Contrast injection is commonly used in
fluoroscopic-­guided technique to confirm needle placement
Functional Anatomy within the piriformis muscle, which has been shown to be
unreliable. Ultrasound is an attractive imaging technique as
The piriformis muscle (Latin: pirum, pear, forma, shape) was it provides visualization of the soft tissue and neurovascular
named by Flemish anatomist Adriaan van den Spieghel structures and allows real-time imaging of needle insertion
(Spigelius) (1578–1625). Originating from the anterior sur- toward the target. The accuracy of needle placement with
face of the sacrum between first and fourth sacral foramina, ultrasound was estimated 95%. With the increasing popular-
37 Piriformis and Obturator Internus Injection 511

Fig. 37.2 Four different physical examinations for the piriformis syndrome. (Reproduced with permission from Philip Peng Educational Series)

ity of ultrasound for intervention, the ultrasound-guided and the piriformis muscles (Fig. 37.5). By internal and exter-
technique will be described in details. nal rotation of the patient’s hip with the knee flexed, the piri-
formis muscle can be seen gliding underneath the gluteus
maximus muscle. The sequence of scanning the PSIS first
Specific Technique for Piriformis Muscle and then moving the probe caudally is important because the
ultrasound image of the lesser sciatic notch may be confused
With the patient in prone position, a low-frequency curvilin- with that of the greater sciatic notch.
ear probe (2–5 MHz) is initially placed caudal and lateral to Once the piriformis muscle is identified, a long 22-gauge
the posterior inferior iliac spine (PSIS) to visualize the glu- 3.5-in. needle is directed toward the thickest part of the piri-
teal muscles and ilium (Fig. 37.5). With the angle of the formis muscle in the sciatic notch and the tip position should
probe orientated along the long axis of the piriformis muscle, be confirmed with hydrolocation (Fig. 37.6). The needle
the probe is moved in caudal direction until the medial half insertion can be made medially or laterally to the ultrasound
of the hyperechoic line (ilium) recedes. At this level, two probe. Some clinician prefers to inject in the tendinous part
separate muscular layers are identified: the gluteus maximus of the muscle.
512 P. Peng and D. Jankovic

Fig. 37.3 (Left panel) Posterior view of the piriformis muscle (1) and with the gluteal inferior nerve, (3) the greater trochanter, (4) quadratus
sciatic nerve (2). (Right panel) High separation of the sciatic nerve (1): femoris, (5) sacrotuberous ligament, (6) the pudendal nerve in the
the common peroneal nerve courses through the piriformis and the tib- ischiorectal fossa. (Reproduced with permission from Danilo Jankovic)
ial nerve through the infrapiriform foramen, (2) the piriformis muscle

For intramuscular injection, the literature describes a vol- from medial to lateral direction until contact with bone. A
ume of 5 mL. However, in the author’s opinion, only 1–2 mL small volume (1 mL) of either local anesthetic or botulinum
of volume is enough to cover the main muscle bulk with toxin (25–50 units) is administered once the tip of the needle
ultrasound guidance. Too aggressive a volume will cause is confirmed with hydrolocation.
localized pain, and it defeats the purpose of the injection,
which is to facilitate the rehabilitation and stretching of the
piriformis. The injectate can be local anesthetic or a solution Complication
of botulinum toxin (50 units).
Other than the general complication from any injection such
as injection or hematoma and the complication related to the
 pecific Technique for Obturator Internus
S injectate such as allergic reaction or steroid-related side
Muscle and Tendon effects, two particular complications need to be included in
the counseling of the procedures. One is the localized tender-
The position of patient and initially scanning are similar to ness in an already spastic muscle. The potential factors that
what is described above. The probe is moved in caudal direc- may minimize these side effects are avoidance of multiple
tion further until it is at the level of ischial spine (Fig. 37.7). needle entry and minimizing the volume of injectate. If local
At this level, the bony structure appears straight. From there, anesthetic is used, the duration is limited, and it will be coun-
further caudal movement of the probe will reveal the lateral terproductive to have localized pain to prevent the patient
part of the lesser sciatic notch, and the bony configuration is from performing stretching or rehabilitation. Another is
very different from ischial spine. Medial to the bone, the related to the sciatic nerve involvement, either because of the
hypoechoic shadow is the obturator internus muscle needle injury or spread of local anesthetic to the nerve with
(Fig. 37.8). A 22-gauge 3.5-­in. needle is inserted in plane neurological complication.
37 Piriformis and Obturator Internus Injection 513

a b c

PM

SN

83.1% 13.7% 1.3%

d e f

0.5% 0.08% 0.08%

Fig. 37.4 The six routes (a–f) by which portions of the sciatic nerve may exit the pelvis. PM piriformis muscle. (Reproduced with permission
from Philip Peng Educational Series)

Practical Tips When injecting the obturator internus, turn on the Doppler
to visualize the pudendal artery and avoid it.
Start the scan from the ilium (caudal to PSIS) as it assures
the “two-muscle” arrangement caudal to it as the greater sci-
atic notch. The view in lesser sciatic notch can mimic the Literature Review
picture as in greater sciatic notch.
In case one is not sure, the fascia plane between the glu- Piriformis syndrome is a non-discogenic extrapelvic cause
teus maximus and piriformis (quite common in repeated of sciatic nerve compression or irritation and is estimated to
Botox injection of the piriformis when the piriformis is atro- account for 6% to 8% of all cases of sciatica. There are no
phic), internal and external rotation of the piriformis muscle clear definite diagnostic criteria, and the diagnosis relies on
is a very useful manoeuver to differentiate the gluteus maxi- exclusion of spinal and intrapelvic cause of sciatic and a con-
mus and piriformis muscle. stellation of clinical features. Systematic review of the clini-
The greater sciatic notch orientated posterolaterally. cal features revealed for consistent findings in piriformis
Therefore, the idea probe position is to tilt medially to opti- syndrome in literature: buttock pain, pain aggravated on sit-
mize the view of the notch. ting, tenderness near the greater sciatic notch, pain on any
514 P. Peng and D. Jankovic

Gluteus
maximus
A
Piriformis
B Sacrospinous
ligament

Ischial
spine

Sciatic
nerve
Alcock
canal
Pudendal
Sacrotuberous
Pudendal artery ligament
nerve
a c

Fig. 37.5 The left upper figure shows the position of the scan. (a) The left upper figure. The scan can be optimized by aligning the probe with
ultrasound image when the probe is in position A. The sonogram shows the long axis of piriformis and tilting the probe in medial orientation. Pi
the iliac crest and the gluteus maximus (G Max), medius (G Med), and piriformis. (c) The Doppler scan as b. (Reproduced with permission
minimus (G Min) muscles. The arrow indicates the superior gluteal from Philip Peng Educational Series)
artery and nerve. (b) Ultrasound image corresponds to the scan b in the

Fig. 37.6 Ultrasonography shows the position of the needle insertion. The needle is inserted in plan from medial to lateral position. Pi piriformis,
G Max gluteus maximus. Arrowhead: sciatic nerve. (Reproduced with permission from Philip Peng Educational Series)
37 Piriformis and Obturator Internus Injection 515

a Bony contour b

A
Iliac crest
A

B
Greater sciatic notch
B ischium

C
C
Ischial spine
D

D
Lesser sciatic notch
ischium

c d

Fig. 37.7 (a) This figure shows the position of the probe in different the bony contour is straight, and a hyperechoic line on the medial side
position and the bone signatures in each scan. The scan sequence is of the ischial spine is the sacrospinous ligament (arrows in the right
similar to the scanning of piriformis, starting from the iliac crest, the lower figure). G Max and Med Min stand for gluteus maximus and
greater sciatic notch, and then the ischial spine (b–d). (b) At the iliac medius and minimus, respectively. The sonogram at position D is
crest, three gluteus muscles can be visualized. (c) At the greater sciatic shown in Fig. 37.8. (Reprinted with reproduction from Philip Peng
fossa, the piriformis muscle (Pi) is seen. (d) At the ischial spine level, Educational Series)

maneuver that increases piriformis muscle tension, and limi- the long-lasting pain relief increased to 100% when obtura-
tation of straight leg raising. In physical examination, almost tor internus was injected.
all of them had tenderness to deep palpation over the greater Other than clinical features, other investigations are
sciatic notch. The provocative test is helpful. The sensitivity mainly to exclude other causes of sciatica. Electrodiagnostic
and specificity of those tests are summarized in a recent testing is usually normal in patient with piriformis syndrome
review article by Probst et al. but is usually to reveal lumbosacral radiculopathy or other
Obturator internus syndrome may present with clinical source of pain in lower extremity. Likewise, CT scan and
features similar to that of piriformis syndrome. Both pirifor- MRI are not specific in the diagnosis of piriformis syndrome
mis and obturator internus fuse together prior to the insertion but serve to exclude other pathologies.
in greater trochanter in 43% of patients, allowing simultane- By suppressing the signal of the tissue around the nerve,
ous stretching of both tendons during hip rotations. In some MR neurography improves visualization of peripheral
individuals, it was shown that the obturator internus, not the nerves. In a large case series with patients who had pain in
piriformis, impinged on the sciatic nerve in early flexion. the sciatic nerve distribution with unclear diagnosis or failed
There is also report that patient with apparent piriformis syn- response to lumbar spine surgery, MR neurography revealed
drome received partial benefit from piriformis injection but edema or hyperintensity in the ipsilateral sciatic nerve rela-
516 P. Peng and D. Jankovic

Fig. 37.8 From the ischial spine level (as in Fig. 37.7d), further caudal the sacrotuberous ligament continues to be observed, and the pudendal
movement of the probe will reach the lesser sciatic notch. Please note neurovascular bundle will move close to the OI in the Alcock’s canal.
the bony contour. Because of the orientation of the bone and obturator Deep to the sacrotuberous ligament, two pelvic floor muscles can be
internus (OI) muscle is close to 90° to the ultrasound probe, the OI seen: coccygeus (labeled blue deep to the sacrotuberous ligament) and
appears as a hypoechoic structure. If the clinician carefully observes the iliococcygeus muscle (outlined by yellow line). (Reprinted with per-
structures transitioned from the ischial spine to the less sciatic notch, mission from Philip Peng Education Series)

tive to the contralateral side in 94% of patients. Of these the contracture of the affected musculature and reduce con-
patients, 88% reproduced their symptoms with the flexion, nective tissue adhesions in the area. The techniques include
adduction, and internal rotation (FAIR). Combining the find- relaxation exercises for the pelvic floor muscles, stretching
ing of unilateral sciatic nerve hyperintensity at the sciatic exercises for the gluteal muscles, massage of the piriformis,
notch and asymmetry of the piriformis had a specificity of and exercises to mobilize the sacroiliac articulation, and
0.93 and sensitivity of 0.64 for predicting good-to-excellent lumbar spine should be performed. Other recommended
outcome from piriformis muscle release surgery. techniques include intermittent cold with stretching, internal
Piriformis syndrome causing sciatica usually responds to transrectal or transvaginal massage of the muscle, ischemic
conservative treatments, including physical therapy; lifestyle compression with a tennis ball, ultrasound application, short-
modification; symptomatic relief of muscle and nerve pain wave diathermy in conjunction with a full course of physical
with nonsteroidal anti-inflammatory agents, tricyclic antide- therapy, self-stretching of the muscle, corrective actions
pressants, muscle relaxants, neuropathic pain agents such as (e.g., for lower limb length differences), postural and activity
gabapentin, pregabalin, and carbamazepine; and psychother- stress reduction, and avoidance of prolonged immobilization
apy. When patients fail to respond to simple conservative of the affected lower limb when driving vehicles for long
therapy, interventional modalities are considered. In rare cir- distances. Focused shock waves have been successfully used
cumstances, surgical release of the piriformis has been for couple decades now for common orthopedic indications.
described for difficult cases of piriformis syndrome, but this The treatment of trigger points in the piriformis muscle with
is occasionally accompanied by morbidity. focused shock waves is a new and promising noninvasive
Physical therapy should be considered as the initial treat- method as a part of multimodal therapy.
ment for piriformis syndrome. The primary consideration in Mixing the local anesthetic solution with 20–40 mg of a
treating piriformis with osteopathic manipulation is to relieve long-acting corticosteroid (e.g., long-acting methylpred-
37 Piriformis and Obturator Internus Injection 517

nisolone) is also recommended. Experience shows that Suggested Reading

long-­acting local anesthetics do not provide any substan-
tial advantages over short-acting agents. In addition to the Abram SE. Treatment of lumbosacral radiculopathy with epidural ste-
roids. Anesthesiology. 1999;91:1937–41.
anti-­inflammatory properties, steroids also have Bartret AL, Beaulieu CF, Lutz AM. Is it painful to be different? Sciatic
membrane-­stabilizing properties. The response to these nerve anatomical variants on MRI and their relationship to pirifor-
injectate can be immediate but may be of short duration. mis syndrome. Eur Radiol. 2018;28:4681–6.
Benzon et al. reported that 16 of 19 patients responded to Beaton LE, Anson BJ. The sciatic nerve and the piriformis muscle.
Their interrelation and possible cause of coccygodynia. J Bone Joint
piriformis muscle injections over a short-term follow-up Surg Am. 1938;20-A:686–8.
period of 3 months. However, the majority of these patients Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome: ana-
had associated diagnoses, including herniated disks, spinal tomic considerations, a new injection technique, and a review of the
stenosis, failed back surgery syndrome, and complex literature. Anesthesiology. 2003;98:1442–8.
Carro LP, Hernando MF, Cerezal L, et al. Deep gluteal space problems:
regional pain syndrome. Filler et al. reported on 46 patients piriformis syndrome, ischiofemoral impingement and sciatic nerve
who received local anesthetic injections. Sixteen percent release. Muscles Ligaments Tendons J. 2016;6:384–96.
had sustained pain relief for periods ranging from 8 months Cassidy L, Walters A, Bubb K, Shoja M, Tubbs SR, Loukas M. Piriformis
to 6 years; 8% had 2–4 months of relief but required a sec- syndrome: implications of anatomical variations, diagnostic tech-
niques, and treatment. Surg Radiol Anat. 2012;34:479–86.
ond injection; 37% had 2–4 months of relief but experi- Dalmau-Carola J. Myofascial pain syndrome affecting the piriformis
enced recurrence after a second injection; 24% of the and the obturator internus muscle. Pain Pract. 2005;5(4):361–3.
patients benefited for only 2 weeks; and 16% experienced Durrani Z, Winnie AP. Piriformis muscle syndrome: an underdiagnosed
no benefit. cause of sciatica. J Pain Symptom Manage. 1991;6:374–9.
Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and
Botulinum toxin type A inhibits the release of acetylcho- piriformis syndrome: diagnosis by magnetic resonance neurography
line from peripheral cholinergic nerve endings, functionally and interventional magnetic resonance imaging with outcome study
denervates muscle fibers, and causes flaccid paralysis. The of resulting treatment. J Neurosurg Spine. 2005a;2(2):99–115.
literature supports the analgesic efficacy of the use of botuli- Filler AG, Haynes BA, Jordan SE, et al. Sciatica of nondisc origin and
piriformis syndrome: diagnosis by magnetic resonance neurography
num toxin A. Compared with a mixture of lidocaine and ste- and interventional magnetic resonance imaging with outcome study
roid as well as normal saline (placebo), botulinum toxin of resulting treatment. J Neurosurg Spine. 2005b;2:99–115.
provided superior pain relief in patients with piriformis syn- Fishman LM, Anderson C, Rosner B. BOTOX and physical therapy
drome in a double-blind, randomized, placebo-controlled in the treatment of piriformis syndrome. Am J Phys Med Rehabil.
2002;81:936–42.
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physical therapy, significant pain relief (>50% reduction in and physical therapy in the treatment of piriformis syndrome: a
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520 G. Bellingham and P. Peng

nerve blockade may assist in facilitating a diagnosis of pain, (4) no objective sensory loss on clinical examination,
pudendal neuralgia or to confer periods of analgesia as a and (5) positive anesthetic pudendal nerve block.
treatment option. Pudendal nerve blockade may satisfy the last essential
To assist in the identification of the subset of pudendal Nantes criterion if the pain is relieved for the duration of the
neuralgia-pudendal entrapment neuropathy (PNE), the local anesthetic. However, as described in the original arti-
Nantes criteria have been proposed which list clinical inclu- cle, a positive diagnostic block may not be specific for
sion and exclusion criteria. Essential criteria include (1) pain pudendal neuralgia, as alternative causes of the perineal pain
in the anatomical territory of the pudendal nerve, (2) symp- will be anesthetized if they are situated within the nerve’s
toms worsened by sitting, (3) patient not woken at night by territory.

Functional Anatomy
Table 38.1 Indications for pudendal nerve block
Surgical procedures Obstetric anesthesia or analgesia The ventral rami of S2, S3, and S4 commonly form the
Hemorrhoidectomy Augment analgesia when sacral pudendal nerve, yet contributions from S1 and S5 nerve
Penile prosthesis surgery sparing occurs during epidural
Hypospadias repair catheter use roots have been documented. Contributing nerve roots may
Circumcision Instrumented deliveries either combine to form a single pudendal nerve or form
Prostate biopsy Episiotomies between 2 and 3 “trunks,” which may or may not combine to
Placement of prostate HDR Repair of perineal tears form the pudendal nerve and its terminal branches (inferior
brachytherapy McDonald cerclage
Suburethral tape placement rectal, perineal, and dorsal branches).
Colpoperineorrhaphy Once formed, the pudendal nerve and its trunks briefly
Transvaginal pelvic exit the pelvis to enter the gluteal region, beneath the pirifor-
reconstructive surgery mis muscle via the infrapiriform notch (Figs. 38.1 and 38.2).

Gluteus
maximus

Piriformis
Sacrospinous
ligament

Ischial
spine

Sciatic
nerve
Alcock Sacrospinous ligament
canal
Pudendal Sacrotuberous Inferior rectal N.
Pudendal artery ligament
nerve
Alcock’s cancal

Perineal branch of pudendal N

Dorsal nerve of penis/clitoris

Posterior view Anterior view

Fig. 38.1 Left: posterior view of the pelvis showing the piriformis the greater sciatic foramen. The nerve gives rise to the inferior rectal
muscle and the neurovascular bundle deep to it. The pudendal nerve and nerve, the perineal nerve, and the dorsal nerve of the penis or clitoris.
artery run between the sacrospinous and sacrotuberous ligaments. The inferior rectal nerve branches from the pudendal nerve prior to
Right: anterior view of the pelvis showing the pudendal nerve arising Alcock’s canal. N nerve. (Reproduced with permission from Philip
from S2 to S4 and exiting the pelvis to enter the gluteal region through Peng Educational Series)
38 Pudendal Nerve 521

Fig. 38.3 Anatomy of the perineum (1). Pudendal nerve, (2) inferior
rectal nerves, (3) perineal nerves, (4) internal pudendal artery, (5) inter-
nal pudendal veins, (6) inferior rectal artery, (7) ischiorectal fossa, (8)
vaginal orifice, (9) ischial tuberosity, (10) gluteus maximus muscle,
Fig. 38.2 Anatomic specimen. (1) Pudendal nerve and pudendal ves- (11) anus. (Reproduced with permission from Dr. Danilo Jankovic)
sels in the ischiorectal fossa, (2) sacrotuberous ligament, (3) sciatic
nerve. (Reproduced with permission from Dr. Danilo Jankovic)
distance of 2 to 3 cm from the inferior border of the symphy-
sis pubis.
The nerve then courses between the sacrospinous and sacro- The pudendal nerve divides into three branches: the infe-
tuberous ligaments, adjacent to the ischial spine. At this rior rectal branch, the perineal branch, and the dorsal nerve
point, the nerve may cross over the posterior aspect of either of the penis/clitoris (Figs. 38.1 and 38.3).
the sacrospinous ligament or the ischial spine. Anatomical The inferior rectal branch descends to occupy the lower
study has revealed that the nerve crosses the sacrospinous half of the ischiorectal fossa. It subdivides into cutaneous
ligament in 80% of cases, while in 15% of cases, it crosses branches that supply sensory innervation to the anal canal
the ischial spine. Remaining variations contained multi-­ and the skin around the anus. Sensory innervation may
trunked nerves crossing both the ischial spine and sacrospi- include the skin of the scrotum. The inferior rectal branch
nous ligament. provides the main motor innervation to the external anal
The relationship of the pudendal artery to the nerve has sphincter, and investigations have also documented occa-
also been examined from anatomical study. In 80% of cases, sional motor innervation to the levator ani muscle as well,
the pudendal nerve lies medial to the artery, while in 10% of through an “accessory rectal nerve.” The inferior rectal
cases, the nerve lies lateral to the artery. Remaining anatomi- branch can pierce through the sacrospinous ligament as it
cal relationships observed include having the artery lie proceeds to the ischiorectal fossa, which can be a possible
between two trunks, and in 7.5% of cases, the artery crossed site of entrapment.
the nerve. The perineal branch of the pudendal nerve divides into
After passing at the level of the ischial spine, the nerve superficial and deep branches. The superficial branch pro-
reenters the pelvis through the lesser sciatic foramen to con- vides sensory innervation through the posterior scrotal/pos-
tinue its course anteriorly through a fascial tunnel formed terior labial nerve, which contributes to the innervation of
along the medial border of the obturator internus muscle the posterior aspect of the scrotum or labia majora. This
known as Alcock’s canal (Fig. 38.1). Alcock’s canal lies branch may join the sensory branches of the inferior rectal
medial to the obturator internus muscle and is formed by a branch. The deep branch supplies motor innervation to the
splitting of the muscle’s fascia into a medial and lateral layer. muscles of the pelvic floor and the deep perineal pouch. The
The medial layer covers the pudendal neurovascular bundle external urethral sphincter receives voluntary innervation
and fuses below with obturator fascia. The lateral layer is from this branch. Other muscles that receive motor innerva-
continuous with the obturator fascia. The length of the canal tion include the transverse perinei, bulbospongiosus, and
has been measured from 1.4 to 1.8 cm in adults, ending at a ischiocavernosus muscles. Motor innervation has also been
522 G. Bellingham and P. Peng

reported to include the anterior part of the external anal

sphincter and the levator ani muscle.
The dorsal nerve of the penis or clitoris is the final branch
of the pudendal nerve. This branch pierces through the supe-
rior fascia of the urogenital diaphragm once it reaches the
inferior pubic ramus. Beyond this point, the nerve travels in
a pouch that is defined by the crus of the penis/clitoris ante-
riorly and inferiorly. The branch may then pierce either the
inferior fascia of the urogenital diaphragm or pierce above
the inferior transverse pubic ligament. Once exited the pelvis
at this point, the nerve travels anterior to the pubic bone in a
groove known as the “sulcus nervi dorsalis penis/clitoris.” It
then deflects ventrally to innervate the penis or clitoris.

Technique

Transvaginal Technique Fig. 38.4 Transvaginal access. (1) Ischial spine, (2) sacrospinous liga-
ment, (3) pudendal nerve. (Reproduced with permission from Dr.
Danilo Jankovic)
The pudendal nerve can be blocked transvaginally through a
“blind” technique using the ischial spine as an anatomic
landmark (Fig. 38.4). The distal end of an introducer kit is
used to guide the needle toward the pudendal nerve, which
allows for infiltrating needles to be advanced 1.0 to 1.5 cm
beyond their distal openings. Introducers described in the lit-
erature include the Iowa trumpet or Kobak needle and needle
guide.
The introducer is first placed against the vaginal mucosa,
inferior to the ischial spine. In obstetrical anesthesia litera-
ture, the guide is to be held parallel to the delivery table. The
needle is advanced into the vaginal mucosa, and 1 mL of
local anesthetic is infiltrated. The needle is then advanced
further until contact is made with the sacrospinous ligament,
where another 3 mL of local anesthetic is injected. Care
should be taken at this point to first aspirate for blood to help
exclude intravascular injection prior as the pudendal vessels
will be in close proximity. The needle is then passed through
the ligament into the loose areolar tissue posterior to it, Fig. 38.5 Transperineal access. Rectal palpation of the ischial spine
where another 3 mL of local anesthetic is deposited prior to with the index finger. The needle is introduced into the ischiorectal
fossa. (Reproduced with permission from Dr. Danilo Jankovic)
aspiration. These steps are then repeated, but with the intro-
ducer placed superior to the ischial spine so as to ensure
adequate spread around the pudendal nerve. cles. The ischial spine can be localized by palpation of the
ischial spine by inserting a finger through the vagina or rec-
tum. Once this anatomic landmark is identified, a needle is
Transperineal Technique guided to this point through the skin overlying the ischiorec-
tal fossa (Fig. 38.5). The skin entry point can vary between
This approach has been described in the literature together descriptions. However, maintaining anal sphincter and peri-
with the use of nerve stimulation and has mainly focused on neal muscle contraction while diminishing the stimulating
providing analgesia either for perineal surgical procedures or current to 0.5–0.6 mA is typically used to optimize the final
for management of pudendal neuralgia. needle tip position.
The techniques described commonly include stimulation It should be noted that anal sphincter contraction alone
of the pudendal nerve adjacent to the ischial spine to elicit a might not be sufficient for a satisfactory pudendal nerve
contraction of the external anal sphincter and perineal mus- block, as this may indicate that only the inferior rectal nerve
38 Pudendal Nerve 523

branch is being stimulated. Contraction of the pelvic floor ligament. Investigators have not described any particular cor-
muscles is more desirable as it indicates that the perineal relation between pattern of spread and success of sensory
branch is also being stimulated, signifying that the pudendal blockade.
nerve itself, rather than individual branches, is being
contacted. Ultrasound-Guided
The use of an ultrasound-guided approach to block the
pudendal nerve has been described in the literature. The use
Transgluteal Approach of ultrasound allows for the visualization of soft tissues, nee-
dle advancement, and live spread of injectate around the tar-
Fluoroscopy-Guided get structures. The use of ultrasound guidance has been
Blockade of the nerve is accomplished by targeting the nerve described for blockade of the pudendal nerve at the level of
within the gluteal region as it courses adjacent to the ischial the ischial spine as well as at Alcock’s canal.
spine (Fig. 38.6).
Patients are placed in a prone position. A fluoroscope is
then positioned over the targeted side of blockade to obtain Level of the Ischial Spine
an oblique view 5–20° to the side to be blocked. This view
exposes the ischial spine more clearly, avoiding the overlap- Patients are placed in a prone position, and a curvilinear
ping with the pelvic brim. Once the ischial spine is identi- transducer with a low frequency (2–5 MHz) is required
fied, a skin entry point on the buttock is marked at the tip of because of greater tissue depths. The transducer is first posi-
the ischial spine. After skin infiltration with local anesthetic tioned over the ilium at the level of the posterior superior
is achieved, a spinal needle can be advanced, coaxial to the iliac spine (PSIS). The ilium appears as a straight, hyper-
fluoroscopic beam, until it contacts the bony surface of the echoic line descending laterally (Fig. 38.7). As scanning
spine. Once satisfied, 1 mL of contrast medium can be continues caudally to the level of greater sciatic notch, the
injected to confirm appropriate soft tissue spread. Once com- hyperechoic line of the ilium starts to regress from the medial
plete, injection of the chosen solution can take place. aspect of the screen. The lateral aspect of the ultrasound
Contrast spread patterns described include spread in an screen transitions to a curved hyperechoic line revealing the
irregular or round pattern at the tip of the ischial spine. posterior aspect of the acetabulum. At this point, two muscu-
Additionally, spread can occur along the ipsilateral obturator lar layers can be identified: the gluteus maximus and the piri-
internus muscle, sacrotuberous ligament, or sacrospinous formis muscles.
Moving the probe in the caudal direction to the ischial
spine reveals four changes in the sonographic image: the
transition of curved posterior portion of the acetabulum to
the straight ischial spine, disappearance of the piriformis
muscle, appearance of a dense hyperechoic line extending
medially from the ischial spine, and appearance of the
pudendal artery. The most likely location of the pudendal
nerve is medial to this artery, and careful scanning may
reveal its fascicular structure.
Once the anatomy is identified as best possible, a needle
is advanced medial to the probe at a steep angle, using an
in-­plane approach. Owing to the steep angle of needle
advancement, the needle insertion point should be 2 cm away
from the probe. Movement of the tissues or spread of injec-
tate may be used to act as surrogate markers for locating the
needle tip position.
The needle will pierce through the sacrotuberous liga-
ment, which may provide sturdy resistance to advancement.
One may feel a “pop” sensation as the needle passes through.
At this juncture, injection can begin under direct ultrasound
visualization. Ideally, the spread of the injectate is medial to
the pudendal artery and is contained between the sacrotuber-
Fig. 38.6 Fluoroscopy-guided pudendal nerve block. FH femoral
head, Lat lateral, IS tip of the ischial spine. (Reproduced with permis- ous and sacrospinous ligaments. If the injectate does not fol-
sion from Philip Peng Educational Series) low this pattern, the needle can be repositioned. There is no
38 Pudendal Nerve 525

Fig. 38.8 Left: position of the probe and needle injection. Right: cor- outlined in dotted line. The sacrotuberous ligament is shaded in green
responding sonography. The obturator internus is seen as an hypoechoic color, and the needle is indicated by arrows. (Reproduced with permis-
structure medial to the ischium as indicated by arrowheads, and the sion from Philip Peng Educational Series)
pudendal neurovascular bundle at the entrance of the Alcock’s canal is

Table 38.2 Needle types and injectate for different approaches

Approach Indication Needle gauge and type Injectate
Transvaginal Obstetrical analgesia 22-gauge, 150-mm needle 9-mL 1% lidocaine
Obstetrical analgesia via tubular introducer 20-mL 1% lidocaine
Obstetrical analgesia Not specified 20-mL 1% mepivacaine
Obstetrical analgesia Not specified 5-mL 2% prilocaine
Not specified
Transperineal Colpoperineorrhaphy 100-mm stimulating needle 10-mL 0.25% bupivacaine
Episiotomy analgesia 100-mm stimulating needle 15-mL 0.75% ropivacaine
Chronic pelvic pain and anorectal surgery 22-gauge, 100-mm 5-mL 0.25% bupivacaine
Transrectal ultrasound-guided prostate stimulating needle 10-mL 1% prilocaine
biopsy 22-gauge spinal needle
Transgluteal Chronic perineal pain 25-gauge, 3.5″ spinal needle 3-mL 0.38% ropivacaine and 20-mg
fluoroscopy triamcinolone
Transgluteal Pudendal neuralgia 22-gauge, 120-mm insulated 5-mL, 0.25% bupivacaine in 1:200,000
ultrasound stimulating needle epinephrine and 40 mg methylprednisolone

Table 38.2 provides a survey of needle types and injectates otomy, and may only be fully established in time for the
used to perform pudendal nerve blocks according to the repair.
approach used. Other more common complications can include unin-
tended blockade of adjacent nerves. If pudendal nerve block-
ade is performed at the ischial spine, local anesthetic spread
Complications to the sciatic nerve may lead to sensory and motor blockade
of the lower limb. Depending on the patient setting, this
When performing pudendal nerve blockade for obstetrical could lead to delays in ambulation, risk of falls, or delayed
anesthesia, the most frequently reported complication has discharge from hospital or clinic. A randomized controlled
been block failure. When used during the second stage of study comparing fluoroscopic- and ultrasound-guided
labor, failure rates of the block have ranged from 10 to 50% pudendal nerve blockade through a transgluteal approach
in the literature. This may be due to failure of the local anes- revealed an incidence of sciatic nerve sensory loss in 7/23
thetic to reach the nerve or improper timing of the block fluoroscopy-guided procedures and 3/23 ultrasound-guided
placement. If the block is placed as the fetal head is crown- procedures. Motor weakness in the form of foot drop was
ing, nerve blockade may not be effective in time for an episi- noted in two patients for each group.
526 G. Bellingham and P. Peng

The posterior femoral cutaneous nerve is another nerve tion is important to perform effective nerve blocks and to
near the pudendal nerve at the level of the ischial spine that avoid complications.
also provides sensory innervation to the perineum. If a In most cases, the pudendal nerve crosses the sacrospi-
pudendal nerve blockade is being used to assist in the diag- nous ligament, rather than crossing over the ischial spine,
nosis of a pelvic pain syndrome, local anesthetic spread to and lies medial to the pudendal artery. It is important to recall
the posterior femoral cutaneous nerve may lead to false-­ that the nerve may lie lateral to the artery in some cases
positive results. (approximately 1 in 10) or exist as trunks lying medially and
The pudendal nerve provides motor innervation to the laterally to the artery. These variations could account for a
urethral sphincter and external anal sphincter, and loss of failed or partial block.
muscle tone may lead to temporary incontinence of bladder The authors suggest injecting medial to the pudendal ves-
or bowel function. In the study comparing fluoroscopic- to sel at the level of the ischial spine. If there is a prominent
ultrasound-guided techniques of pudendal nerve blockade, vessel lateral to the ischial spine, it is likely the inferior glu-
only 1 patient of 23 experienced bladder incontinence with teal artery instead of the pudendal artery. Care should be
bilateral pudendal nerve blockade. Although this may be an taken to perform a color Doppler scan in this area to avoid
infrequent occurrence, patients should be made aware of this mistaking these vessels.
possibility. If the injection is performed under ultrasound, attention
Practitioners and patients should also be made aware of should be paid to spread of the injectate laterally. When one
the uncommon, yet serious complications that are possible witnesses lateral spread beyond the ischial spine, injection
through pudendal nerve blockade. When used for labor anal- should be stopped to prevent the spread to the sciatic nerve
gesia, cases of fetal distress and neonatal local anesthetic given its proximity.
toxicity have been documented. Presentations of the neo- The authors recommend a systematic approach to ultra-
nates with local anesthetic toxicity have included hypotonia, sound scanning for anatomical landmarks to facilitate puden-
apnea, bradycardia, cyanosis, prolonged QT interval, and dal nerve blocks through a transgluteal approach. This is best
seizure activity. Factors that may increase the risk of this accomplished by first scanning for the iliac crest since it is
event include fetal ion trapping in the presence of acidosis easily recognized as a single hyperechoic line. Scanning then
and increased local anesthetic vascular uptake from the continues caudally toward the greater sciatic notch and then
perineum during labor. to the ischial spine.
Introduction of infection after transvaginal blocks for Since the plane of greater sciatic notch is laterally ori-
labor analgesia has been reported due to seeding of bacteria ented, the probe should ideally be tilted medially, so that the
into soft tissues from vaginal mucosa. This can lead to seri- ultrasound beam is directed toward the notch. This allows for
ous morbidity and mortality, with two deaths having been better visualization of the greater sciatic notch and its con-
reported in the literature. Abscess formation has been tents and the changes in sonoanatomy as scanning continues
reported posterior to the hip joint, into the gluteal muscula- caudally.
ture, or the retropsoal space. Of note, authors of these reports Due to the stiffness of the sacrotuberous and sacrospinous
have highlighted the risk of delays in diagnosis as the clinical ligaments, care should be taken not to overshoot the place-
presentation can be initially confused with normal postpar- ment of the needle tip. This may occur if initial resistance to
tum pain from sacroiliac joint strain or trochanteric bursitis. needle advancement is met with a “give way” of the needle
The formation of significant hematoma after pudendal once it passes through the ligament. If this occurs, the needle
artery puncture has also been described in the literature in should be pulled back or carefully imaged to ensure proper
conjunction with infection. After blind infiltration for labor placement between the ligaments.
analgesia, an infected retroperitoneal hematoma along the
iliac and psoas muscles has been reported, which extended
from the midpelvis to the infrarenal fossa. Infection rather Literature Review
than blood loss was the principal concern in this case,
however. Perioperative Pain Control

There have been a number of investigations evaluating the

Practical Tips utility of this block for hemorrhoidectomy, as the postopera-
tive pain of this procedure can be very severe. Pudendal
An important anatomical landmark for performing a puden- nerve blockade has been found to confer substantial benefits
dal nerve block is the ischial spine. This is a common loca- for pain control over other types of analgesia, such as neur-
tion for nerve infiltration for obstetrical, perioperative, and axial blocks, general anesthesia, or nonspecific local anes-
chronic pain purposes. Knowledge of anatomy at this loca- thetic infiltration to the soft tissues of the perineum. In
38 Pudendal Nerve 527

additional, the use of this block is associated with reduced labor has been raised when epidural analgesia is used.
length of patient stay in hospital, reduced oral analgesic con- Increased dosing of epidural analgesia with local anesthetic
sumption, and improved patient satisfaction over other meth- during the second stage of labor can lead to increased weak-
ods of analgesia. ness of abdominal muscles, thereby diminishing forces
Urinary retention after hemorrhoidectomy is a common required to facilitate a delivery.
and undesirable side effect of anal surgery, as well as with Xu et al. sought to determine if the use of pudendal nerve
neuraxial anesthetic techniques. The use of pudendal nerve blockade during the second stage of labor reduced supple-
blockade has been shown to significantly reduce this particu- mental epidural dosing, thereby helping to prevent a pro-
lar postoperative complication. longed second stage of labor in nulliparous women. Pudendal
The evaluation of benefits of pudendal nerve blockade has nerve blockade was performed using ultrasound guidance,
also been investigated for urological procedures such as and the study was conducted as a prospective, double-blind,
penile prosthesis surgery, hypospadias repair and circumci- randomized controlled trial. The group receiving the puden-
sion in pediatric population, prostate biopsy, and placement dal nerve block required significantly less hourly bupiva-
of prostate HDR brachytherapy. The use of pudendal nerve caine boluses through their epidural catheter and reduced the
blockade has been described for gynecologic surgical proce- length of the second stage of labor by 33.8 min.
dures such as placement of suburethral tape and colpoperine-
orrhaphy. Pudendal nerve blockade, however, has not proven
useful to reduce pain after transvaginal pelvic reconstructive Pudendal Neuralgia
surgery.
Pudendal nerve blocks have been employed for patients suf-
fering from pudendal neuralgia and have failed conservative
Obstetrical Practice techniques. Targets for nerve infiltration are possible sites of
entrapment such as at the level of the ischial spine between
The use of pudendal nerve blockade during labor has typi- the sacrospinous and sacrotuberous ligaments or Alcock’s
cally been reserved for the second stage of labor. During this canal.
stage, pain is experienced in the perineum and becomes Studies have investigated the effectiveness of pudendal
somatic, innervated by the S2 to S4 nerve roots and the nerve infiltration for relief of this chronic pain syndrome but
pudendal nerves. have been heterogeneous in methodology. For example, vari-
Pudendal nerve block was likely used prior to the intro- ations exist in the chosen technique to perform the block
duction of epidural anesthesia techniques. However, it can (e.g., CT guidance or landmark-guided infiltration), single or
still be employed when neuraxial techniques are contraindi- repeated injections, choice of outcome measures, or duration
cated or if sacral sparring occurs during epidural catheter of follow-up.
use. This nerve block has been described for facilitating Investigations have also had considerable variability in
instrumented deliveries, episiotomies, repair of perineal the way in which patients are diagnosed and included to
tears, and McDonald cerclages for incompetent cervices. study this condition. For example, some investigations
The literature examining the effectiveness of local anes- adhere to the Nantes criteria to establish the diagnosis of
thetic infiltration during the second stage of labor has pri- pudendal neuralgia, while others only presume a diagnosis
marily focused on the use of paracervical blocks. However, of the condition without taking any confirmatory steps for
pudendal nerve infiltration has been evaluated in several patient study inclusion. These are considerable limitations
studies. There have been two studies that have directly com- when attempting to make conclusions about effectiveness of
pared the effectiveness of a single-shot spinal anesthetic to this block from the literature.
pudendal nerve blockade during the second stage of delivery. Despite these challenges, a recent systematic review of
The investigation by Pace et al. sought to compare the effec- the literature has attempted to extract some generalizations
tiveness of these interventions for women requesting analge- for the effectiveness of interventions for drug-resistant
sia during advanced labor, defined as cervical dilation greater pudendal neuralgia. For nerve infiltration, an immediate
than 7 cm. The investigation by Hutchins compared these improvement in pain intensity is achieved in 77% to 82% of
two techniques for instrumental delivery. In both studies, the patients. Data analysis further revealed that improvement in
neuraxial technique demonstrated superiority to pudendal pain intensity is experienced in 62% of patients at 3 months
nerve blockade for degree of analgesia and patient and 6.8% to 12.2% of patients at 1-year, post-procedure.
satisfaction. Functional outcome measures were not reported in this
Although neuraxial techniques for labor analgesia may review.
offer superior pain relief compared to the use of pudendal Notably, there has been one randomized controlled trial
blockade alone, concern for prolonging the second stage of evaluating the role of the addition of steroid to pudendal
528 G. Bellingham and P. Peng

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domized, double-blind, placebo-controlled study. Urology. SI. Periprostatic local anesthesia with pudendal block for trans-
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532 D. Jankovic

Fig. 39.2 Peripheral pain pathways during labor. (Reproduced with

permission from Danilo Jankovic)

Vaginal Delivery

Bilateral paracervical block alleviates the pain of the first

stage of labor, and this is the most frequent use of this block.

• Avoid: In prematurity, fetal distress, and uteroplacental

Fig. 39.1 Anatomy. (1) Aorta and inferior vena cava, (2) superior insufficiency.
hypogastric plexus, (3) pelvic (inferior hypogastric plexus), (4) lumbo-
sacral sympathetic ganglia, (5) lumbosacral plexus. (Reproduced with
permission from Danilo Jankovic) Therapeutic

• Relief of severe dysmenorrhea.

Indications • Endometritis and parametritis.

Paracervical block has a limited role in modern obstetric

practice, except in cases where central neural blockade is not Diagnostic
feasible or is unavailable.
Differentiation of severe dysmenorrhea from other similar
complaints which may be associated with menstruation.
Surgical

• Bilateral block may be used for dilatation of the cervix Materials

and uterine curettage.
• Occasionally, it may be combined with pudendal nerve The IOWA trumpet, Kobak instrument is used as a guide for
block and local infiltration to perform a vaginal the placement of the needle (20-gauge, 12–14 cm needle)
hysterectomy. (see Chap. 38).
39 Paracervical (Uterosacral Block) 533

Technique

Paracervical and uterosacral blocks are identical procedures

and the local anesthetic solution bathes the same plexus and
ganglia. If the solution is deposited at the 3 and 9 o’clock
positions, the block is termed paracervical, and if solution is
deposited at the 4 and 8 o’clock positions, the block is termed
uterosacral (Fig. 39.4). The pelvic (inferior hypogastric)
ganglia and plexus are anesthetized when this block is
performed.

Position and Landmarks

The patient is placed in the supine position with her legs

apart and partially in the lithotomy.
position. The injection is made in the lateral fornices of
the vagina.

• Vaginal examination should be performed immediately

before the block to determine the precise position of the
presenting part.
• Maternal and fetal vital signs should be determined
immediately before the block.
Fig. 39.3 The needle is introduced through the submucosa into the
lateral vaginal fornix. (1) Lateral vaginal fornix, (2) ostium uteri, (3)
Procedure uterine artery, (4) round ligament of uterus. (Reproduced with permis-
sion from Danilo Jankovic)
1. The needle is introduced through the submucosa into the
lateral vaginal fornix (Fig. 39.3). Dosage
The guide, with needle tip protected, is directed into
the lateral fornices between 3 and 4 o’clock and between The duration of the analgesia will vary with the local anes-
8 and 9 o’clock, by the index and middle fingers, so that thetic, its concentration, and the total dose used:
the tip of the guide does not depress the vaginal mucosa
excessively and to determine the precise location of the • 0.25% Bupivacaine provides 90–150 min of analgesia.
needle and to protect the vaginal tissues and the fetal pre- • 1% mepivacaine provides 90–150 min of analgesia.
senting part from inadvertent puncture by the advancing • 1% procaine or 2% chloroprocaine provides 40 to 50 min
needle (Fig. 39.4). of analgesia.
2. The needle is then introduced into the uterosacral • When performing a paracervical block, fetal heart rate
ligament. and maternal uterine contractions should be monitored
The needle should be inserted with a guard (e.g., an immediately preceding and for some time following the
Iowa Trumpet) so that the needlepoint cannot protrude block.
beyond the guard for more than 5–7 mm. This maneuver
prevents inadvertent intravascular injection and also pre-
vents damage to the fetal presenting part. Complications
3. After careful aspiration at various levels (blood), the local
anesthetic is injected on an incremental basis. • Systemic toxic reactions (see Chap. 5).
Approximately 5–10 mL of the chosen local anesthetic • Fetal distress, bradycardia, fetal acidosis, neonatal depres-
should be used in each fornix for satisfactory paracervical sion, and low Apgar scores. Paracervical injection may
block. lead to high levels of local anesthetics in the fetus, up to
4. The needle is removed, the guide redirected to the other 70% of fetuses will have arrhythmias (principally brady-
side of the cervix, and the injection repeated. cardia) within 10 min of injection.
534 D. Jankovic

Fig. 39.4 The guide, with

the needle tip protected, is
directed into the lateral
fornices between 3 and 4
o’clock and between 8 and 9
o’clock. (1) Vaginal fornix,
(2) ostium uteri. (Reproduced
with permission from Danilo
Jankovic)

• Fetal deaths from bupivacaine cardiotoxicity have also general anesthesia). It is important to recognize that the
been reported. block itself causes considerable discomfort. Adding sodium
• Block of the sciatic nerve, neuritis of the sciatic nerves, or bicarbonate to lidocaine results in decreased pain during
both. They may be a result of the needle being inserted injection (1 mL of 8.4% sodium bicarbonate per 10 mL of
further than 1.5 cm beyond the vaginal mucosa, the use of local anesthetic). The addition of fentanyl to lidocaine may
great volume of local anesthetic solution, or a combina- improve pain control. In addition, anecdotally, the smaller
tion of these. the needle size (e.g., 25G vs. 22G), the less pain experi-
• Hematoma of the parametrium. This occurs from trauma enced with injection. Until recently, however, despite its fre-
to a blood vessel during execution of the block. Finally, quent use, the data were conflicting on paracervical block
uterine artery hematoma, cervical abscess, and uternal efficacy for cervical dilation pain. The number of injection
trauma have been reported. sites did not seem to make a difference in the pain experi-
• Injections have occasionally been made directly into the enced with cervical dilation. A 20 mL block is superior to a
fetal scalp. 10 mL volume block. The multiple injections at the 2, 4, 8,
• A transient decrease in intensity and/or frequency of uter- and 10 o’clock positions are not necessary. The 4 and 8
ine contractions could be associated with the local anes- o’clock positions allow one to reach the nerve plexuses trav-
thetic, especially when epinephrine is used to perform the eling along the uterosacral ligaments. The available evi-
block. dence does not show if paracervical block is inferior,
equivalent, or superior to the alternative analgesic tech-
niques, either in terms of efficacy or safety. Some women
Literature Review are likely to experience anesthesia is hazardous, for exam-
ple, when patients are frail, unwell, or when no anesthesi-
Cervical dilation and uterine interventions (such as hyster- ologist is available. Paracervical local anesthesia offers an
oscopy, endometrial biopsies, fractional curettage, and suc- alternative for cervical dilation and uterine intervention as it
tion terminations) can be performed without any analgesia does not require general anesthetic equipment or personnel
or anesthesia, with regional anesthetic injections as with trained to give general anesthesia. Twenty-six studies
paracervical block, using oral or intravenous analgesics and involving 2790 women compared paracervical block and
sedatives, or under general anesthesia. Many gynecologists other anesthetic and analgesia methods for women undergo-
use paracervical local anesthesia but its effectiveness is ing uterine interventions.
unclear. The paracervical block with lidocaine is a com- There was evidence that paracervical block reduced the
monly used part of analgesia in many outpatient gyneco- risk of severe pain but not any pain. There was little evidence
logic procedures, including suction d&c. The majority of to support the belief that paracervical block made any con-
abortions are performed using a paracervical block (without sistent difference to any outcome.
39 Paracervical (Uterosacral Block) 535

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