Anesth Pain Med.  2018 Apr;13(2):128-142. 10.17085/apm.2018.13.2.128.

Ultrasound-guided truncal blocks for perioperative analgesia

Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. koh9726@naver.com

Abstract

The widespread application of ultrasound in clinical anesthesiology has led to an increase in the number of practitioners performing peripheral nerve blocks of the trunk to produce analgesia and anesthesia for surgeries involving the thorax, abdomen, and lower extremities. The use of real-time ultrasound has allowed the peripheral nerves, planes, and plexuses of the trunk to be located more accurately and has improved the success rate of blocks. Compared to central neuraxial techniques, many types of truncal blocks are relatively easy to perform and have low side effect profiles. As a result, truncal blocks have been introduced to provide perioperative analgesia for surgeries involving the thorax and abdomen. The most frequently used truncal block techniques include the paravertebral block, intercostal block, pectoralis and serratus anterior block, rectus sheath block, transversus abdominis plane block, and ilioinguinal and iliohypogastric nerve blocks. Recently introduced techniques also include the quadratus lumborum and erector spinae plane blocks. To apply each block correctly and reduce the likelihood of related side effects and complications, the practitioner must have a thorough understanding of the anatomical region, optimal block positioning, and device selection and management.

Keyword

Analgesia; Nerve block; Trunk; Ultrasonography

MeSH Terms

Abdomen
Analgesia*
Anesthesia and Analgesia
Anesthesiology
Lower Extremity
Nerve Block
Peripheral Nerves
Thorax
Ultrasonography

Figure

  • Fig. 1 Ultrasound image of the paravertebral block in transverse approach technique. The ultrasound probe is placed in the transverse axis. The paravertebral space is located beneath the transverse process seen in the image and above the pleura (arrows). The needle is inserted in-plane in the lateral to medial direction. White dashed line with arrow presents the needle trajectory. Arrows: pleura, ESM: erector spinae muscle, L: lamina, PVS: paravertebral space, T: transverse process.

  • Fig. 2 Ultrasound image of the paravertebral block in parasagittal approach technique. The ultrasound probe is placed in the parasagittal axis. The paravertebral space is located under the superior costotransverse ligament (yellow dashed line) and above the pleura (arrows). The needle is inserted in-plane in the caudal to cephalad direction (white dashed line with arrows). Arrows: pleura, Red dashed line: intertrasverse ligament, Yellow dashed line: superior costotransverse ligament, ESM: erector spinae muscle, PVS: paravertebral space, R: rib, T: transverse process.

  • Fig. 3 Ultrasound image of the intercostal block. The ultrasound probe is placed in the parasagittal axis. The needle is inserted in-plane in a caudal to cephalad direction to locate the needle tip between the internal intercostal muscle and the innermost intercostal muscle. Arrows: pleura, EXT: external intercostal muscle, IM: innermost intercostal muscle, INT: internal intercostal muscle, R: rib.

  • Fig. 4 Ultrasound image of the Pecs 2 block. The ultrasound probe is placed in the parasagittal axis at the level of 3rd and 4th rib. The needle is inserted in-plane in a cranial to caudal direction to locate between 1) the pectoralis major and minor; and 2) pectoralis minor and serratus anterior muscle. Red arrow: thoracodorsal artery, Yellow arrows: pleura, PM: pectoralis major, Pm: pectoralsis minor, R3: third rib, R4: fourth rib, SA: serratus anterior.

  • Fig. 5 Ultrasound probe positions for the transversus abdominis plane (TAP) block, rectus sheath block and ilioinguinal nerve block. (A) subcostal TAP block, (B) lateral TAP block, (C) posterior TAP block, (D) rectus sheath block, (E) ilioinguinal nerve block.

  • Fig. 6 Ultrasound image of the subcostal transversus abdominis plane block. The needle is positioned in-plane between the transversus abdominis muscle and the rectus abdominis muscle (arrow heads). Arrow heads: target plane of local anesthetic deposit, EO: external oblique, IO: internal oblique, RA: rectus abdominis, TA: transversus abdominis muscle.

  • Fig. 7 Ultrasound image of the lateral transversus abdominis plane block. The needle is positioned in-plane between the transversus abdominis muscle and the internal oblique abdominis muscle (arrows). Arrows: target plane of local anesthetic deposit, EO: external oblique, IO: internal oblique, TA: transversus abdominis muscle.

  • Fig. 8 Ultrasound image of the posterior transversus abdominis plane block. The needle is positioned in-plane above the aponeurosis of the transversus abdominis muscle (arrows). Arrows: target plane of local anesthetic deposit, LD: latissimus dorsi muscle.

  • Fig. 9 Ultrasound image of the rectus sheath plane block. The needle is positioned in-plane under the rectus abdominis muscle and the posterior rectus sheath (arrows). Arrows: target plane of local anesthetic deposit, EO: external oblique, IO: internal oblique, RA: rectus abdominis, TA: transversus abdominis muscle.

  • Fig. 10 Ultrasound image of the ilioinguinal and iliohypogastric nerve blocks. The needle is positioned in-plane in the lateral to medial direction between the transversus abdominis muscle and the internal oblique abdominis muscle (arrows). The bony shadows in the right lower corner is the anterior superior iliac spine. Arrows: target plane of local anesthetic deposit, EO: external oblique, IO: internal oblique, TA: transversus abdominis muscle.

  • Fig. 11 Ultrasound image of the quadratus lumborum (QL) block. The “Shamrock” image is obtained. 1) Posterior QL block: the needle is positioned in the fascial layer posterior to the QL muscle (upper arrows), 2) anterior QL block: the needle is positioned in between the QL muscle and the psoas major muscle (lower arrows). Upper (down facing) arrows: target plane of local anesthetic deposit for the posterior QL block, Lower (upper facing) arrows: target plane of local anesthetic deposit for the anterior QL block, AV: abdominal viscera, ESM: erector spinae muscle, PM: psoas major muscle, QL: quadratus lumborum muscle, VB: vertebral body.

  • Fig. 12 Ultrasound image of the erector spinae plane block. The ultrasound probe is placed in the parasagittal axis. The needle is inserted in-plane in a cranial to caudal direction to locate the needle tip between the transverse process and the erector spinae muscle (white dashed line with arrows). White dashed line with arrow presents the needle trajectory. Arrows: target plane of local anesthetic deposit, ESM: erector spinae muscle, PVS: paravertebral space, R: rib, T: transverse process.


Cited by  1 articles

Current evidence of ultrasound-guided fascial plane blocks for cardiac surgery: a narrative literature review
Boohwi Hong, Chahyun Oh, Yumin Jo, Soomin Lee, Seyeon Park, Yoon-Hee Kim
Korean J Anesthesiol. 2022;75(6):460-472.    doi: 10.4097/kja.22564.


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