Anesth Pain Med.  2023 Apr;18(2):198-203. 10.17085/apm.22250.

Bolus intertransverse process block and continuous erector spinae plane block for perioperative analgesic management of video-assisted thoracoscopic surgery - Three cases report -

• Yamamoto Y
• Tanaka N
• Kadoya Y
• Umehara M
• Suzuka T
• Kawaguchi M

• KMID: 2543661
• DOI: http://doi.org/10.17085/apm.22250

Abstract

Background
Common regional anesthesia approaches for video-assisted thoracoscopic surgery (VATS) include paravertebral block (PVB) and erector spinae plane block (ESPB). PVB is considered a deep nerve block which is contraindicated in antithrombotic therapy. ESPB is effective when administered as a bolus, as well as continuously. However, the recently proposed intertransverse process block (ITPB) ensures more effective diffusion of the local anesthetic into the paravertebral space. Case: We report cases of three patients who received bolus ITPB (costotransverse foramen block and mid-point transverse process-to-pleura block in one and two cases, respectively) combined with continuous ESPB when a deep nerve block could not be administered. Opioids were not required postoperatively, and all postoperative numerical rating scale scores (0–10) at rest were maintained below 4.
Conclusions
The combination of bolus ITPB and continuous ESPB may be an alternative analgesic method when deep nerve blocks are contraindicated in VATS.

Keyword

Costotransverse foramen block; Erector spinae plane block; Intertransverse process block; Mid-point transverse process-to-pleura block; Peripheral nerve block; Thoracic surgery

Figure

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  Fig. 1. Ultrasonographic visualization of a costotransverse foramen block (case 1). Color Doppler was used to confirm local anesthetic administration. ESM: erector spinae muscle, NR: neck of the rib, TP: transverse process. Yellow arrow: needle pathway.

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  Fig. 2. Ultrasound image after catheterization into the erector spinae plane (case 1). Normal saline solution was used to confirm the correct catheter insertion position. ESM: erector spinae muscle, NS: normal saline solution, TP: transverse process. White arrowhead: catheter.

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  Fig. 3. Schema representing the point of local anesthetic administration by the nerve blocks. ESPB targets the erector spinae plane, PVB targets deeper than the SCTL, and CTFB and MTPB target sites deeper than the erector spinae plane but shallower than the SCTL. These blocks allow the local anesthetic to reach the PVS more easily compared to ESPB (orange arrows). It should be noted that the puncture point and CTFB image can only be obtained by moving the probe slightly more medially. CTFB: costotransverse foramen block, ESPB: erector spinae plane block, MTPB: mid-point transverse process-to-pleura block, PVB: paravertebral block, PVS: paravertebral space, SCTL: superior costotransverse ligament, TP: transverse process.

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