Erector spinae Block: Parasagittal Inplane, Caudal to cephalad needling and catheter insertion in 2 cases (rib fractures and open nephrectomy) with very good pain relief.
very useful Madan, thanks a lot. I often struggle to differentiate between rib and transverse process, and then further medially between tr process and lamina of the vertebra. so 2 questions 1) any tips to diff between rib and tr process, and 2) if inadvertent injection too medially on lamina( rather than on tr process), will it make a difference in efficacy.. thanks a lot in advance
Sorry delayed reply. Rib= rounded, pleura immediately below it, Transverse process=Square shaped, pleura dives away, you would need a lateral probe angulation to find the pleura. If in doubt, use a transverse view, find the costotransverse notch and then rotate the probe sagittally. Generally its a fascial plane, what I could infer from cadaveric studies, is that the spread from the lamina is not as extensive as from the transverse process, similarly, some of the proposed mechanisms of action of ESP block are via the channels created by the blood vessels/dorsal nerves, which accounts for its paravertebral spread. Hope this answers your questions.
Is it possible the spread is intramuscular? It looks like the catheter may travel deep to original injection plane within intertransverse connective tissue?
Yes, there is always has an intramuscular spread when a Tuohy needle is used due to the large diameter of the tuohy orifice. We described this phenomenon of splitting of the layers of a longitudinal muscle as "lamination". A transverse view will help identify whether the spread is intramuscular or in the fascial plane. The catheter may traverse more than just one plane depending on length inserted and stiffness of the catheter and the path of least resistance. Clinical effect probably may not differ.
Normally we insert a multiorifice catheter (Pajunk- Rectus sheath catheter or Portex Epidural catheter). The maximum distance we recommend insertion is 5cms as the catheters have a high incidence of folding/kinking/knotting of inserted any longer.
very useful Madan, thanks a lot.
I often struggle to differentiate between rib and transverse process, and then further medially between tr process and lamina of the vertebra.
so 2 questions
1) any tips to diff between rib and tr process, and 2) if inadvertent injection too medially on lamina( rather than on tr process), will it make a difference in efficacy.. thanks a lot in advance
Sorry delayed reply. Rib= rounded, pleura immediately below it, Transverse process=Square shaped, pleura dives away, you would need a lateral probe angulation to find the pleura. If in doubt, use a transverse view, find the costotransverse notch and then rotate the probe sagittally. Generally its a fascial plane, what I could infer from cadaveric studies, is that the spread from the lamina is not as extensive as from the transverse process, similarly, some of the proposed mechanisms of action of ESP block are via the channels created by the blood vessels/dorsal nerves, which accounts for its paravertebral spread. Hope this answers your questions.
Is it possible the spread is intramuscular? It looks like the catheter may travel deep to original injection plane within intertransverse connective tissue?
Yes, there is always has an intramuscular spread when a Tuohy needle is used due to the large diameter of the tuohy orifice. We described this phenomenon of splitting of the layers of a longitudinal muscle as "lamination". A transverse view will help identify whether the spread is intramuscular or in the fascial plane. The catheter may traverse more than just one plane depending on length inserted and stiffness of the catheter and the path of least resistance. Clinical effect probably may not differ.
well placed catheter
Thank you for the video. Which catheter and how deeply (I mean distance inserted)?
Normally we insert a multiorifice catheter (Pajunk- Rectus sheath catheter or Portex Epidural catheter). The maximum distance we recommend insertion is 5cms as the catheters have a high incidence of folding/kinking/knotting of inserted any longer.
Thank you!
At what level do you perform ESP block for nephrectomy, sir?
I would aim around T7/T8 Territory