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Different Approaches to Ultrasound-Guided REVIEW ArtICLE David S. Warner, M.D., Editor Different Approaches to Ultrasound-guided Thoracic Paravertebral Block An Illustrated Review Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/123/2/459/268052/20150800_0-00033.pdf by guest on 24 September 2021 Annelot C. Krediet, M.D., Nizar Moayeri, M.D., Ph.D., Geert-Jan van Geffen, M.D., Ph.D., Jörgen Bruhn, M.D., Ph.D., Steven Renes, M.D., Ph.D., Paul E. Bigeleisen, M.D., Gerbrand J. Groen, M.D., Ph.D. This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. ABSTRACT Given the fast development and increasing clinical relevance of ultrasound guidance for thoracic paravertebral blockade, this review article strives (1) to provide comprehensive information on thoracic paravertebral space anatomy, tailored to the needs of a regional anes- thesia practitioner, (2) to interpret ultrasound images of the thoracic paravertebral space using cross-sectional anatomical images that are matched in location and plane, and (3) to briefly describe and discuss different ultrasound-guided approaches to thoracic paravertebral blockade. To illustrate the pertinent anatomy, high-resolution photographs of anatomical cross-sections are used. By using voxel anat- omy, it is possible to visualize the needle pathway of different approaches in the same human specimen. This offers a unique presentation of this complex anatomical region and is inherently more realistic than anatomical drawings. (ANESTHESIOLOGY 2015; 123:459-74) HORACIC paravertebral (TPV) nerve block produces Different landmark-based techniques exist, with some Tipsilateral, segmental, somatic, and sympathetic nerve techniques using electrostimulation guidance or pressure mea- blockade in contiguous thoracic dermatomes. The technique surement as additional tools.1–9 With the advent of ultrasound was first described in 1905 by Sellheim and reintroduced into imaging in regional anesthesia, this tool is increasingly used clinical practice by Eason and Wyatt in 1978.1 Since then, it also for TPV blockade, resulting in a rapid development of dif- has become increasingly popular for treating acute and chronic ferent ultrasound-guided approaches in recent years.10–22*†‡ pain of thorax, abdomen, and pelvis. It can be used unilaterally Given the fast development and increasing clinical or bilaterally, with a single injection technique or via a catheter. relevance of ultrasound guidance for TPV blockade, this This article is featured in “This Month in Anesthesiology,” page 1A. Supplemental Digital Content is available for this article. Direct URL cita- tions appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). Figure 5 was adapted by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina. Excerpts of this work have been presented during a poster session at the American Society of Anesthesiologists 2011 Annual Meeting in Chicago, Illinois, on October 18, 2011 (Abstract A1174, “Interpreting the sonoanatomy of the thoracic paravertebral space using reconstructed anatomical cross-sections”). The Supplemental Digital Content has been presented as a scientific exhibit at the American Society of Anesthesiologists 2011 Annual Meeting in Chicago, Illinois, on October 15–19, 2011 (11-SEE-4819- ASAHQ, “Interpreting the sonoanatomy of the thoracic paravertebral space by correlating animated anatomical and ultrasound images”). Submitted for publication August 14, 2014. Accepted for publication May 5, 2015. From the Department of Anesthesiology (A.C.K.) and Department of Neurosurgery (N.M.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, University Medical Center Nijmegen, Nijmegen, The Netherlands (G.-J.v.G., J.B., S.R.); Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland (P.E.B.); and Pain Center, Department of Anesthesiology, University Medical Center Groningen, University of Groningen, The Netherlands Groningen, (G.J.G.). * Vandepitte C, Stopar Pintaric T, Gautier PE: Thoracic paravertebral block. Available at: http://www.nysora.com/techniques/neuraxial- and-perineuraxial-techniques/ultrasound-guided/3277-thoracic-paravertebral-block.html. Accessed June 30, 2014. † Luyet C: Paravertebral nerve block. Available at: http://www.ultrasoundblock.com/index.php/nerve-block-techniques/nerve-blockother/ paravertebral-ultrasound-block. Accessed June 30, 2014. ‡ Gautier PE: European society of regional anaesthesia and pain medicine 30th annual congress 2011, Web cast. Available at: http://academy. esraeurope.org/esra/2011/30th/10994/philippe.gautier.intercostal.block.paravertebral.block.html?history_id=635072. Accessed June 30, 2014. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 123:459–74 Anesthesiology, V 123 • No 2 459 August 2015 Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Ultrasound-guided Thoracic Paravertebral Block review article strives (1) to provide comprehensive informa- The ultrasound images were collected in healthy volunteers, tion on TPV anatomy, tailored to the needs of a regional using either a SonoSite S-nerve (USA) or a BK Medical Flex anesthesia practitioner, (2) to interpret ultrasound images of Focus (Denmark) ultrasound platform with a linear-array the TPV space using cross-sectional anatomical images that transducer oscillating at 15 MHz. It should be noted that are matched in location and plane, and (3) to briefly describe the anatomy can vary between individuals and that the mea- and discuss different ultrasound-guided approaches to TPV surements of distances are only indicative. blockade. Boundaries and Continuities of the TPV Space Images The TPV space is situated directly adjacent to the thoracic spine To illustrate the pertinent anatomy, high-resolution photo- bilaterally. Its medial boundaries are the vertebral bodies, the Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/123/2/459/268052/20150800_0-00033.pdf by guest on 24 September 2021 graphs of anatomical cross-sections are used. The anatomical intervertebral discs, and the intervertebral foramina where it images were obtained by sectioning blocks of tissue contain- connects to the epidural space. Laterally, the TPV tapers and ing the spine (T1 to T12) of a human cadaver (male, age continues as intercostal space, a transition that takes place near 40, body mass index: 24) with a heavy-duty sledge cryomi- the costotransverse joint. Superiorly and inferiorly, the TPV crotome (PMV, Stockholm, Sweden) at an interval of 78 space is partially separated from the adjacent levels by the ribs μm. The surface of each section was photographed at high and transverse processes at each thoracic level. However, the resolution and the resultant photographs were processed adipose tissue at the anteromedial corner of the TPV space is with self-developed software (Enhanced Multiplanar Refor- continuous over all thoracic levels, as shown in figure 1. Pos- matting Along Curves) to digitally reconstruct the three teriorly, the TPV space is bounded by the transverse process, orthogonal planes (sagittal, frontal, and transversal) and the rib and the superior costotransverse ligament (SCTL), as oblique cross-sections. The technique is described in detail shown in figures 1 to 3. The SCTL runs from the superior bor- elsewhere.23 Tape-mounted histology was also acquired and der of the neck of the rib to the lower border of the transverse stained according to a modified Mallory-Cason protocol process of the vertebra immediately above (fig. 3, C and D). for large cryosections, which is a general oversight stain.24 It can consist of more than one layer and contain gaps.25–27 Fig. 1. Thoracic paravertebral space at thoracic level T5. The thoracic paravertebral space is high- lighted in turquoise in both the transversal plane (left side of body) and the sagittal plane (right side of body). es = erector spinae muscle; r = rib; SCTL = superior costotransverse ligament; SP = spinous process; TP = transverse process; trap = trapezius muscle. Anesthesiology 2015; 123:459-74 460 Krediet et al. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. EDUCATION of the lower thoracic TPV space toward the retroperitoneal space containing the lumbar plexus, but the clinical signifi- cance of this pathway is uncertain. Contents of the TPV Space The TPV space is filled with adipose tissue that contains the intercostal nerve, artery and vein, and the sympathetic trunk. Unlike at the intercostal location, the neurovascular structures are not yet arranged in a standard position (fig. 3). The intercos- tal nerve comes into the TPV space from medial and gradually assumes a position along the inferior edge of the rib toward lat- Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/123/2/459/268052/20150800_0-00033.pdf by guest on 24 September 2021 eral. The posterior intercostal artery and vein both enter the TPV space from anteromedial. The artery usually lies in the inferior half of
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