Ultrasound-guided TQL injections consistently cover the thoraco-lumbar innervation relevant to the AIC graft donor site. The injectate spread seen in anatomical dissections correlated with the dermatomal anesthesia clinically. The TQL has the potential to provide reliable analgesia for patients undergoing AIC bone graft harvesting.

Editor-We read with great interest the recent study by Marhofer and colleagues 1 which assessed dislocation rates of interscalene and femoral perineural catheters in volunteers. We wish to commend the authors on addressing and reporting a common problem that most anaesthesiologists encounter when placing continuous catheters yet which is largely ignored in the literature. Obviously, there is a significant problem with leakage, as demonstrated by the effort of many clinicians to secure the catheter with glue (e.g. Dermabond), 2 3 catheter tunnelling, or both. 4 Despite this, most articles focus on reporting high rates of success (and use various definitions of 'success') 5 and do not adequately address problems with leakage or dislodgement. We agree completely with the observations made by Marhofer and colleagues and are not surprised at the reported 15% dislocation rate and the positive correlation between time and rate of dislocations. At our institution, catheter dislocation and leakage at the insertion site are significant concerns when placing catheters using the traditional catheter-through-needle (CTN) method. Such problems led us recently to conduct studies examining the underlying cause of leakage and dislodgement. After careful study of the physical mechanisms behind perineural catheter insertion, we concluded that dislodgement results primarily from the diameter of the catheter (e.g. 20 G) being smaller than that of the needle (e.g. 18 G) used for initial skin puncture (Fig. 1). Thus, the catheter is not held tightly by the skin, leaving space for local anaesthetic to leak upon injection. A simple solution is to borrow from the commonly used i.v.

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Continuous interscalene block is popular for shoulder surgery, but there are several challenges when performing this continuous block. The interscalene catheter is susceptible to incidental dislodgement and migration due to movement of the head and neck. Another important consideration is phrenic nerve involvement; the phrenic nerve is susceptible to being incidentally anaesthetised with local anaesthetic during interscalene block, owing to its close proximity to the interscalene groove. We present two cases: firstly, a case demonstrating an interscalene catheter insertion approach that provides an effective spread of local anaesthetic perineurally within the interscalene groove, with the additional benefit of preventing catheter dislodgement. Secondly, we present a case in which ultrasound-guided interscalene catheter insertion resulted in phrenic nerve palsy in an asthmatic patient, where dilution or 'wash-off' of local anaesthetic with normal saline and repositioning of the catheter under ultrasound guidance resulted in rapid recovery of respiratory function and adequate pain control.

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Sonography using cadavers is beneficial in teaching and learning sonoanatomy, which is particularly important because imaging of the airway can be challenging due to the cartilaginous landmarks and air artifacts. In this exploratory study, we have attempted to compare the airway sonoanatomy of cadavers and live models. Our observations support the use of cadavers as teaching tools for learning airway sonoanatomy and practicing procedures involving airway structures, such as superior laryngeal nerve blocks, transtracheal injections, and needle cricothyroidotomy, before performance on patients in clinical situations. We believe this process will improve patient safety and enhance the competency of trainees and practitioners in rare procedures such as needle cricothyroidotomy.