The ultrasound-guided retrolaminar block

Abstract

Purpose Paravertebral blocks have gained in popularity and offer the possible benefit of reduced adverse effects when compared with epidural analgesia. Nevertheless, pulmonary complications in the form of inadvertent pleural puncture are still a recognized risk. Also, the traditional paravertebral blocks are often technically difficult even with ultrasound guidance and constitute deep noncompressible area injections. We present our experience with the first three patients receiving ultrasound-guided retrolaminar blocks for managing the pain associated with multiple rib fractures. Clinical features The vertebral laminae are identified by ultrasound imaging in a paramedian sagittal plane by sequentially visualizing the pleura and ribs, transverse processes, and the corresponding laminae (from lateral to medial). The block needle is guided to contact the lamina, and the local anesthetic injectate is visualized under real-time imaging. A catheter is inserted and used for continuous analgesia. In three consecutive patients, verbal rating scale (VRS) pain scores were reduced from 10/10 to less than 5/10, and no technical difficulties, complications, or adverse effects were encountered. Conclusions Successful analgesia was achieved in all three cases utilizing continuous infusion and intermittent boluses with ultrasound-guided retrolaminar blocks. These results show the feasibility of this approach for patients with multiple rib fractures. RésuméObjectif Les blocs paravertébraux ont gagné en popularité et offrent l'avantage de réduire potentiellement les effets secondaires comparativement à l'analgésie péridurale. Toutefois, les complications pulmonaires, sous forme de ponction pleurale involontaire, demeurent un risque bien connu. En outre, les blocs paravertébraux conventionnels sont souvent difficiles à réaliser d'un point de vue technique et ce, même sous échoguidage, étant donné qu'il s'agit d'injections profondes réalisées dans des zones non compressibles. Nous rapportons notre expérience auprès des trois premiers patients à recevoir un bloc rétrolaminaire échoguidé pour la prise en charge de la douleur associée à une fracture multiple des cô tes. É léments cliniques Les lames vertébrales sont identifiées par ultrason dans un plan sagittal paramédian en visualisant la plèvre et les cô tes, les apophyses transverses, et les lames correspondantes (des lames latérales aux médiales) séquentiellement. L'aiguille du bloc est guidée jusqu'à ce qu'elle atteigne la lame, et l'anesthésique local injecté est visualisé par imagerie en temps réel. Un cathéter est inséré et utilisé pour l'analgésie en continu. Chez trois patients consécutifs, les scores de douleur sur une échelle visuelle ont baissé de 10/10 à Author contributions Christopher Voscopoulos, Dhamodaran Palaniappan, Jose Zeballos, Kamen Vlassakov, and Hanjo Ko performed blocks. Christopher Voscopoulos, Dhamodaran Palaniappan, Jose Zeballos, Kamen Vlassakov, Hanjo Ko, Michael Kapottos, David Janfaza, and Agnieszka Trzcinka contributed to writing the paper. ...

Analgesic Effect of Double-Level Retrolaminar Paravertebral Block for Breast Cancer Surgery in the Early Postoperative Period: A Placebo-Controlled, Randomized Clinical Trial

“…In previous reports, an initial dose of 20-30 ml of local anesthetic was injected, followed by continuous injection or intermittent bolus injections through a catheter (Juttner et al 2011;Zeballos et al 2013;Voscopoulos et al 2013;Yoshida et al 2015;Murouchi and Yamakage 2016). In the current study, we attempted to provide postoperative analgesia with an initial dose of local anesthetic.…”

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

“…The TPVB is easier and safer than TEA to perform, but it is not devoid of possible complications such as pneumothorax, hemodynamic compromise, or total spinal anesthesia (54)(55)(56)(57)(58). Thus, new approaches to the TPVB for breast surgery have been proposed: the retrolaminar block (RLB) and the midpoint transverse process to pleura block (MTP block) (59,60). In both cases, the local anesthetic is injected near the paravertebral space providing similar effect.…”

Phrenic nerve block for thoracic surgery - a reply

“…Their study is limited to patients undergoing thoracic surgery for non-small cell lung cancer. Both thoracotomy and video-assisted thorascopic surgical approaches have been described for lung volume reduction surgery in patients with chronic obstructive pulmonary disease [3], and in the treatment of tuberculosis where medical management alone is insufficient [4]. Unilateral phrenic nerve palsy is unlikely to be tolerated in both such patient groups, where the pathology is bilateral.…”

“…We believe that the traditional teaching for multi-level injection (based on the landmark technique) will not reliably place the needle tip several millimeters from the pleura, and within the paravertebral space, hence the need (with a landmark technique) for multiple injections. The recently described retrolaminar PVB [3] and erector spinae plane block [4] involve injections well posterior to the SCTL, and yet would seem to result in paravertebral spread.…”

“…Even though anaesthesia is perceived to be a low oxygen-requiring state, Shibutani et al have suggested that a DO 2 of at least 330 ml.min À1 is required to prevent tissue oxygen deprivation under anaesthesia, and that a higher rate of supply would be required to achieve this [3]. Therefore, I would suggest that the minimum amount of oxygen that should be supplied is significantly higher than 250 ml.min À1 and perhaps anaesthetists using low flows, and for emergency situations, should consider flows nearer 500 ml.min…”