Ultrasonography-guided modified thoracolumbar interfascial plane block: a new approach

Abstract

To the Editor,A recent study published by Hand et al. described an ultrasonography-guided thoracolumbar interfascial plane (TLIP) block. 1 This block involves injecting local anesthetics between the multifidus and longissimus muscles at the third lumbar vertebral level to block the dorsal rami of thoracolumbar nerves. 2 Hand et al. made the injection between the multifidus and longissimus muscles by positioning the block needle at a 30°angle from the skin and advanced it from a lateral to medial direction ( Figure).Herein, we describe our TLIP modification where we inject the anesthetics between the longissimus and iliocostalis muscles after having advanced the needles at a 15°angle in a medial to lateral direction. Our modified method has several advantages.1. Advancing the needle from a medial to lateral direction eliminates the risk of possible inadvertent neuraxial injection.2. Injecting between the iliocostalis and longissimus muscles results in a dermatomal area of analgesia similar to that obtained with an injection made between the multifidus and longissimus muscles. We have demonstrated this area of analgesia using radiopaque dye injections (with specific patient consent) where the distribution of the local anesthetics spread two levels caudal and cranial to the injection site. Twenty minutes after injection, we could show a corresponding dermatomal area (using a pinprick test) of reduced sensation. 3. Sonographic imaging more easily discerns the distinction between the longissimus and iliocostalis muscles than between the multifidus and longissimus muscles, thereby potentially increasing the success rate of the block.These modifications to the TLIP block will require further study to investigate their potential advantages more fully. Such investigations, including magnetic resonance imaging and cadaveric studies combined with ultrasonography, should be beneficial for evaluating the block's potential anatomic spread. When compared with some other nerve blocks, interfascial plane blocks are highly dependent on sufficient volumes of local anesthetics to spread between the muscle layers and fascial planes. The TLIP block might be useful for 2 and 3 vertebral level spinal surgical procedures as well as minimally invasive spinal surgery.

Efficacy of ultrasound-guided modified thoracolumbar interfascial plane block for postoperative analgesia after spinal surgery: a randomized-controlled trial

“…We believe this is simpler to perform and reduces the risk of neuraxial puncture. 5 The aim of this study was to investigate the effect of the modified TLIP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery. The study was registered with ClinicalTrials.gov (NCT03079076).…”

“…Those in the control group (n = 20) received bilateral ultrasound-guided injections of 2 mL 0.9% saline subcutaneously; those in the TLIP group (n = 20) received ultrasound-guided bilateral modified TLIP block with 20 mL 0.25% bupivacaine as described here. 5 A successful block was defined as loss of cold sensation in the T7-L1 dermatomes 20 min after block application.…”

Standardization of nomenclature for paraspinal interfascial nerve block: adding some more confusion

“…They reported that the cutaneous distribution of sensory loss may be over only a restricted lumbar area 7. Ali Ahiskalioglu and colleagues described a modification of TLIP block in regards to the plane into which LA agent is deposited, needle direction and angle of introduction 8. Instead of the plane between MF and LG, they deposited the LA in between LG and iliocostalis (IC) muscles and termed it as modified thoracolumbar interfascial plane block 8.…”

“…Ali Ahiskalioglu and colleagues described a modification of TLIP block in regards to the plane into which LA agent is deposited, needle direction and angle of introduction 8. Instead of the plane between MF and LG, they deposited the LA in between LG and iliocostalis (IC) muscles and termed it as modified thoracolumbar interfascial plane block 8. Hironobu Ueshima and Hiroshi Otake performed TLIP block at the level of second lumbar vertebra and referred to it as modified TLIP block 9.…”

“…They suggested that it has a wider sensory loss and can be used for “lumbar vertebra surgery at the thoracolumbar region” 9. Later on the same year in which Ali Ahiskalioglu and colleagues published their modified TLIP block,8 Hironobu Ueshima and Hiroshi Otake also described the deposition of LA in the plane between LG and IC and termed it as lateral TLIP block 10. It is not known whether the direction and angle of insertion of the needle is similar to that reported by Ali Ahiskalioglu and colleagues.…”