Parascapular Sub‐Iliocostalis Plane Block: Comparative Description of a Novel Technique for Posterior Rib Fractures

Abstract

We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateral-posterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. No complications were reported. The efficacy of the PSIP block may potentially depend on different mechanisms of action: (1) direct action in the fracture site by craniocaudal myofascial spread underneath the erector spinae muscle (ESM); (2) spread to deep layers through tissue disruption caused by trauma, to reach the proximal intercostal nerves; (3) further medial spread through deeper layers to the midline to block the posterior and ventral spinal nerves; (4) medial spread below the ESM, to reach the posterior spinal nerves (more reliably than rhomboid intercostal / sub-serratus [RISS] block); and (5) lateral spread in the sub-serratus (SS) plane to reach the lateral cutaneous branches of the intercostal nerves; while avoiding significant negative hemodynamic effects associated with techniques such as the paravertebral block (PVB), erector spinae plane (ESP) block or its variations, or thoracic epidural analgesia (TEA). A comparative comprehensive overview of the regional techniques described for posterior chest trauma is presented, including TEA, PVB, ESP block, retrolaminar block, mid-point to transverse process block, costotransverse foramen block, RISS, and serratus anterior plane (SAP) block. Lay Summary:We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateralposterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. &

Impact of Ultrasound-Guided Deep Serratus Anterior Plane Block Combined With Dexmedetomidine as an Adjuvant to Ropivacaine Inpatient Quality of Recovery Scores Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial

“…Previous reports indicate that dexmedetomidine combined with a paravertebral block was found to reduce opioid dosage during thoracoscopic surgery ( 49 ). Paraspinal thoracic block can reduce the consumption of opioids in early postoperative breast surgery, which may be related to the anesthetic time of ropivacaine ( 50 ) avoided the complications of epidural block in breast surgery patients ( 51 ). Unilateral ESPB was administered during modified radical mastectomy, similar to a unilateral thoracic epidural block and without hemodynamic side effects, can reduce the use of opioids after breast cancer ( 52 ).…”

The novel continuous bilateral parascapular sub-iliocostalis plane block for thoracic spinal surgery

“…In the last decade, retrolaminar, erector spinae plane (ESP) blocks or different types of paraspinal intrafascial blocks have been described for lumbar spine surgery [3]. Theoretically, at thoracic level, ESP block may provide good analgesic quality, but they may also cause several undesirable effects at this level, particularly in bilateral techniques, such as central sympathetic blockade, weakness of the chest wall, and risk of fall during ambulation, because thoracic ESP block may spread easily toward the paravertebral space (PVS), through the costotransverse foramina [5].…”

“…due to its safer profile it allows rapid ambulation reducing the risk of fall comparing to the thoracic ESP block [3]; however, anatomical studies are needed to prove its applicability and advantages.…”

“…During major thoracic spinal surgery, available regional anesthetic techniques may impinge on the surgical site [ 1 , 2 ] and interfere with postoperative neurological evaluation [ 1 , 2 ]. With this letter, we aim to propose the use of the continuous bilateral parascapular sub-iliocostalis plane (PSIP) block, which has been recently evaluated for posterior rib fractures [ 3 ], for thoracic spinal surgery given its safer profile [ 4 ]. The patient authorized the publication of this letter with anonymized details.…”

“…The most commonly implemented techniques for thoracic spinal surgery to date are epidural analgesia or intrathecal morphine, but these may be associated with significant adverse effects [ 1 ]. In the last decade, retrolaminar blocks, erector spinae plane (ESP) blocks, and different types of paraspinal intra-fascial blocks have been evaluated for lumbar spinal surgery [ 3 ]. While ESP blocks may theoretically provide good quality analgesia at the thoracic level, they may also cause several undesirable effects.…”