Hironobu Ueshima

Ultrasound-Guided Quadratus Lumborum Block: An Updated Review of Anatomy and Techniques

Purpose of Review. Since the original publication on the quadratus lumborum (QL) block, the technique has evolved significantly during the last decade. This review highlights recent advances in various approaches for administering the QL block and proposes directions for future research. Recent Findings. The QL block findings continue to become clearer. We now understand that the QL block has several approach methods (anterior, lateral, posterior, and intramuscular) and the spread of local anesthetic varies with each approach. In particular, dye injected using the anterior QL block approach spread to the L1, L2, and L3 nerve roots and within psoas major and QL muscles. Summary. The QL block is an effective analgesic tool for abdominal surgery. However, the best approach is yet to be determined. Therefore, the anesthetic spread of the several QL blocks must be made clear.

Clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery

• ・ESP block injects a local anesthetic around the erector spinae muscle at the T5 spinous process.

Ultrasound-guided transversus thoracic muscle plane block: a cadaveric study of the spread of injectate

[1] Borglum J, Moriggl B, Lonnqvist PA, Christensen AF, Sauter A, Bendtsen AF. Ultrasound-guided transmuscular quadratus lumborum blockade. Br J Anaesth 2013 [http://bja.oxfordjournals.org/forum/topic/ brjana_el%3B9919, Accessed on 24th November, 2014]. [2] Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block—an alternative to transversus abdominis plane block. Paediatr Anaesth 2013;23:959-61. [3] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2. [4] Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011;66:1023-30. [5] Verma A, Bajpai M, Baidya DK. Lumbotomy approach for upper urinary tract surgeries in adolescents: feasibility and challenges. J Pediatr Urol 2014;10:1122-5.

The ultrasound-guided transversus thoracic muscle plane block is effective for the median sternotomy

An ultrasound-guided transversus thoracic muscle plane (TTP) block has been reported for a few years [1, 2]. TTP block can be blocked anterior branches of intercostal nerves (Th2-6). Therefore, we think that thoracic muscle plane block is effective for the median sternotomy. We report two cases of median sternotomy performed with the TTP block. Case 1 was an 84-year-old man with hypertension and aortic stenosis who underwent aortic valve replacement. Considering the efficacy of the perioperative analgesia, we performed bilateral TTP blocks after general anesthesia. The TTP blocks were administered bilaterally by injection of 0.375% levobupivacaine 40 mL in total (20 mL injected into each side) between the transversus thoracic muscle and the intercostal muscle between the fourth and fifth connecting at the sternum by using a high-frequency linear probe. Thirty minutes after applying the blocks, the median sternotomy was performed. The hemodynamics did not change during the median sternotomy. The postoperative course was uneventful. Case 2 was a 75-year-old man with thymoma who underwent thymomectomy. Considering the efficacy of the postoperative analgesia, we performed bilateral TTP blocks after general anesthesia. The dosage of bilateral TTP blocks was the same as that in case 1. Forty minutes after applying the blocks, the median sternotomy was performed. The hemodynamics did not change during the median sternotomy. The postoperative course was uneventful, and she was discharged without the need for analgesics. The results demonstrated that the bilateral TTP blocks were effective for good perioperative pain of the median sternotomy. The TTP block, which is a shallow block, must be safe as compared with a paravertebral nerve block

Clinical efficacy of modified thoracolumbar interfascial plane block

An ultrasound-guided thoracolumbar interfascial plane (TLIP) block reported in 2015 [1,2] inject a local anesthetic into the fascial plane between the multifidus and longissimus muscles at approximately the level of the third lumbar vertebra (L3) and can block the ventral rami of the thoracolumbar nerves (L2, 3). Therefore, TLIP block will provide for good perioperative pain of lumbar vertebra surgery around L2, 3. But it is said that the efficacy of TLIP block except the region of the L2, 3 is not effective [1]. In an anatomical point of view, we think TLIP block at the thoracolumbar region block the ventral rami of the thoracolumbar nerves. This time, we report two cases of lumber vertebra surgery performing the TLIP block except the level of the L2, 3. Case 1 was a 74-year-old man with diabetes who underwent lumbar laminoplasty at L1-2. Considering the efficacy of the postoperative analgesia, we performed bilateral TLIP blocks after general anesthesia. The TLIP blocks were administered bilaterally by injection of 0.15% levobupivacaine 40 mL in total (20 mL injected into each side) into the fascial plane (Figure) between the multifidus and longissimus muscles at approximately the level of L2 using a high-frequency linear probe attached to the LOGIQ e Premium (GE Healthcare Japan, Tokyo). The general anesthesia was performed using total intravenous anesthesia (propofol, remifentanil and rocuronium). The postoperative course was uneventful, and there was no additional analgesic for postoperative pain relief in the perioperative period. Case 2 was an 80-year-old man with chronic renal failure who underwent a tumor resection for a spinal cord tumor at Th8. Because we cannot use non-steroidal anti-inflammatory drugs as some additional analgesic for postoperative pain relief, we performed bilateral TLIP blocks after general anesthesia. The dosage of the TLIP block was the same as that in Case 1. The perioperative course was uneventful, and she was discharged without the need for analgesics. The results demonstrated that the efficacy of TLIP block except the level of the L2, 3 is effective for good perioperative pain of lumbar vertebra surgery. As compared

Lower limb amputations performed with anterior quadratus lumborum block and sciatic nerve block

The anterior quadratus lumborum block (QLB) has been used as both a trunk nerve block and a lower limb nerve block [1,2]. Compared with lumber plexus nerve block, anterior QLB can be safety performed on patients who take anticoagulant because of a shallow nerve block. We report two successful cases of lower limb amputation with an anterior QLB on a patient who had previously lumber surgery. Case 1 was a 75-yearman (173 cm, 78 kg)whowas scheduled for a right above-knee amputation because of arteriosclerosis obliterans. For this disease, he had been taking an anticoagulant. Because of lumbar spinal stenosis, he had undergone lumbar laminectomy 15 years ago. Considering his history of lumbar laminoplasty, we chose to perform an anterior QLB and a subgluteal sciatic nerve block. Monitors were placed on the patient after he entered the operating room. Next, the ultrasound-guided nerve blocks were performed by using a low-frequency convex probe attached to a LOGIQ e Premiumultrasound system (GE Healthcare Japan, Tokyo, Japan). For the anterior QLB, a 20-mL injection of 0.375% levobupivacainewas administered between the right psoasmajor muscle and right quadratus lumborum. For the subgluteal sciatic nerve block, 20mL of 0.375% levobupivacaine was injected underneath the right gluteus muscle between the ischium tuberosity and the femur. Twentyminutes after these blockswere applied, the patient underwent the amputation without a sedative. During the perioperative period, no remarkable events occurred and no additional analgesics were administered. Case 2 was an 80-year man (173 cm, 63 kg) who was scheduled for a right above-knee amputation because of arteriosclerosis obliterans. He had undergone artificial dialysis

Optimal site of administration of the PECS 1 block

• PECS 1 block injected local anesthetic into the space between the PMM and the PmM at third ribs.

Clinical experiences of ultrasound-guided lateral thoracolumbar Interfascial plane (TLIP) block

An ultrasound-guided thoracolumbar interfascial plane (TLIP) block injects a local anesthetic into the fascial plane between the multifidus and longissimus muscles at approximately the level of the third lumbar vertebra (L3), and can block the ventral rami of the thoracolumbar nerves (L2, 3) [1]. Therefore, the TLIP block provides good perioperative pain relief during lumbar vertebra surgery, as reported by some studies on the TLIP block [2,3]. However, as the injection site is near the incision site of the lumber vertebra surgery, the TLIP block may carry a risk of infection. The lateral TLIP block is administered at the fascial plane between the iliocostal muscle and longissimus muscles at approximately the level of the lumbar vertebra. Compared with conventional TLIP block, the local anesthetic injection into the lateral TLIP may have a decreased risk of infection. We report two cases of lateral TLIP block in which local anesthetic was injected into the lateral TLIP for lumber vertebra surgery. Case 1 was a 67-year-old woman with no complication who underwent lumbar laminoplasty at L2–3. Considering the efficacy of the postoperative analgesia, we performed lateral TLIP blocks bilaterally after general anesthesia. The blocks were administered bilaterally by injection of 20 mL 0.2% levobupivacaine per side (40 mL toral) into the fascial plane between the iliocostal muscle and longissimus muscles at approximately the level of L3 using a high-frequency linear probe attached to the LOGIQ e Premium ultrasound (GE Healthcare Japan, Tokyo, Japan). General anesthesia was performed using total intravenous anesthesia (propofol, remifentanil, and rocuronium). The postoperative

Successful cases of S-ICD implantation performed under the serratus plane block.

•The complications associated with conventional ICDs involve the transvenous leads.•A subcutaneous ICD has been developed as a new device.•The combination TTPB and SPB are effective perioperative pain relief for the S-ICD.

Ultrasound-guided thoracolumbar interfascial plane block: a cadaveric study of the spread of injectate

• Thoracolumbar interfascial plane (TLIP) block injects a local anesthetic between the multifidus and longissimus muscles.