Sir,
Thoracolumbar interfascial plane block (TLIP) targets the dorsal rami of the spinal nerves as it emerges posteriorly between the multifidus and longissimus muscles. It was described as providing analgesia for posterior lumbar spine surgeries. This principle of blocking the dorsal rami as they traverse through the paraspinal muscles can be applied at the thoracic level also. Here, we describe our experience with a thoracic multifidus interfascial plane block in a posterior thoracic spine surgery.
A 70-year-old male was posted for excision of an extradural mass at the level of the sixth thoracic (T6) vertebral spine. Under standard monitoring, general anesthesia was induced according to the institutional protocol with fentanyl, propofol, and atracurium and endotracheal tube was placed. He was turned prone and the block was performed under aseptic precautions. A mixture of 40 ml of 0.375% ropivacaine and dexamethasone 4 mg was used for the block. A linear high-frequency transducer was placed transversely in the midline at the level of the T6 vertebra and the spinous process was identified. The probe was then moved to one side to identify the paraspinal muscles. A 22G, 50 mm nerve stimulator needle was introduced in an in-plane technique, from lateral to medial direction into the fascial plane between multifidus and longissimus muscles and 20 ml of the drug was deposited [Figure 1]. The block was repeated on the opposite side. There was no tachycardia or hypertension on the incision which indicated good analgesia. No long-acting opioid was given and the patient was extubated comfortably at the end of surgery. For postoperative analgesia, intravenous paracetamol 1 gm was given eighth hourly. He did not require additional analgesics and his numeric rating scale pain scores remained below 3 till 48 h postoperatively.
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Figure 1: Sonoanatomy of the thoracic paraspinal muscles. The drug is deposited in the fascial plane between the multifidus and longissimus muscles
Posterior decompression and instrumentation of the spine are associated with severe postoperative pain and necessitate multimodal analgesia for the management. Various options, including opioids, nonsteroidal anti-inflammatory drugs, gabapentin, and wound infiltration with local anesthetics, are routinely used in the management of postoperative pain in these surgeries. Fascial plane blocks are emerging as the latest trend in regional anesthesia.[1] In 2015, Hand et al. described the TLIP block for providing analgesia in lumbar spine surgeries.[2] The dorsal ramus blocks provide focused analgesia for spine surgeries. The TLIP block does not interfere with intraoperative neuromonitoring or cause motor blockade.[3] The TLIP block was shown to be superior to wound infiltration in lumbar spine surgeries.[4] There is controversy regarding the nomenclature of these blocks.[5] The corresponding block performed at the cervical level is termed the multifidus cervicis plane block.[6] The volume and concentration of the local anesthetic required for these blocks need to be studied further.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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2. Hand WR, Taylor JM, Harvey NR, Epperson TI, Gunselman RJ, Bolin ED, et al. Thoracolumbar interfascial plane (TLIP) block:A pilot study in volunteers. Can J Anaesth 2015;62:1196–200.
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