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Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation

Elsharkawy, Hesham, MD, MBA, MSc*; Maniker, Robert, MD; Bolash, Robert, MD; Kalasbail, Prathima, MD§; Drake, Richard L., PhD; Elkassabany, Nabil, MD, MSCE**

Regional Anesthesia and Pain Medicine: October 2018 - Volume 43 - Issue 7 - p 745–751
doi: 10.1097/AAP.0000000000000824
REGIONAL ANESTHESIA AND ACUTE PAIN: ORIGINAL ARTICLES

Background and Objectives Fascial plane blocks are rapidly emerging to provide safe, feasible alternatives to epidural analgesia for thoracic and abdominal pain. We define a new option for chest wall and upper abdominal analgesia, termed the rhomboid intercostal and subserratus plane (RISS) block. The RISS tissue plane extends deep to the erector spinae muscle medially and deep to the serratus anterior muscle laterally. We describe a 2-part proof-of-concept study to validate the RISS block, including a cadaveric study to evaluate injectate spread and a retrospective case series to assess dermatomal coverage and analgesic efficacy.

Methods For the cadaveric portion of the study, bilateral ultrasound-guided RISS blocks were performed on 6 fresh cadavers with 30 mL of 0.5% methylcellulose with india ink. For the retrospective case series, we present 15 patients who underwent RISS block or RISS catheter insertion for heterogeneous indications including abdominal surgery, rib fractures, chest tube–associated pain, or postoperative incisional chest wall pain.

Results In the cadaveric specimens, we identified staining of the lateral branches of the intercostal nerves from T3 to T9 reaching the posterior primary rami deep to the erector spinae muscle medially. In the clinical case series, dermatomal coverage was observed in the anterior hemithorax with visual analog pain scores less than 5 in patients who underwent both single-shot and continuous catheter infusions.

Conclusions Our preliminary cadaveric and clinical data suggest that RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia.

From the *Departments of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, and CCLCM of Case Western Reserve University, Cleveland Clinic, Cleveland, OH;

Department of Anesthesiology, Columbia University, New York, NY; and

Departments of Pain Management and Evidence Based Pain Research and

§Outcomes Research, Anesthesiology Institute, Cleveland Clinic; and

Cleveland Clinic Lerner College of Medicine, Cleveland, OH; and

**Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Accepted for publication March 10, 2018.

Address correspondence to: Hesham Elsharkawy, MD, MBA, MSc, Department of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code E31, Cleveland, OH 44195 (e-mail: elsharh@ccf.org).

H.E. has received unrestricted educational funding from PAJUNK (Norcross, GA) and consultant fees from Pacira Pharmaceuticals, Inc. Those companies had no input into any aspect of the present project design or manuscript preparation.

The authors declare no conflict of interest.

All images are created and used with permission of Cleveland Clinic Center for Medical Art and Photography.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.rapm.org).

Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.