Analgesia of abdominal visceral and somatic pain.

The subcostal nerve (T12), ilioinguinal nerve (L1) and iliohypogastric nerve (L1) run across the anterior side of the quadratus lumborum (QL) muscle between the QL muscle and the transversalis fascia (TF).

The subcostal, ilioinguinal and iliohypogastric nerves are sandwiched between the QL muscle and the psoas major muscle (PMM).

– informed consent

– monitoring

– intravenous access (and maybe sedation)

– sitting position, relaxed and slumped

– demarcate landmarks

– infiltrate with local anaesthetics

Technique 1:
– inject 15-20 mL of local anaesthetic at the midpoint of the desired level
– expect blockade of 4-5 dermatomes

Technique 2:
– extend blockade by 4-5 injections of 4-5 mL

Levels:
– simple mastectomy T3-T4
– open cholecystectomy T6-T7

The needle is inserted with a lateral to medial in-plane approach.

In the axial plane, the thoracic paravertebral space (TPS) is a triangle with the base turned towards the vertebral spine, the parietal pleura and the endothoracic fascia are the antero-lateral border and the internal intercostal membrane is the posterior border. The apex points into the intercostal space laterally. The TPS communicates with the epidural space via the intervertebral foramina, with the mediastinum antero-medially, and with the intercostal space laterally.

The internal intercostal membrane is continuous with the internal intercostal muscle (between the external intercostal muscles and the innermost intercostal muscles) laterally and the superior costotransverse ligament medially.

The TPS extends down to the vertebral body of L1.

The thoracic paravertebral space is located where the intercostal muscles meet the transverse processes.

Colour Doppler mode can be very useful to identify blood vessels surrounding deeply located target nerves.

Analgesia after

– breast surgery

– thoracic surgery

– chest trauma

– abdominal surgery (inguinal herniorrhaphy, appendectomy, nephrectomy)

– upper limb surgery