Regional Anesthesia and Pain Medicine • Volume 42, Number 1, January-February 2017
Reply to Dr Price (S. Dhir and R. V. Sondekoppam, personal
Accepted for publication: October 19, 2016.
To the Editor:
W e welcome the opportunity to re-
spond to the comments of Dr Price1
regarding our study.2 We are delighted
to have comments from a pioneer in the
technique of suprascapular and axillary
nerve blocks.3
We agree that the short-axis transverse
approach to the axillary nerve would in-
deed provide better vision and more stabil-
ity for the performer. However, we found it
difficult to maintain the needle-probe align-
ment in the same plane while performing
the axillary nerve block, especially in pa-
tients with higher body mass index.
In response to the second point, our
understanding is that the best visibility of
the quadrangular space is on the lateral as-
pect of the humerus rather than the deeper
part of the posterior deltoid because of the
circumflex humeral artery, and we depos-
ited the drug there. The 3 parts of the del-
toid muscle are inserted on the lateral
aspect of the humerus on 3 discrete areas
of the deltoid tubercle.4,5 However, the dif-
ferent components of the deltoid muscle are
difficult to visualize with the type of ultra-
sound machines we have.
It is well known that the main innerva-
tion of the shoulder joint is by suprascapular,
axillary, and subscapular nerves, whereas
the acromion has an additional innervation
from the lateral pectoral nerve.6 While the
suprascapular nerve can be blocked any-
where along the length of the omohyoid mus-
cle or at the suprascapular notch, blocking the
subscapular and axillary nerves may be chal-
lenging because of their deeper anatomical
location. The axillary nerve is the last
branch of the posterior cord, which travels
on the ventral surface of the subscapularis
muscle along with the upper and lower
subscapular nerves before entering the
quadrangular space.
It is interesting to know that Dr Price
noted differences in block extent with
such subtle landmark changes. The me-
dial spread of the drug observed by Dr
Price would have covered not only the ra-
dial nerve but also the upper and lower
subscapular nerves, thereby improving
the analgesic potential of the axillary
nerve block performed in the posterior
deltoid area.
We have been performing posterior
cord with suprascapular nerve block in pa-
tients at risk of respiratory dysfunction
from phrenic nerve blockade. The analge-
sic efficacy is better than isolated axillary
nerve and suprascapular nerve block
and comparable to interscalene block
© 2016 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
The erector spinae plane block (ESPB)
oral communication, 2016) but at a cost of
muscle weakness. In our study, the radial
nerve was not blocked reliably in SSAX group
(nearly 90% failure, unpublished data); there-
fore, it did avoid upper-limb weakness.
A more posterior approach to the axil-
lary nerve or a posterior cord block may be
superior to isolated axillary nerve block for
shoulder analgesia, and further anatomical
studies may shed more light on the drug
spread and the effects of axillary nerve
block location.
Shalini Dhir, MD
Department of Anesthesiology
and Perioperative Medicine
Western University
London, Ontario, Canada
Rakesh V. Sondekoppam, MD
Department of Anesthesiology
and Pain Medicine
University of Alberta
Edmonton, Alberta, Canada
The authors declare no conflict
of interest.
REFERENCES
1. Price D. Optimizing the combined suprascapular
and axillary nerve (SSAX) block. Reg Anesth
Pain Med. 2017;42:122.
2. Dhir S, Sondekoppam RV, Sharma R, Ganapathy S,
Athwal GS. A comparison of combined
suprascapular and axillary nerve blocks to
interscalene nerve block for analgesia in
arthroscopic shoulder surgery: an equivalence
study. Reg Anesth Pain Med. 2016;41:564–571.
3. Price DJ. The shoulder block: a new alternative to
interscalene brachial plexus blockade for the
control of postoperative shoulder pain. Anaesth
Intensive Care. 2007;35:575–581.
4. Sakoma Y, Sano H, Shinozaki N, et al.
Anatomical and functional segments of the
deltoid muscle. J Anat. 2011;218:185–190.
5. Standring S. Gray’s Anatomy: The Anatomical
Basis of Clinical Medicine. 39th ed. Edinburgh,
Scotland: Elsevier Churchill Livingstone; 2005.
6. Aszmann OC, Dellon AL, Birely BT, McFarland EG.
Innervation of the human shoulder joint and its
implications for surgery. Clin Orthop Relat Res.
1996:202–207.
Similarities Between the
Retrolaminar and Erector
Spinae Plane Blocks
Accepted for publication: September 3, 2016.
To the Editor:
W ith great interest, we read the recent
brief technical report written by
Forero et al.1 We would like to present our
related views and experience.
Letters to the Editor
is a novel analgesic technique in thoracic
neuropathic pain. The ESPB has been re-
ported to be effective for both acute and
chronic pain associated with metastatic dis-
ease, malunion of multiple rib fractures,
and video-assisted thoracoscopic lobectomy.
To perform ESPB, 2 approaches can be
used: needle approach 1 (ESPB 1) and nee-
dle approach 2 (ESPB 2). In ESPB 1, local
anesthetic is injected into the interfascial
space between the rhomboid major and
erector spinae muscles. In ESPB 2, local an-
esthetic is injected into the interfascial space
between the erector spinae and external in-
tercostal muscles. In both approaches,
blocks are performed 3 cm from the mid-
line at the level of the T5 transverse pro-
cess. In 2013, Voscopoulos et al2 and
Zeballos et al3 described the retrolaminar
block as a useful technique for pain
caused by multiple rib fractures and modi-
fied radical mastectomy.4 In this technique,
needle approach injects local anesthetic at
the dorsal space of the T4 spinous pro-
cess. The penetration position is 1 cm lat-
eral to the T4 spinous process.
It may seem that the ESPB and re-
trolaminar block techniques are similar, as
they are administered near the ventral and
dorsal rami of the thoracic spinal nerve;
nevertheless, the 2 penetration sites are
2 cm apart. Both these sensory blocks
were previously reported1,3 to anesthetize
up to a few intervertebral spaces around
the T5 with a bolus injection of 20 mL
local anesthetic.
As the insertion depth is shallower for
the ESPB than for the retrolaminar block,
the ESPB may be safer. However, the ESPB
may not provide effective analgesia over
as wide a range of the lower thoracic spine
and lumbar spine because of the absence
of the rhomboid major muscle at lower
thoracic or lumbar spines. For including
a wider range of the lower thoracic spine
and lumbar spines, the retrolaminar block
may be more effective. If a dorsal block of
the lower thoracic spine and lumbar spine is
required, the thoracolumbar interfascial plane
block may provide effective analgesia.5–7
In conclusion, it seems that the ESPB
is similar to the retrolaminar block. How-
ever, the retrolaminar block may be more
effective than the ESPB on a wider range
of the lumbar spine.
Hironobu Ueshima, MD, PhD
Hiroshi Otake, MD, PhD
Department of Anesthesiology
Showa University Hospital
Tokyo, Japan
The authors declare no conflict
of interest.
123
Letters to the Editor
REFERENCES
1. Forero M, Adhikary SD, Lopez H, Tsui C,
Chin KJ. The erector spinae plane block: a novel
analgesic technique in thoracic neuropathic pain.
Reg Anesth Pain Med. 2016;41:621–627.
2. Voscopoulos C, Palaniappan D, Zeballos J, Ko H,
Janfaza D, Vlassakov K. The ultrasound-guided
retrolaminar block. Can J Anaesth. 2013;60:
888–895.
3. Zeballos JL, Voscopoulos C, Kapottos M, Janfaza D,
Vlassakov K. Ultrasound-guided retrolaminar
paravertebral block. Anaesthesia. 2013;68:649–651.
4. Murouchi T, Yamakage M. Retrolaminar block:
analgesic efficacy and safety evaluation.
J Anesth. 2016 in press.
5. Hand WR, Taylor JM, Harvey NR, et al.
Thoracolumbar interfascial plane (TLIP) block:
a pilot study in volunteers. Can J Anaesth. 2015;
62:1196–1200.
6. Ueshima H, Sakai R, Otake H. Clinical
experiences of ultrasound-guided thoracolumbar
interfascial plane block: a clinical experience.
J Clin Anesth. 2016;33:499.
7. Ueshima H, Otake H. Clinical efficacy of
modified thoracolumbar interfascial plane block.
J Clin Anesth. 2016;30:74–75.
Consideration of Block
Nomenclature
Erector Spinae Plane Block
or Retrolaminar Block?
Accepted for publication: September 3, 2016.
To the Editor:
e congratulate Dr Forero et al1 on
W their article addressing the dermato-
mal effect of erector spinae plane block
(ESPB). Their results show that the block
may be effective with this easy maneuver.
Moreover, the spread of the injectate was
clearly shown with cadaveric dissection.
However, it is important to note that
current literature on retrolaminar block
(RLB),2,3 or paravertebral block lamina
technique,4 has already shown similar
technique and analgesic effect for surgical
patients. The ultrasound-guided technique
of ESPB is almost identical to that of
ultrasound-guided RLB shown in the previ-
ous article.3 Dr Forero and colleagues have
demonstrated that superficial ESPB had no
cutaneous sensory block and that deep in-
jection into the interfascial plane between
the transverse process and the erector spinae
muscle resulted in complete sensory loss
over the ipsilateral thorax. The pictures of
the anatomical location of the needle tip
placement under ultrasound guidance were
identical to that of RLB.1,3
At this early stage of investigation
regarding ESPB and RLB, it remains
124
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 42, Number 1, January-February 2017
unknown whether these different approaches
will produce identical spread of local anes-
thetics or clinical effect. However, we have
already confirmed that ultrasound-guided
RLB injections, either on the lamina or on
the transverse process, spread in the same
plane. Hence, we consider that the deep in-
jection of ESPB may be identical to RLB.
We believe it necessary to establish
some consistency regarding the anatomical
comprehension and the nomenclature of
concerning block procedure. A new, dif-
ferent name for the same maneuver could
be quite ambiguous and misleading. Until
we have evidence to suggest otherwise, we
should not assume that ESPB is novel.
Takeshi Murouchi, MD
Department of Anesthesia
Kitami Red Cross Hospital
Kitami, Japan
The author declares no conflict
of interest.
REFERENCES
1. Forero M, Adhikary SD, Lopez H, Tsui C,
Chin KJ. The erector spinae plane block: a novel
analgesic technique in thoracic neuropathic pain.
Reg Anesth Pain Med. 2016;41:621–627.
2. Murouchi T, Yamakage M. Retrolaminar block:
analgesic efficacy and safety evaluation.
J Anesth. 2016;30:1003–1007.
3. Voscopoulos C, Palaniappan D, Zeballos J, Ko H,
Janfaza D, Vlassakov K. The ultrasound-guided
retrolaminar block. Can J Anaesth. 2013;60:
888–895.
4. Jüttner T, Werdehausen R, Hermanns H, et al.
The paravertebral lamina technique: a new
regional anesthesia approach for breast surgery.
J Clin Anesth. 2011;23:443–450.
Reply to Dr Ueshima and
Dr Murouchi
Accepted for publication: October 5, 2016.
To the Editor:
e thank Drs Ueshima and Otake1 and
W Dr Murouchi2 for their observa-
tions and we welcome the opportunity to
clarify aspects of the erector spinae plane
(ESP) block.
We did not mean to suggest in our re-
port3 that there are 2 alternative approaches
to the ESP block but were instead describ-
ing the evolution of our development of
the ESP block. We started with injection
superficial to the erector spinae muscle
but subsequently discovered that injec-
tion in the tissue plane deep to erector
spinae muscle was preferable, and this
is the only technique that we currently
© 2016 American Society of Regional Anesthesia and Pain Medicine
recommend and practice. We would dis-
courage further use and promulgation
of the terms “ESPB 1” and ESPB 2”1 to
avoid confusion.
Dr Ueshima1 is correct in pointing out
that the rhomboid major muscle has its
inferior border at T6, which limits its use-
fulness as a sonographic landmark at lower
levels. This is another reason we recom-
mend focusing on identifying only the trans-
verse process and the erector spinae muscle
and injecting deep to the latter. The erector
spinae muscle extends all the way into the
lumbar region, and our clinical experience
to date indicates that the ESP block can,
in fact, provide abdominal analgesia if
performed at the level of the T7 or T8
transverse processes.
We respectfully disagree with Dr
Murouchi2 insofar as we believe that the
ESP block and retrolaminar block are dis-
tinctly different techniques that deserve
their own names. There are some similar-
ities, chiefly that injection occurs deep to
xerector spinae muscle and that the mecha-
nism of action likely involves diffusion of
LA into the paravertebral space through the
nonbony gaps between adjacent vertebrae.
However, the 2 blocks have very different
sonoanatomical targets (lamina vs trans-
verse process), and as a result, the inser-
tion point is different: the ESP is at least
2 cm more lateral, as Dr Ueshima has
pointed out. Voscopoulos et al4 illustrate
this very clearly in their article when they
describe the sequential visualization of
ribs, transverse processes, and finally
lamina. We believe Dr Murouchi may have
misinterpreted the figure presented in their
article in which they illustrate the differ-
ent images obtained at different parasagittal
planes through the thoracic vertebra, includ-
ing the transverse process view that we use
in the ESP block, but the needle approach
is clearly shown as one that contacts the
lamina. The increased depth and bulk of
the erector spinae muscle in this location
may hinder local anesthetic spread and thus
clinical effect; we note that the retrolaminar
block produced inferior analgesia com-
pared with thoracic paravertebral block-
ade following breast surgery.5
A technique that is much more similar
to the ESP block is the intercostal-paraspinal
block described by Roué et al.6 However, it
again differs slightly in that it utilizes a
parasagittal plane lateral to that of the
ESP block, over the ribs, rather than the
transverse processes. We agree with Dr
Murouchi that further investigation is
needed to determine if these various points
of injection result in different patterns of
spread and clinical effect.
Finally, we would like to point out that
the thoracolumbar interfascial plane block7