Interfascial plane blocks also known as Truncal blocks are US guided regional blocks of thorax and abdomen. They have been used extensively for acute pain management and now their role is further expanding for chronic pain conditions. It has been suggested that they work by neural adhesiolysis, breaking the pain cycle by blocking the pain signals and also by anti-inflammatory action of steroids used with local anesthetic.

1. Newer Truncal Blocks:
Do they have place in current practice?
Dr Ashok Jadon,
Tata Motors Hospital
Jamshedpur

2. Introduction: Road map
• Introduction of truncal blocks & their necessity
• How they function
• Classification/ Nomenclature
• Newer Truncal blocks
• Place of TBs in current practice; Evidence
• Conclusions

3. Moving away from central neuraxial blocks
Fascial Plane Blocks
Technically easier to
perform
Less risk Decreased side effects Multimodal analgesia ? Evidence
Epidural
Hypotension
Urinary
Retention
Headache Anticoagulation
Neurologic
complication
Failure rate Cost
**ULTRASOUND**

4. Truncal Blocks (TBs); Introduction
• TBs are Interfascial plane blocks

5. *Classification: Abdominal, Thoracic, Para-spinal
Transversus abdominis plane
(TAP) block
MA/ SC/ Post.
Quadratus lumborum block
(QLB)
QLB-1,2,3,4
Rectus sheath block
IIN & IHN blocks
Transversalis fascia plane
(TFP) block
Interpectoral plane (IPP)
block (PAC-1 &2) (PAC-0 )
Serratus anterior plane
(SAP) block (S & D)
Parasternal intercostal plane
(PIP) block (S&D)
Pectoserratus plane (PSP)
block
Rhomboid intercostal plane
block
Supraspinatus plane block
(S&D)
 Paravertebral block
(PVB)
 Erector spinae plane
(ESP) block
 Intertransverse process
(ITP) block
 Retrolaminar block (RLB)
 Costotransverse
Foramen Block
 Thoracolumbar
Interfascial plane (TLIP)
block (M-TLIP)
*El-Boghdadly K, et al. Reg Anesth Pain Med 2021;46:571–580.

6. RAPM (2017): 133-183

7. TAP Block

8. Indications of TAP Block
• Almost in all the abdominal surgery
• LSCS
• Gynecology Surgery
• Laparotomies
• Cholecystectomies
• Hernia surgery

9. Subcostal TAP Block
• Covers UPPER abdominal wall!
(Hebbard 2008, 2010)
• Covers lateral intercostal branches
(for subcostal incision T6-T7)
• Drive needle in caudal & lateral
direction
• Similar 72 hr VAS scores with
Epidural infusion for upper
abdominal surgery 2011 in RCT

10. Tran, et al. Anesthesiology 2019

12. •7 RCTs
•Subcostal approach outperforms standard analgesic regimen
)
(no block or periportal infiltration
•None of the studies employed multimodal analgesia.
Laparoscopic
Cholecystectomy
Recommendation: Subcostal
TAP
• 3 RCTs, 2 studies reported statistically significant decrease in pain scores
(<2pts), opioid consumption (3mg in 24 hrs), time to ambulation (1.7hrs)
and PO intake (2.4hrs) in TAP group. (Clinical relevance?)
• One study that employed multimodal (acetaminophen, ketorolac, LA
infiltration) reported NO Difference with subcostal TAP
Bariatric
Surgery
Recommendation: evidence
does not support block
Tran, et al. Anesthesiology 2019

13. • OPEN: 3 RCTs. Both lateral and posterior TAP showed reduction in pain scores
and opioid consumption
• Laparoscopic: 2 RCTs. Does not support lateral TAP
Appendectomy
Recommendation:
Open - Lateral or
post TAP
•OPEN: Both lateral and posterior TAP showed reduction in pain scores and opioid consumption
•Laparoscopic: 2 RCTs. Lateral TAP decreased pain scores and opioid consumption compared to
port infiltration/no block
•Bilateral: 1 RCT. Preperitoneal LA outperformed TAP block
•Only one study used multimodal
Inguinal
Hernia
Repair
Recommendation:
None
Tran, et al. Anesthesiology 2019

14. • 2018 Systematic Review and Meta Analysis
• Lateral TAP: statistically significant difference in early (2 hours) and late (24 hours)
pain scores with movement only. (? clinical sig of 0.2 to 0.7)
• Similar pain at rest, breakthrough pain & opioid consumption
Laparoscopic
• TAP vs placebo: (2 RCTs) TAP decreased pain scores and morphine consumption
• Epidural vs single shot: Epidural superior but side effects
• Continuous TAP vs epidural: Mixed
• 1 favored epidural, 2 showed similar analgesia with TAP but increased need for
breakthrough analgesia
Open
Oh et al. Surgical endoscopy. 2018
Tran, et al. Anesthesiology 2019

15. A Meta-Analysis of Randomized Controlled Trials Concerning the Efficacy of
Transversus Abdominis Plane Block for Pain Control After Laparoscopic
Cholecystectomy.
Wang et al.
Conclusion: This meta-analysis concludes that TAP block is
more effective than a conventional pain control, but not
significantly different from another local incisional pain control
that is port site infiltration.
Analysis based on 23 studies containing data on 1,450
patients.

16. In conclusion:
1. Epidural analgesia was statistically superior to TAP block in the postoperative
pain score at rest at 12 h and the need for i.v. morphine-equivalent consumption at
the 0–24 h interval.
2. But these differences were not clinically important.
3. Risk benefit ratio favors TAP block
3213 article identified & 18 randomized controlled trials were selected for data
analysis

17. Results: Six RCTs with 568 patients were included
1. TAP block provided comparable pain control, lower 24 h and total opioid
consumption,
2. Shorter time to ambulation and urinary catheter time, and lower incidence of
sensory disturbance and postoperative hypotension compared with TEA.
3. The 48-h opioid consumption, PONV incidence, and hospital stay were similar
between groups.
4. When laparoscopic surgery was the only surgical approach employed, TAP
block provided additional benefits of shorter time to first flatus and lower
incidence of PONV compared with TEA.

18. Conclusions for TAP block
• Posterior and sub-costal approaches provides reliable analgesia
• Posterior TAP could cover Visceral Pain
• Adjuvants may be beneficial to prolong the analgesia
• Need for Quality RCTs:
• Comparing Post TAP Vs QLB
• Liposomal Vs Catheter
• Role of adjuvants
• Research for optimal multimodal analgesic regimen

20. Conclusions:
QLB is superior to TAPB in reducing morphine consumption, fentanyl
consumption, VAS score at 24 h postoperatively, the number of patients
requiring analgesia postoperatively, and the incidence of dizziness.

21. In conclusion:
1. QLB compared with TAP block for analgesia following caesarean
delivery suggest that both interventions provide comparable
postoperative analgesia and opioid-sparing effects.
2. Both Blocks were superior to controls

22. European Journal of Anaesthesiology: February 2021 - Volume 38 - Issue 2 - p 115-129
Twenty-seven studies constituting 1557 patients were reviewed.
Twelve studies with 803 patients were included in the meta-analysis on the primary
outcome.
The aim of this review was to evaluate the efficacy and safety of QLB for postoperative
analgesia.
The primary outcome was cumulative opioid consumption at 24 h postoperatively.
CONCLUSION: QLB reduced postoperative opioid consumption, prolonged the time to the
first rescue opioid analgesic and diminished the incidence of PONV.
QLB appears to be an applicable option for postoperative analgesia after abdominal and
hip surgery.

23. by Little C et al
19 April 2021 Volume 2021:14 Pages 57—65
Conclusion:
1. The existing data support using quadratus lumborum blocks for
postoperative pain control and opioid reduction in patients receiving open or
laparoscopic nephrectomy.
2. Compared to epidural analgesia, quadratus lumborum blocks appear to
provide equivalent analgesia with less hemodynamic compromise, and less
postoperative nausea and vomiting, with a shorter duration of urinary
catheterization analgesia, time to mobilization and return of bowel function.

26. Pectoral Blocks

29. A total of 8 RCTs involving 542 patients were included.
Conclusion: The SAP block reduced pain scores and 24-h postoperative opioids
consumption.
In addition, there is fewer incidence of PONV in the SAP block group.

30. Seven RCTs, with a total of 489 patients were included
Conclusion: Compared with GA , SAP block significantly reduces postoperative
pain and nausea and vomiting in patients undergoing VATS.

31. 51 studies: nine randomised control trials; 13 cohort studies; 19 case
series; and 10 case reports.
Conclusion: The current evidence supports the efficacy and safety of
serratus anterior plane and the pectoral nerves blocks as analgesic
options in cardiothoracic surgery.

32. Thirteen randomized controlled trials evaluating 679 patients across
different surgical procedures were included.
The primary objective was postoperative opioid consumption
Conclusion: Erector spinae plane block is an effective strategy to
improve postsurgical analgesia (Moderate quality evidence).

33. Erector Spinae Plane Block
• Erector Spinae Plane Block Similar to Paravertebral Block for
Perioperative Pain Control (Pain Physician 2021)
• Compared with SAP, ESP provides superior quality of
recovery at 24 h, lower morbidity, and better analgesia after
minimally invasive thoracic surgery.

34. Summary; Take home messages
• TBs are safe and effective techniques for postoperative
analgesia
• Their optimal efficacy can be achieved by judicious use
(proper indication/proper drug and dose/ proper technique)
• Till date no TB has been recognized as a standard of care
however, enough evidence is present that TBs influences the
patient care.
• Research is still on for various clinical outcomes.

35. Conclusions:
•Truncal Blocks have significant role in current
clinical practice.
•Future High level RCT followed by meta-analysis
may help in the decision making for the choice
of TB in particular situation.

36. Thank you!
Questions??