2024 KSCTVA ITPB Retro SCTL block intertransverse process block

1. Hot topics in thoracic anesthesia
Regional anesthesia for thoracic surgery
2024KSCTVAAnnualMeeting
BoohwiHong,ChungnamNationalUniversity,Korea
koho0127@gmail.com

2. 2
Contents Lecture slides

3. 3
Which one is best regional analgesia for thoracic surgery?
TPVB, ESPB, INB, SPB, Control
21 RCT
1391 Patients

4. 4
TPVB, Paramedian Sagittal Oblique

5. 5
TPVB, Transverse in-plane
IIM
TP
Apex of TPVS

6. 6
Complications of TPVB
529 pt. 2163 TPVB
Parasagittal approach
Zero pleural punctures
Two patients were found to have a pneumothorax on postoperative chest X-ray
No LAST
856 pt. 1427 TPVB (285 uni & 571 bi)
Transverse, In-Plane,
Symptomatic bradycardia and hypotension (n = 3)
Vasovagal episode (n = 1),
Local anesthetic systemic toxicity (n = 2).
No incidence of suspected accidental pleural puncture or symptomatic
pneumothorax
382 pt. 1349 TPVB

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CostoTransverse Foramen Block

8. 8
Costotransverse Foramen
• metabolic response to injury
Journal of Anesthesia (2021) 35:102–111

9. 9
CTFB is comparable to TPVB

10. 10
Paravertebral by proxy
• Injection posterior to the SCTL
• T2 to T7 bilaterally
• 5 ml of methylene blue T2
• Sympathetic chain (T1–T7 on the left, and T4–T8 on the right)
• Intercostal nerves T1–T7
• Nerve roots in the paravertebral spaces, bilaterally.
Paravertebral space is not a true anatomical compartment
and that the SCTL is not a barrier to diffusion of injectate as
previously thought.

11. 11
Paravertebral by proxy
10 ml T2, T3, T4
Decreased sensation

12. 12
Paravertebral by proxy
STIL block
CT block
MTP block

13. 13
Paravertebral by proxy
STIL block
CT block
MTP block
CTF block
ESP block
Retrolamina block

14. 14
New nomenclature, ITP block
Injection in the tissue between two transverse processes,
posterior to the superior costotransverse ligament or
halfway between the posterior aspect of the transverse
process and the pleura.
Thoracic paraspinal block

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Intertransverse tissue complex
Intertransverse ligament
Fat tissue
Levator costarum muscle
Superior costotransverse ligament

16. 16
Recent updates on paravertebral anatomy
IAP IAP
IAP

17. 17
Costotransverse Foramen = Medial Slit
IAP

18. 18
Passage to TPVS, Not diffusion mechanism
SCTL
Korean J Anesthesiol 2022;75(4):295-306

19. 19
Costotransverse Foramen
Korean J Anesthesiol 2022;75(4):295-306

20. 20
Costotransverse space
Intersegmental
spreading
Costotransverse ligament

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Retro-SCTL space = Target of ITPB

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ITPB = Retro SCTL space injection
The retro- SCTL space, used as a target point for the ITP
block, has potential anatomical pathways to the TPVS.
The CTF and CTS appeared to create the anatomical
conduit for injectate spread anteriorly and
intersegmentally from the retro-SCTL space to the TPVS.
20 ml, T4-5

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Whole new concept?
Levator costarum m.

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Inferior articular process level
Anesthesiology 2015; 123:459-74

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Redefined paravertebral anatomy

26. 26
ITPB, Major breast cancer surgery
• Placebo ITP
• 10 ml T2,T4,T6
• Opioid consumption 24 hr
• No difference
• Subpectoral implant
• vs. TPVB
• 5 ml T2~6
• Worst resting pain in recovery room
• Median difference 0 (0 to 0) < 1

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Pectoralis muscle innervation

28. 28
ITPB, VATS
T5/T6, 15 mL of 0.5% ropivacaine
ITPB TPVB

29. 29
Recent Cadaveric Study
T2, 10 mL

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Recent Cadaveric Study
20 mL, between T4 and T6

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Dorsal rami, TPVB vs. ITPB
IAP
IAP

32. 32
ITPB single vs multiple
Single: 21 mL T4/5
Multiple: 7 mL T2/T3, T4/T5 and T6/T7
Single: 3/12
Multiple: 1/12

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Reliability of standard dermatome
Journal of Clinical Anesthesia 88 (2023) 111127

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TPVB ITPB
ITPB ITPB

35. 35
ITPB, Out of plane