This document discusses various nerve blocks for thoracic and abdominal pain management including: 1. Paravertebral blocks are commonly used for postoperative analgesia after thoracic and breast surgeries as well as for rib fractures and herpes zoster pain. 2. Intercostal nerve blocks provide analgesia after procedures like thoracotomy but are rarely adequate for intraoperative anesthesia. 3. Transversus abdominis plane blocks are indicated for abdominal surgeries like appendectomy and hernia repair through the triangle of Petit technique. 4. Other blocks discussed include intrapleural, illioinguinal, illiohypogastric, thoracic epidural, and c

1. THORACIC AND ABDOMINAL
NERVE BLOCKS
MODERATOR : Dr KAMAL KISHORE
Speaker : Tapas Singh

2. Contents
• Paravertebral block
• Intercoastal nerve block
• Transversus abdominis plane block
• Intrapleural block
• Illioinguinal and illiohypogastric blocks
• Thoracic epidural block
• Celiac plexus block

3. PARAVERTABRAL BLOCKS
POSTOPERATIVE SURGICAL MISCELLANEOUS
ANALGESIA: ANESTHESIA:
•Fractured ribs
• Thoracic surgery • Breast surgery
• Breast surgery • Herniorrhaphy •Therapeutic control
• Cholecystectomy • Chest wound of hyperhydrosis
• Renal and ureteric exploration •Liver capsule pain
surgery after blunt trauma
• Herniorrhaphy •Acute postherpetic
• Appendectomy neuralgia
• Video-assisted
thoracoscopic surgery

4. Regional Anatomy
Wedge shaped area on both
sides of vertebra
BOUNDARIES:
• Anterior/lateral: Parietal
pleura
• Posterior: Superior
costo-transverse
ligament
• Medial: Postero-lateral
aspect of the vertebral
body, intervertebral disc
and the intervertebral
foramen
COMMUNICATIONS:
• Intercostal space
laterally
• Epidural space medially
• Paravertebral space on
the other side via the
prevertebral and
epidural space.

5. Patient position & landmarks
Position : Sitting or lateral
decubitus, with
kyphotic attitude
supported by a
attendant.
Landmarks :
• Spinous processes
along the midline
• Tip of scapula : T10
• Paramedian line 2.5
cms lateral to midline

6. Technique
• At thoracic level :
Spinous process of
upper vertebrae is at
level of transverse
process of lower
spine.
Needle Insertion Point:
2.5 cm lateral to the
tip of spinous process.
Saggital section through the thoracic
paravertebral space showing a needle that
has been advanced above the transverse
process.

7. Technique
Procedure consists of 3
maneuvers
1. Contacting transverse
processes of individual
vertebrae (depth 2-4 cms)
2. Withdrawing needle to skin
level and reinserting it 10 deg
caudal or cranial
3. Inserting needle 1 cm deeper
than level of transverse
processes
• Called “Walking Off”
(Cranially/Caudally)

8. Technique

9. Technique (Continuous Thoracic paravertebral
block)
• The same method can be modified and a catheter can be
placed in the paravertebral space for giving more prolonged
post operative analgesia
• A Touhy’s needle is used for the procedure and a catheter is
inserted 5 cms beyond the tip of the needle
• Catheter is ideally inserted 1-2 segmental levels below the
thoracotomy incision

10. Commonly used drugs
Onset Anesthesia Analgesia
(min) (hrs) (hrs)
2% Lidocaine 10-15 2-3 3-4
(plus HCO3 +
epinephrine)
0.5% 15-25 4-6 12-18
Bupivacaine
(plus
epinephrine)
0.5% 12-25 4-6 12-18
ropivaicaine
(+epinephrine)

11. Local Anesthetic: 3-4 ml/ level for multiple level block, 15-20 ml for single
level, and infusion @ 0.1 ml/kg/h. Appropriate drugs: bupivacaine 0.25-
0.5%, ropivacaine 0.25-0.5%, or lidocaine 1%; with epinephrine (2.5
μg/ml).
Mechanism and Spread of Anesthesia: 15 ml bupivacaine 0.5% in TPVs
produces unilateral somatic block over 5 (range: 1-9) dermatomes, and
sympathetic block over 8 (range 6-10) dermatomes.
Possible areas of spread:
• May remain localized
• May spread to contiguous levels above and below
• Intercostal space laterally
• Epidural space, mostly unilateral and insignificant, in up to 70%
• Single 15-20 ml injection as effective as multiple 3-4 ml/site.
• Increasing volume may predispose to bilateral anesthesia
• If a wide block (≥ 5 dermatomes) is desired, preferable to do multiple
injections, or 2 injections several dermatomes apart

12. Contraindications
ABSOLUTE RELATIVE
• Infection at the site • Coagulopathy
of needle insertion, • Kyphoscoliosis (chest
• Empyema deformity may
• Allergy to local predispose to pleural
anesthetic drugs, or thecal puncture)
and • Patient with
• Tumor occupying the previous
TPVS. thoracotomy: TPVs
may be obliterated
by scar tissue and
adhesion of lung to
chest wall

13. INTERCOASTAL NERVE BLOCKS
(ICNB)
• Mostly used for postoperative analgesia after
surgeries like thoracotomy, mastectomy,
cholecystectomy, gastrostomy etc
• Neurolytic ICNB’s are used to treat chronic
painful conditions like post thoracotomy and
mastectomy pain
• Also used in rib fractures

14. Applied anatomy
• Each intercoastal nerve has four parts
- gray ramus comminucans
- posterior cutaneous branch
- lateral cutaneous branch
- anterior cutaneous branch

16. • Positioning – pt may be sitting, prone or lateral.
key is to pull scapulae laterally to facilitate access
to posterior angle of ribs above T7
• Inferior border of ribs marked just lateral to
sacrospinalis muscle ( 6-8cm lateral to midline in
lower ribs, 4-6cm in upper ribs )
• A 22-24 G inserted at 20 degree cephalad angle
• After inserting to a depth of 1 cm rib is
encountered, which is walked off in cephalad
direction

17. • Insert 3 mm more tilll a pop of internal
intercoastal fascia is felt
• After negative aspiration, 3-5 ml of LA is
injected
• 1-2% lignocaine with or without epinephrine,
bupibacaine 0.25-0.5% and ropivacaine 0.5-
0.75% is used

21. • The ideal angle of entry into the subcostal groove is
about 20° cephalad.
• A continuous catheter may be better tolerated in
cases that require repeated blocks at multiple levels.
• ICNB provides excellent analgesia but is seldom
adequate for intraoperative anesthesia.
• Supplemental analgesia may be required in
continuous ICNB especially if the area of pain is wide.

22. • Epidural block should be considered as a better
alternative to bilateral ICNBs because of the risk
of bilateral pneumothorax and the potential for
local anesthetic toxicity due the increased amount
of local anesthetic required.
• Absorption of local anesthetic from the intercostal
space is rapid and toxicity is usually an important
concern.
• ICNB above T7 may be difficult because of the
scapulae and an alternative technique such as
paravertebral or epidural block should be
considered.

23. complications
• Pneumothorax
• Lung injury
• Local anaesthetic toxicity
• Peritoneal and abdominal viscera injury
• Intrathecal drug injection

24. Transverse abdominis plane (TAP)
block
• INDICATIONS
 appendectomy
Hernia repair
Caesarean section
Abdominal hysterectomy
Prostactectomy
Laproscopic surgery

26. • Anterolateral abd wall
supplied with ant. Rami
of spinal nerves T7 to L1
•

27. Transversus abdominis plane block
(TAP)
Mc Donnell et Al, An Analg 2007; vol 106 : 193-97.
27

28. Transversus abdominis plane block
(TAP)
Mc Donnell et Al, An Analg 2008; vol 106 : 186-91.
28

29. • Triangle of petit
• Double pop technique
• First and second pop
external and internal
oblique muscle
respectively
• Dosage : 20 to 30 ml of
any L.A in usual
concentrations; volume
dependent block

30. Transversus abdominis plane block
(TAP)
30

31. complications
• Few,single case report of intra hepatic
injection
• Intraperitoneal injection
• Bowel hematoma
• Transient femoral nerve palsy
• Systemic toxicity

32. INTRAPLEURAL BLOCK
• Indications are open cholecystectomy, mutiple
rib fractures and chronic painfull conditions
like malignancy, acute herpes zoster and post
herpetic neualgia
• Post thoracotomy analgesia is inconsistent
due to presence of drain tubes and blood in
pleural space

34. • Site is choosen between T6 to T8 at 10 cm from
posterior midline
• Sponateously breathing patient, should be asked to
hold his breath after exhalation
• In anaesthetised pt circuit should be disconnected
• Can be performed in both lateral and supine position
• L.A 20 to 25 ml,usually .25% bupivacaine is used
• Continous infusions have also been employed at rate of
0.125 ml/kg/hr
• Positioning of patient imp

36. complications
• Pnumothorax
• Chest walll hematoma
• Systemic absorption
• Horner’s syndrome

37. Illioinguinal and illiohypogastric blocks
• Indications for ilioinguinal/iliohypogastric blocks
include anesthesia for any somatic procedure
involving the lower abdominal wall/inguinal region
such as inguinal herniorrhaphy
• For analgesia after surgical procedures using a
Pfannenstiel incision as for cesarean section and
abdominal hysterectomy.
• Do not provide visceral anesthesia
• When used for inguinal herniorrhaphy, the sac must
be infiltrated with local anesthetic to complete
anesthesia for the procedure.

38. APPLIED ANATOMY
• Both the iliohypogastric and ilioinguinal nerves
emanate from the first lumbar spinal root.
• Superomedial to the anterior superior iliac spine,
the iliohypogastric and ilioinguinal nerves pierce the
transversus abdominus to lie between it and the
internal oblique muscles.
• Their ventral rami pierce the internal oblique to lie
between the internal and external oblique muscles
before giving off branches.
• The iliohypogastric nerve supplies the skin over the
inguinal region. The ilioinguinal nerve runs
anteroinferiorly to the superficial inguinal ring,
where it emerges to supply the skin on the
superomedial aspect of the thigh

40. • Initially, the anterior superior iliac spine is palpated and a
mark made 2 cm medial and 2 cm superior from it .
• The needle is inserted through the skin puncture site
perpendicular to the skin.
• Increased resistance is met as the needle encounters the
external oblique muscle. A loss of resistance is appreciated
as the needle passes through the muscle to lie between it
and the internal oblique. After the initial loss of resistance
and negative needle aspiration for blood, 2 mL of local
anesthetic are injected.
• The needle is then inserted farther to encounter another
resistance, which is the internal oblique muscle.

41. • A further loss of resistance is appreciated once
the needle passes through the internal oblique to
lie between it and the transversus abdominus
muscle. After the second loss of resistance,
another 2 mL of local anesthetic are
administered.
• The needle is then withdrawn to skin and
redirected at a 45-degree angle medially to again
pierce the external and then the internal
obliquemuscles . After each loss of resistance, 2
mL of local anesthetic are again administered.

42. • The needle is then returned to skin and
inserted 45 degrees laterally, and the
procedure is repeated. Thus, a total of 12 mL
of local anesthetic is placed in a fan-like
distribution between the external and internal
oblique and the internal oblique and
transversus abdominus muscles

44. Contraindications
• There are no specific contraindications for
these blocks apart from the generic
contraindications to performance of any
regional block such as infection at the
procedure site, allergy to local anesthetics,
indeterminate neuropathy, and so on.

45. Thoracic epidural
• Most commonly used in thoracotomies for
post op pain relief
• Anatomy of vertebral column makes
technique of thoracic epidural slightly
different
• Medain and para median approach

48. Celiac Plexus Block
• anesthesia for intra-abdominal surgery
• reduce stress and endocrine responses to
surgery

49. Anatomy and Technique
• contains visceral afferent and efferent fibers
derived from T5 to T12 by means of the
greater, lesser, and least splanchnic nerves
• The vena cava lies anteriorly to the right, and
on the left anteriorly is the aorta
• kidneys lie laterally, with the pancreas anterior

50. • patient in the prone position and a pillow
beneath the abdomen
• lines are drawn connecting the spine of T12
with points 7 to 8 cm laterally at the lower
edges of the 12th ribs
• A 20-gauge, 10- to 15-cm needle is inserted on
the left side through a skin wheal at a 45-
degree angle toward the body of T12 or L1

52. Side Effects and Complications
• Hypotension
• Spinal, epidural, or intravascular injection
• pneumothorax
• puncture of viscera, such as the kidney,
ureter, or gut
• retroperitoneal hematoma.

53. Thank you