Objective To improve the safety and effectiveness of ultrasound-guided paravertebral block through observing the relationship between the spinal nerve and the transverse process or the lateral costotransverse ligament in adult cadavers. Methods Eighteen cadavers with normal thoracic spines were collected in this study. The cross point between the lateral edge of the lamina and the thoracic spinal nerve root was taken as the starting point for measurement. The distances between the starting point and the midpoint of the posterior inferior border of transverse process and the midpoint of the inferior border of the lateral costotransverse ligament were measured. According to Mitchell FL's "Three Groups" principle, the adjacent three thoracic segments were divided into 1 group and 12 segments were divided into 4 groups, which were named as T1~3 group, T4~6 group, T7~9 group and T10~12 group, respectively. The one-way ANOVA were performed between the intervals of spinal nerve-transverse process and the intervals of spinal nerve- lateral costotransverse ligament in different groups. Results （1）Intervals of spinal nerve-transverse process：average distance was (16.13±5.59) mm. It showed a trend of increasing first and then decreasing from the segment T1 (16.62±3.67) mm to the segment T12（9.76±3.75) mm. The T5 segment was the largest, which was(18.88±5.78) mm. The upwards or downwards from T5 segment gradually decreased. The distance of spinal nerve-transverse process of T1~3 group, T4~6 group, T7~9 group and T10~12 group were (17.50±4.67) mm、(18.19±5.62) mm、(16.92±5.28) mm、(12.00±4.42) mm respectively. There were significant differences among T10~12 and T1~3 (P<0.01), T4~6 (P<0.01), T7~9 group (P<0.01). (2) Intervals of spinal nerve-lateral costotransverse ligament: average distance was (17.67±3.76) mm. The distances of spinal nerve-lateral costotransverse ligament of T1~3 , T4~6 , T7~9 and T10~12 group were (16.95±3.82) mm、(17.55±3.89) mm、(17.81±3.83) mm、(18.30±3.43) mm, respectively. There was no significant difference between each two groups (P>0.05). Conclusions It is important to pre-estimate the puncture depth before and during ultrasound-guided thoracic paravertebral nerve block to avoid spinal nerve injury and even spinal anesthesia.
Key words
Thoracic paravertebral block； Ultrasound-guided； Puncture depth； Applied anatomy
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References
[1] Womack J, Pearson JD, Walker IA, et al. Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study[J]. Anaesthesia, 2019, 74(5): 594-601.
[2] Miyawaki H, Ogata H, Nakamoto S, et al. Effects of thoracic paravertebral block on nociceptive levels after skin incision during video-assisted thoracoscopic surgery[J]. Med Sci Monit, 2019, 25: 3140-3145.
[3] Sondekoppam RV, Uppal V, Brookes J, et al. Bilateral thoracic paravertebral blocks compared to thoracic epidural analgesia after midline laparotomy: a pragmatic noninferiority clinical trial[J]. Anesth Analg, 2019, 129(3): 855-863.
[4] Marhofer P, Harrop-Griffiths W, Kettner SC, et al. Fifteen years of ultrasound guidance in regional anaesthesia: part 1[J]. Br J Anaesth, 2010, 104(5): 538-546.
[5] Wang YF, Xu XQ, Yuan HJ. Inadvertent spinal anesthesia during ultrasound-guided thoracic paravertebral nerve block in a patient with nerve root sheath cyst[J]. A A Pract, 2019: 12(6): 199-201.
[6] Krediet AC, Moayeri N, van Geffen GJ, et al. Different approaches to ultrasound-guided thoracic paravertebral block: an Illustrated review[J]. Anesthesiology, 2015, 123(2): 459-474.
[7] Geelhoed MA, Viti JA, Brewer PA. A pilot study to investigate the validity of the rule of threes of the thoracic spine[J]. J Manual Manipulative Therapy, 2005, 13(2): 91-93.
[8] Moore DC. "No paresthesias-no anesthesia," the nerve stimulator or neither[J]? Reg Anesth, 1997, 22(4): 388-390.
[9] Hu Z, Liu D, Wang ZZ, et al. The efficacy of thoracic paravertebral block for thoracoscopic surgery: a meta-analysis of randomized controlled trials[J]. Medicine (Baltimore), 2018, 97(51): e13771.
[10] Reusz G, Sarkany P, Gal J, et al. Needle-related ultrasound artifacts and their importance in anaesthetic practice[J]. Br J Anaesth, 2014, 112(5): 794-802.
[11] Eason MJ, Wyatt R. Paravertebral thoracic block? a reappraisal[J]. Anaesthesia, 1979, 34(7): 638-642.
[12] Richardson J, Cheema SP, Hawkins J, et al. Thoracic paravertebral space location. A new method using pressure measurement[J]. Anaesthesia, 1996, 51(2): 137-139.
[13] Paraskeuopoulos T, Saranteas T, Kouladouros K, et al. Thoracic paravertebral spread using two different ultrasound-guided intercostal injection techniques in human cadavers[J]. Clin Anat, 2010, 23(7): 840-847.
[14] Neal JM, Barrington MJ, Brull R, et al. The second ASRA practice advisory on neurologic complications associated with regional anesthesia and pain medicine: executive summary 2015[J]. Reg Anesth Pain Med, 2015, 40(5): 401-430.
[15] Lang SA. The use of a nerve stimulator for thoracic paravertebral block[J]. Anesthesiology, 2002, 97(2): 521-522.
[16] Cowie B, Mcglade D, Ivanusic J, et al. Ultrasound-guided thoracic paravertebral blockade: a cadaveric study[J]. Anesth Analg, 2010, 110(6): 1735-1739.
[17] Chelly JE, Uskova A, Merman R, et al. A multifactorial approach to the factors influencing determination of paravertebral depth[J]. Can J Anaesth, 2008, 55(9): 587-594.
[18] Boretsky K, Visoiu M, Bigeleisen P. Ultrasound-guided approach to the paravertebral space for catheter insertion in infants and children[J]. Paediatr Anaesth, 2013, 23(12): 1193-1198.
