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Eur J Anaesthesiol 2014; 31:305309yr
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02ORIGINAL ARTICLESpread of dye after single thoracolumbar
paravertebralinjection in infants
A cadaveric study
Andrew A. Albokrinov and Ulbolgan A. FesenkoBACKGROUND
Thoracolumbar paravertebral block (PVB)is one method of providing
regional anaesthesia for abdomi-nal wall surgery in children. It is
common practice whenperforming a PVB for abdominal wall anaesthesia
to injecta certain volume of local anaesthetic solution in the
para-vertebral space at several levels. This increases the
durationof the procedure and makes it more invasive.
OBJECTIVES To determine the character of dye spreadin infants
paravertebral space, to check the feasibility ofsingle injection
PVB and to determine the optimal volume ofinjectate necessary to
cover the paravertebral segmentsresponsible for sensation of the
lower abdomen.
DESIGN Experimental study.
SETTING Single centre, University Hospital, April 2013 toAugust
2013.
SUBJECTS Twenty infant cadavers.
INTERVENTION Ultrasound-guided, single
thoracolumbarparavertebral injections were performed on infant
cadavers.
MAIN OUTCOME MEASURE The total number of para-vertebral segments
stained after dye injection and specificight European Society of
Anaesthesiology. U
This article is accompanied by the following Invited Com
Lonnqvist P-A, Bosenberg AT. Anatomical dissections are
ninformation for regional anaesthesia. Eur J Anaesthesiol 20
m the Regional Childrens Clinic Hospital, Lviv, Ukraine
rrespondence to Andrew A. Albokrinov, MD, Department of
Anesthesia and Intensivl: +380672867103; e-mail:
[email protected]
65-0215 2014 Copyright European Society of
Anaesthesiologyvertebral levels of cephalad and caudad spread of
dye in theparavertebral space.
RESULTS Dye was present in the paravertebral spaces ofall
cadavers. Spread of dye within the paravertebral spacewas different
depending on dye volume. Strong correlationwas found between the
volume of injectate and the numberof paravertebral segments
involved. The number of spinalnerve roots surrounded with dye
corresponded with thenumber of paravertebral segments involved.
T11, T12 andL1 nerve roots were stained in all cadavers. The
optimalinjectate volume to involve T10-L1 segments was defined
as0.2 to 0.3 ml kg1.
CONCLUSION Single thoracolumbar paravertebral injectionat T12-L1
level leads to caudad and cephalad spreadof injectate in a
dose-dependent manner. Single injectionthoracolumbar paravertebral
injections could be performedfor lower abdomen anaesthesia in
infants. We suggestthat a single injection of 0.2 to 0.3 ml kg1 of
local anaes-thetic in the thoracolumbar paravertebral space
couldprovide adequate coverage of the dermatomes of the
lowerabdomen.
Published online 18 March 2014Introduction
Regional anaesthesia for lower abdominal incisions (suchas open
inguinal hernia repair, hydrocoele repair, openappendicectomy, open
varicocele repair, orchidopexy)can be achieved with spinal,
epidural or peripheralregional blocks, such as
ilioinguinal-iliohypogastric,transversus abdominis plane (TAP) and
thoracolumbarparavertebral block (PVB). Peripheral regional
blocksare often the technique of choice in paediatric
patientsnauthorized reproduction of this article is prohibited.
mentary:
ot obsolete. Cadaver studies can still provide important14;
31:303304.
e Care, Regional Childrens Clinic Hospital, 79008, Lysenka Str.
31, Lviv, Ukraine
DOI:10.1097/EJA.0000000000000071
mailto:[email protected]://dx.doi.org/10.1097/EJA.0000000000000071
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306 Albokrinov and Fesenko
Fig. 1
Ultrasound probe and needle position during
thoracolumbarparavertebral injection in an infant cadaver.because
of the lower incidence of complications ascompared with neuraxial
methods,13 and the avoidanceof adverse events such as hypotension
and urinaryretention.47 Data from the scientific literature
showthat PVB for anaesthesia of the lower abdomenis more effective
and reliable than TAP block8 andilioinguinal-iliohypogastric nerve
block.9
The safety and efficacy of PVB was demonstrated ina
meta-analysis examining thoracic PVB, which showed acomparable
analgesic effect and a better complicationprofile of PVB as
compared with epidural anaesthesia,6
as well as in reports focusing on PVB for abdominal
wallanaesthesia.3,10
It is common practice when performing a PVB forabdominal wall
anaesthesia to inject a certain volumeof local anaesthetic solution
into the paravertebralspace at several levels in order to achieve
anaesthesiaof the corresponding dermatomes.4,1113 There are anumber
of scientific publications however, showing theclinical efficacy of
a single injection thoracic PVB14 andthe possibility of local
anaesthetic solution spread notonly between thoracic segments of
the paravertebralspace, but also between thoracic and lumbar
para-vertebral spaces.1518 There are data on the spread oflocal
anaesthetics when performing thoracic PVB in bothadults6,1822 and
children,23 but the nature of spread oflocal anaesthetic or
injectate as part of a single injectionthoracolumbar PVB has not
yet been studied.
The aim of this study was to determine the patternof injectate
spread in infants paravertebral spaces, tocheck the feasibility of
a single injection for PVB andto determine the optimal volume of
injectate necessaryto cover the paravertebral segments responsible
forsensation of lower abdomen.
MethodsApproval was obtained from the Lviv RegionalChildrens
Hospital Ethics Committee (Protocol #3,dated April 4, 2013,
chairperson O. Burda, MD, PhD).Consent was obtained from the
parents of all participantsfor dye injection and autopsy, including
soft tissuedissection, but excluding dissection of spine. The
studywas conducted using 20 fresh, unembalmed infantcadavers
including 12 males and eight females [medianage at death 7 months
(range 1 to 13 months), medianbody mass 4550 g (range 2100 to 8100
g)]. Cadavers weredivided into five equal groups, depending on the
amountof dye injected into paravertebral space (0.1, 0.2, 0.3,
0.4,and 0.5 ml kg1). Unilateral injection of dye into
theparavertebral space was performed prior to cadavericdissection.
The vertebral level was estimated bypalpation of C7 spinous process
and counting caudally.The PVB was performed under ultrasound
guidanceusing a 5 to 10 MHz linear-array probe (SonoSite Titan;ight
European Society of Anaesthesiology. UnEur J Anaesthesiol 2014;
31:305309SonoSite Inc., Washington, USA). The thoracolumbararea was
scanned with the cadaver in the prone positionand the probe located
in the transverse axis. The trans-verse process of the T12 vertebra
and the psoas musclewere identified. A 10 cm, 20-gauge Quincke
spinal needle(Becton-Dickinson, New Jersey, USA) was
insertedlaterally to the probe. The needle was advanced using
atransverse, in-plane visualisation technique in alateromedial
direction until the needle tip appearedbetween the transverse
process and dorsal aspect of thepsoas muscle. At that point, a
single shot of methylene bluedye 1% in distilled water was injected
(Figs 1 and 2).
After dissection of the cadaver and removal of viscera,
thespread of dye within the paravertebral space was studied.The
primary outcome of the study was the total numberof paravertebral
segments stained after dye injection andthe specific vertebral
levels of cephalad and caudadspread of dye within the paravertebral
space. Other datacollected included the spread of dye to the
intercostalspaces, anterior to the vertebral bodies and
contralateralparavertebral space.
Statistical analysis was performed using STATISTICA6.0 software
(StatSoft Inc., Tulsa, USA). Pearsonscorrelation coefficient was
calculated for the amountof dye injected and the stained segments
of the para-verbetral space, anterior dye spread and
contralateraldye spread.authorized reproduction of this article is
prohibited.
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Spread of dye after single thoracolumbar paravertebral injection
307
Fig. 2
Ultrasound image of thoracolumbar paravertebral injection. N,
needle;SP, spinous process; TP, tranverse process.ResultsAll 20
cadavers were examined. The transverse processesof T12 vertebra and
the psoas muscles were locatedultrasonographically in all cases.
Dye was present inthe paravertebral spaces of all cadavers. The
numberof nerve roots, sympathetic ganglia and rami communi-cantes
stained with dye correlated with injected volume.A typical picture
of the observed dye spread is shownin Fig. 3.
Both cephalad and caudad spread of dye was observedin all
cadavers. Cephalad spread was associated withthoracic spinal nerve
root and intercostal space stain-ing. Caudad spread was associated
with lumbar plexusnerve root and dorsal surface of psoas muscle
staining.yright European Society of Anaesthesiology. U
Fig. 3
Th12ContralateralPVS spread
Anterior spread
Intercostalspread
Th12 NRL1 NRL2 NR
Psoas
Spread of dye after thoracolumbar (T12-L1) paravertebral
injectate0.3 ml kg1 with psoas muscle dissected. NR, nerve root;
PVS,paravertebral space.Strong correlation was found between the
volume of dyeinjected and the extent of its cephalad and caudad
spread(r 0.97, P< 0.05). The extent of paravertebral
spacestaining in relation to injectate volume is shown in Fig.
4.
The number of spinal nerve roots surrounded with dyecorresponded
to the number of paravertebral segmentsinvolved. T11, T12 and L1
nerve roots were stainedin all cases. Both anterior and
contralateral spread ofdye was observed, with an incidence
correlating withdye volume (r 0.88 and 0.89, respectively, P<
0.05).Dye was present in the intercostal spaces in all cases.The
level of intercostal spread corresponded to the levelof thoracic
paravertebral space spread (Table 1).
DiscussionThere are controversies in the scientific literature
aboutthe anatomy of the paravertebral space, the possibility
ofinjectate spread between thoracic and lumbar para-vertebral
spaces, and the number of injections neededto achieve adequate
anaesthesia of the abdominal wall.Several studies advocate multiple
injection techniques inPVB for thoracic and abdominal wall
anaesthesia basedon clinical and radiographic signs of superior
distributionof local anaesthetic.3,13,24
Lonnqvist and Hildingsson25 described the T12 vertebralbody and
transverse processes as the caudal boundaryof the thoracic
paravertebral space and insisted thatlocal anaesthetic solution
cannot spread caudally tothe T12-L1 intervertebral disc due to the
origin of thepsoas muscle. Several studies, however, describe
theconnection of thoracic and lumbar paravertebral
spaces.Thoracolumbar spread of injectate via the medial andlateral
arcuate ligaments of the diaphragm to theretroperitoneal space in
relation to the anterior surfaceof the psoas major and quadratus
lumborum muscles wasobserved by Saito et al.2628 The authors
suggest that inthis case, local anaesthetic effects may occur
becauseof blockade of peripheral nerves originating from thelumbar
plexus rather than blockade of spinal nerve roots.Tighe et al.29
noted that the endothoracic fascia dividesthe paravertebral space
into two compartments: anteriorsubserous (extrapleural) and
subendothoracic. As itcontinues inferiorly it runs with the fascia
transversalisof the abdomen dorsal to the diaphragm through
themedial and lateral arcuate ligaments and the aortic hiatus.Batra
et al.30 hypothesised that this endothoracic fasciacould be the
anatomical basis for thoracolumbar injectatespread. The authors
believe that injection of local anaes-thetic in the lower thoracic
paravertebral space posteriorto the endothoracic fascia can lead to
its spread inferiorlythrough the medial and lateral arcuate
ligaments to theretroperitoneal space behind the fascia
transversalis,where the lumbar spinal nerves lie.
The results of our study show that the thoracic and
lumbarparavertebral spaces in infants are anatomically
connectednauthorized reproduction of this article is prohibited.Eur
J Anaesthesiol 2014; 31:305309
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308 Albokrinov and Fesenko
Fig. 4
0.1
L5
L4
L3
L2
L1
Th12
Th11
Th10
Th9
Th8
Th7
Th6
0.2 0.3 0.4 0.5 ml/kg
The extent of paravertebral space staining in relation to
injectate volume. Values shown are median (range).despite the
presence of borders such as the origin of thepsoas muscle (from
vertebral bodies, lateral aspects of discsbetween them and
transverse processes of T12-L5).25,31
Taking into account the fact that T10-L1 spinal nerveroots must
be blocked to provide analgesia for lowerabdominal surgery and
based on the spread of dye withinthe paravertebral space after a
single PVB injectionat T12-L1, our study suggests that 0.2 to 0.3
ml kg1 oflocal anaesthetic solution would provide adequate
spreadwithin the paravertebral space. Larger doses of
localanaesthetic or a PVB at a more cephalad level, may
beconsidered for regional anaesthesia for unilateral upperabdominal
surgery.
The study by Lonnqvist and Hesser32 that included18 paediatric
patients, suggested 0.5 ml kg1 of local anaes-thetic as an optimal
dose to cover at least five thoracicparavertebral segments. Our
results show that smallerdoses of 0.2 and 0.3 ml kg1 were
sufficient in all casesto cover five and six thoracolumbar
segments, respectively.This discrepancy in suggested dosing may be
because ofthe possible peculiarities of injectate spread in
differentight European Society of Anaesthesiology. Un
Table 1 Spread of dye in the paravertebral space, intercostal
spaces, anspace
0.1 ml kgS1 0.2 ml kgS1 0.3 ml k
Median (range) number ofsegments of paravertebralspace
stained
3.0 (3 to 4) 5.5 (5 to 6) 6.0 (6 t
Unilateral intercostal spread (%) 100 100 100Anterior spread (%)
50 75 100Contralateral paravertebral
space spread (%)0 25 25
Eur J Anaesthesiol 2014; 31:305309age groups (neonates versus
infants), because of differentcontrast media (dye versus radiopaque
contrast) or becauseof bias from the small number of patients in
our study.
The anatomical connection between the thoracic para-vertebral
and intercostal spaces and the extensive spreadof dye to these
spaces after PVB was shown by Cowieet al.16 and Burns et al.33 We
also observed dye spreadfrom paravertebral to intercostal spaces in
all cases.Spread of injectate anterior to the vertebra is
describedby Lonnqvist and Hesser,32 Cowie et al.16 and Karmakaret
al.18 and our data support their findings. Injectatespread to the
contralateral paravertebral space is shownby Lonnqvist and
Hesser,32 in a case report of Karmakaret al.34 and by Gadsden et
al.35 Our study supports thesedata and suggests that the incidence
of contralateraldye spread is volume dependent and that a
bilateralblock may be possible, especially when using highvolumes
of local anaesthetic.
Epidural spread of local anaesthetic through the inter-vertebral
foraminae was also observed by Richardsonand Lonnqvist.2 Some
authors describe an incidenceauthorized reproduction of this
article is prohibited.
terior surface of vertebral column and in contralateral
paravertebral
gS1 0.4 ml kgS1 0.5 ml kgS1
Pearsonscorrelation
coefficient (r) P value
o 7) 7.0 (6 to 8) 8.0 (712) 0.97
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Spread of dye after single thoracolumbar paravertebral injection
309of epidural injectate spread of up to 40% after thoracicPVB in
adults.16,35 It is unclear whether contralateralparavertebral dye
spread in infants occurs throughthe epidural space or across the
anterior surface ofvertebral column, or both. We were unable to
examinethis aspect because of a lack of parental consent forspine
dissection.
Data on paravertebral injectate spread in childrenand
adolescents must be obtained to find out the natureof dye spread in
these age groups and the feasibilityof performing single injection
thoracolumbar PVB foranaesthesia of the abdomen.
Thoracolumbar PVB at T12-L1 in infant cadavers leadsto caudad
and cephalad dye spread in a dose-dependentmanner. Single injection
thoracolumbar paravertebralblockade could be performed to provide
regionalanaesthesia of the lower abdomen in infants. This
studysuggests that a single injection of 0.2 to 0.3 ml kg1 oflocal
anaesthetic in the thoracolumbar paravertebralspace could provide
adequate coverage of the derma-tomes of the lower abdomen.
Acknowledgements relating to this articleAssistance with the
article: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Presentation: none.
References1 Ecoffey C, Lacroix F, Giaufre E, et al. Epidemiology
and morbidity of
regional anesthesia in children: a follow-up one-year
prospective surveyof the French-Language Society of Paediatric
Anaesthesiologists(ADARPEF). Paediatr Anaesth 2010;
20:10611069.
2 Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J
Anaesth1998; 81:230238.
3 Eck JB, Cantos-Gustafsson A, Ross AK, Lonnqvist PA. Whats new
inpediatric paravertebral analgesia. Techn Reg An Pain Manag
2002;6:131135.
4 Naja ZM, Hassan MJ, Oweidat M, et al. Paravertebral blockade
vs generalanesthesia or spinal anesthesia for inguinal hernia
repair. Middle East JAnesthesiol 2001; 16:201210.
5 Akcaboy EY, Akcaboy ZN, Baydar M, Gogus N. Ambulatory inguinal
herniarepair: paravertebral block versus spinal anesthesia. Reg
Anesth Pain Med2007; 32:31.
6 Davies RG, Myles PS, Graham JM. A comparison of the analgesic
efficacyand side-effects of paravertebral vs epidural blockade for
thoracotomy:a systematic review and meta-analysis of randomized
trials. Br J Anaesth2006; 96:418426.
7 Jankovic Z. Transversus abdominis plane block: the Holy Grail
ofanaesthesia for (lower) abdominal surgery. Period biol 2009;
111:203208.
8 Melnikov AL, Bjoergo S, Kongsgaard UE. Thoracic paravertebral
blockversus transversus abdominis plane block in major
gynecological surgery:a prospective, randomized, controlled,
observer-blinded study. Local RegAnesth 2012; 5:5561.
9 Naja ZM, Raf M, El-Rajab M, et al. A comparison of nerve
stimulator guidedparavertebral block and ilio-inguinal nerve block
for analgesia after inguinalherniorrhaphy in children. Anaesthesia
2006; 61:10641068.yright European Society of Anaesthesiology. U10
Lonnqvist PA, MacKenzie J, Soni AK, et al. Paravertebral blockade
failurerate and complications. Anaesthesia 1995; 50:813815.
11 Hadzic A. Textbook of regional anesthesia and acute pain
management,1st ed. New York: McGraw-Hill Professional; 2006;
Chapter 43. Thoracic& Lumbar Paravertebral Block.
12 Naja ZM, Raf M, El-Rajab M, et al. Nerve stimulator-guided
paravertebralblockade combined with sevoflurane sedation versus
general anesthesiawith systemic analgesia for postherniorrhaphy
pain relief in children.Anesthesiology 2005; 103:600605.
13 Ozkan D, Akkaya T, Comert A, et al. Paravertebral block in
inguinal herniasurgeries: two segments or 4 segments? Reg Anesth
Pain Med 2009;34:312315.
14 Kaya FN, Turker G, Mogol EB, Bayraktar S. Thoracic
paravertebral blockfor video-assisted thoracoscopic surgery: single
injection versus multipleinjections. J Cardiothorac Vasc Anesth
2012; 26:9094.
15 Berta E, Spanhel J, Gabrhelik T, Lonnqvist PA. Paraverteral
block inchildren. Tech Reg Anesth Pain Manag 2007; 11:247254.
16 Cowie B, McGlade D, Ivanusic J, Barrington MJ.
Ultrasound-guidedthoracic paravertebral blockade: a cadaveric
study. Anesth Analg 2010;110:17351739.
17 Eid HEA. Paravertebral block: an overview. Curr Anaesth Crit
Care 2009;20:6570.
18 Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar
anaesthesia andparavertebral spread after low thoracic
paravertebral injection. Br JAnaesth 2001; 87:312316.
19 Cheema S, Ilsley D, Richardson J, Sabanathan S. A
thermographic study ofparavertebral analgesia. Anaesthesia 1995;
50:118121.
20 Cheema S, Richardson J, McGurgan P. Factors affecting the
spread ofbupivacaine in the adult thoracic paravertebral space.
Anaesthesia 2003;58:684711.
21 Naja MZ, Ziade MF, El Rajab M, et al. Varying anatomical
injection pointswithin the thoracic paravertebral space: effect on
spread of solution andnerve blockade. Anaesthesia 2004;
59:459463.
22 Saito T, Den S, Cheema SP, et al. A single-injection,
multisegmentalparavertebral block extension of somatosensory and
sympathetic block involunteers. Acta Anaesthesiol Scand 2001;
45:3033.
23 Lonnqvist PA. Plasma concentration of lignocaine after
thoracicparavertebral blockade in infants and children. Anaesthesia
1993;48:958960.
24 Naja ZM, El-Rajab M, Al-Tannir MA, et al. Thoracic
paravertebral block:influence of the number of injections. Reg
Anesth Pain Med 2006;31:196201.
25 Lonnqvist PA, Hildingsson U. The caudal boundary of the
thoracicparavertebral space. A study in human cadavers. Anaesthesia
1992;47:10511052.
26 Saito T, Den S, Tanuma K, et al. Anatomical bases for
paravertebralanesthetic block: fluid communication between the
thoracic and lumbarparavertebral regions. Surg Radiol Anat 1999;
21:359363.
27 Saito T, Gallagher ET, Yamada K, et al. Broad unilateral
analgesia.Reg Anesth 1994; 19:360361.
28 Saito T, Gallagher ET, Cutler S, et al. Extended unilateral
anesthesia. Newtechnique or paravertebral anesthesia? Reg Anesth
1996; 21:304307.
29 Tighe SQ, Greene MD, Rajadurai N. Paravertebral block. Contin
EducAnaesth Crit Care Pain 2010; 10:133137.
30 Batra RK, Krishnan K, Agarwal A. Paravertebral block. J
Anaesth ClinPharmacol 2011; 27:511.
31 Mannion S, Barrett J, Kelly D, et al. A description of the
spread of injectateafter psoas compartment block using magnetic
resonance imaging.Reg Anesth Pain Med 2005; 30:567571.
32 Lonnqvist PA, Hesser U. Radiological and clinical
distribution of thoracicparavertebral blockade in infants and
children. Pediatr Anesth 1993;3:8387.
33 Burns DA, Ben-David B, Chelly JE, Greensmith JE.
Intercostally placedparavertebral catheterization: an alternative
approach to continuousparavertebral blockade. Anesth Analg 2008;
107:339341.
34 Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block:
radiologicalevidence of contralateral spread anterior to the
vertebral bodies. Br JAnaesth 2000; 84:263265.
35 Gadsden JC, Lindenmuth DM, Hadzic A, et al. Lumbar plexus
block usinghigh-pressure injection leads to contralateral and
epidural spread.Anesthesiology 2008; 109:683688.nauthorized
reproduction of this article is prohibited.Eur J Anaesthesiol 2014;
31:305309
Spread of dye after single thoracolumbar paravertebral injection
ininfantsIntroductionMethodsResultsDiscussionAcknowledgements
relating to this article
References