Ultrasound Guided Modified Thoracolumbar Interfascial Plane Block: A Preliminary
Result of New Approach
AUTHORS INTRODUCTION
Ultrasound guided thoracolumbar interfascial
Ali Ahiskalioglu1 plane (TLIP) block was first described in 2015 by
Ahmet Murat Yayik1 Hand et al (1). TLIP block involves injection of local
Omer Doymus1 anesthetics between multifidus and longissimus
Kubra Selvitopi1 muscles at the third lumbar vertebra level and can
Elif Oral Ahiskalioglu2 block the dorsal rami of thoracolumbar nerves (2).
Mehmet Aksoy1
Haci Ahmet Alici1
While defining the block, Hand et al. made the
injection between multifidus and longissimus muscles
with a 30 degree angle from lateral to medial.
Differently, we made the injection between
longissimus and iliocostalis muscles with a 15 degree
1 Anesthesiology and Reanimation, Ataturk angle from medial to lateral (3).
University, Erzurum, Turkey
2 Anesthesiology and Reanimation,
Regional Training Hospital, Erzurum,
Turkey METHODS AND MATERIALS
In this preliminary study 20 patients undergoing
spinal surgery (2 or 3 level), ASA I-III were
randomized two groups. Group control ( Group C,
n=10); receive bilateral ultrasound guided 2 ml 0,9%
salin subcutaneusly each block side, Group TLIP
(Group T, n=10) receive ultrasound guided bilateral
TLIP with 0,25 % bupivacaine 20 ml each side. The
procedure was performed with Esote MyLab 30® US
device in 18 Hz frequency linear probe with the
patient was prone position. We made the injection
between longissimus and iliocostalis muscles with a
15 degree angle from medial to lateral at the level of
third vertebral body. Postoperative analgesia was
performed intravenously in the 2 groups twice a day
with dexketoprofen trometamol 50 mg and patient-
CONTACT controlled analgesia with fentanyl. Postoperative
analgesia was evaluated using the visual analog
scale (VAS). Fentanyl consumption were recorded
Name: Ali Ahiskalioglu during the first 24 hours after surgery.
Adress: Anesthesiology and Reanimation,
Ataturk University, Erzurum, Turkey
Email: aliahiskalioglu@hotmail.com
Phone: 90 544 442 4831
Website: https://atauni.edu.tr/ali-ahiskalioglu
RESULTS
Compared with control, the VAS score was
statistically lower in the TLIP group during all
measurements time (P < 0.05). Fentanyl consumption
was lower in the TLIP group compared to the placebo
group at all time periods (0-4, 4-8 and 8-24 h)
(p<0.05). In terms of total fentanyl consumption, 24-h
consumption was lower in the TLIP group compared
to the control group (222.50±115.13 μcq and 462.50 ±
234.59 μcq, respectively) (p=0.009).
Figure 1. Opioid Consumption.
Figure 2. Injection of radiographic dye demonstrates the
multilevel spread of the injected local anesthetic
DISCUSSION
There are several advantages to our modified method
including:
1)advancing the needle from medial to lateral which
eliminates the risk of possible inadvertent neuraxial
injection;
2)injecting between the iliocostalis and longissimus
muscles results in a dermatomal area of analgesia
similar to an injection made between the multifidus
and longissimus muscles. We have shown this by
using radiopaque dye injections (with specific patient
consent) where the distribution of local anesthetics
spread two levels caudally and cranially to the
injection site. Twenty minutes after injection, we were
able to show a corresponding dermatomal area (using
a pinprick test) of reduced sensation.
3)sonographic imaging that is easier to discern the
distinction between the longissimus and iliocostalis
muscles than between the multifidus and longissimus
muscles. Thus potentially increases block success
rates.
Figure 4. Difficult identifying of multifidus
and longisimus muscles
Figure 5. Easy define using USG
Figure 3. Illustration of TLIP block longissimus and intercostalis muscles.
DISCUSSION
These modifications to the TLIP block will
require further study to more fully investigate their
potential advantages.
Such investigations, including MRI and
cadaveric studies combined with ultrasound, should
be beneficial in the evaluation of the block’s potential
anatomic spread.
When compared with some other nerve blocks,
interfascial plane blocks are highly depending on
sufficient volumes of local anesthetics to spread
between muscle layers and fascial planes.
CONCLUSIONS
The TLIP block might be useful in 2 and 3 level
spinal surgical procedures and minimal invasive
spinal surgery by reduce opioid consumption.
To validate this outcome larger groups
randomized controlled trials needed.
REFERENCES
1. Hand WR, Taylor JM, Harvey NR, et al. Thoracolumbar interfascial plane
(TLIP) block: a pilot study in volunteers. Canadian journal of anaesthesia =
Journal canadien d'anesthesie 2015; 62: 1196-200.
2. Ueshima H, Oku K, Otake H. Ultrasound-guided thoracolumbar interfascial
plane block: a cadaveric study of the spread of injectate. J Clin Anesth 2016;
34: 259-60.
3. Ahiskalioglu A, Alici HA, Selvitopi K, Yayik AM. Ultrasound Guided Modified
Thoracolumbar Interfascial Plane Block: A New Approach. . Canadian journal
of anaesthesia. (Accepted manuscript)