PostScript

Reg Anesth Pain Med: first published as 10.1136/rapm-2018-100256 on 11 January 2019. Downloaded from http://rapm.bmj.com/ on 3 May 2019 by guest. Protected by copyright.
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External oblique fascial

To the editor,
We previously hypothesized that local
anesthetic injected in a thoracic fascial
plane might result in clinically useful anal-
gesia of the anterolateral part of the upper
abdominal wall.1 We are most grateful to
Dr Wang and colleagues for sharing prelim-
inary clinical confirmation of our theoret-
ical premise.2 We have recently studied
the spread of dye following injection in
the thoracic fascial planes both deep and
superficial to the external oblique muscle
in a fresh frozen cadaver. We believe this
work adds evidence to the case for poten-
tial use of a thoracic fascial plane block to
achieve analgesia of the upper anterolat-
eral abdominal wall. Ultrasound-guided
injections were carried out using in plane
needling at the level of the sixth inter-
costal space (figure 1A) with the needle
tip terminating either deep (figure 1B and
C) or superficial to the external oblique
muscle in the midclavicular line. A total
volume of 20 mL of fluid was injected on
each side consisting of 2 mL 2.5% Patent
Blue V (Aspen Pharmacare Australia, St
Leonards, Australia) diluted to the total
volume with 0.9% sodium chloride. The
distribution of dye following injection
deep to the external oblique muscle is
shown in figure 2. There was no evidence
of dye spread in the serratus plane.

Figure 1 (A) Ultrasound-guided injection into the thoracic fascial plane deep to the right
external oblique muscle in a cadaver. The costal margin is indicated by a discontinuous black line.
(B) Sonographic appearance of the external oblique fascial plane block. (C) The needle position
is indicated by arrows; SC indicates subcutaneous tissue; EO is the external oblique muscle; ICM
the intercostal muscle. The pleura is indicated by a discontinuous white line. The distribution of
injectate is indicated by the yellow shaded area.
528 Reg Anesth Pain Med April 2019 Vol 44 No 4
 PostScript

Reg Anesth Pain Med: first published as 10.1136/rapm-2018-100256 on 11 January 2019. Downloaded from http://rapm.bmj.com/ on 3 May 2019 by guest. Protected by copyright.
2
Hull York Medical School, York, UK
3
Department of Anaesthesia, County Durham &
Darlington NHS Foundation Trust, Darlington, UK
4
School of Medicine, Dentistry and Biomedical Sciences,
Queen’s University, Belfast, UK
Correspondence to Dr Duncan Lee Hamilton,
Department of Anaesthesia, James Cook University
Hospital, Middlesbrough TS4 3BW, UK;
​duncanleehamilton@​nhs.​net
Contributors DLH: Study idea, ultrasound guided
injections, dissection, writing of first draft, preparation
Figure 2 Cadaveric dissection showing the of figures, editing of article and approval of final
manuscript. BPM: Study idea, editing first draft and
pattern of spread following injection of 20 mL approval of final manuscript. MAJW: Dissection,
blue dye deep to the external oblique muscle preparation of figures, approval of final manuscript.
on the right side, with staining of the lateral EAM: Obtained ethical approval, dissection and
cutaneous branches of thoracoabdominal approval of final manuscript.
nerves T6–T10. EO is the reflected external Funding The authors have not declared a specific
oblique muscle; the costal margin is indicated grant for this research from any funding agency in the
public, commercial or not-for-profit sectors.
by a discontinuous line.
Competing interests None declared.
Injection deep to the external oblique Patient consent for publication Not required.
muscle may have technical advantages over Ethics approval Ethical approval for this study was
the superficial plane due to better delinea- granted by the Ethics Committee at Queen’s University
tion of the target fascial plane between the Belfast, UK.
external oblique and intercostal muscles Provenance and peer review Not commissioned;
on ultrasound imaging, which in turn may internally peer reviewed.
result in improved accuracy. © American Society of Regional Anesthesia & Pain
It is possible that the approach described Medicine 2019. No commercial re-use. See rights and
by Wang et al2 would be suitable for upper permissions. Published by BMJ.
abdominal wall analgesia. However,
recent cadaveric and clinical studies on the
serratus plane block have demonstrated To cite Hamilton DL, Manickam BP, Wilson MAJ, et al.
inconsistent blockade of lateral cutaneous Reg Anesth Pain Med 2019;44:528–529.
branches of the thoracoabdominal nerves
below the T7 level, even with the use of Received 10 November 2018
high volumes (40 mL) of local anesthetic.3 Accepted 18 November 2018
Published Online First 11 January 2019
A more posterior approach to the serratus
Reg Anesth Pain Med 2019;44:528–529.
plane near the inferior angle of scapula
doi:10.1136/rapm-2018-100256
behind the posterior axillary line has
shown blockade of the lateral cutaneous
References
branches of the thoracoabdominal nerves 1 Hamilton DL, Manickam BP. Is a thoracic fascial plane
below T8 level by extension of staining block the answer to upper abdominal wall analgesia?
deep to the external oblique muscle.4 Reg Anesth Pain Med 2018;43:891–2.
Hence, the external oblique plane could 2 Wang Q, Zhang X, Papadimos TJ, et al. Reply to Drs
Hamilton and Manickam. Reg Anesth Pain Med
be a more suitable plane of injection for 2018;43:892–3.
blockade of the anterior divisions of the 3 Biswas A, Castanov V, Li Z, et al. Serratus plane block:
lateral cutaneous branches of the thora- a cadaveric study to evaluate optimal injectate spread.
coabdominal nerves from T6 to T10, Reg Anesth Pain Med 2018;43:854–8.
4 Elsharkawy H, Maniker R, Bolash R, et al. Rhomboid
which is required for anterolateral upper intercostal and subserratus plane block: a cadaveric
abdominal wall analgesia. Moreover, the and clinical evaluation. Reg Anesth Pain Med
injection could be performed with the 2018;43:745–51.
subject in the supine position, and the
site is amenable to catheter insertion.
Further clinical studies are required to
evaluate the dermatomal coverage of this
thoracic fascial plane block. It remains to
be seen whether such a technique would
be appropriate for widespread clinical use.
The potential benefits need to be balanced
against the risk of pneumothorax.
Duncan Lee Hamilton,1,2 Baskar P Manickam,3
Matthew A J Wilson,4 Eiman Abdel Meguid4
1
Department of Anaesthesia, James Cook University
Hospital, Middlesbrough, UK

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