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Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

May 10, 2023/4,750 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

Vol 4 | Issue 1 | January-June 2023 | Page 29-30 | Chethana G. Mapari, Tuhin Mistry, Kartik B. Sonawane, Jagannathan Balavenkatasubramanian DOI: https://doi.org/10.13107/ijra.2023.v04i01.072 Authors: Chethana G. Mapari [1], Tuhin Mistry [1], Kartik B. Sonawane [1], Jagannathan Balavenkatasubramanian [1] [1] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India. […]

Converting Regional Anaesthesia Database into Publication: A Step-based Approach

May 10, 2023/6,332 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

Vol 4 | Issue 1 | January-June 2023 | Page 04-06 | Mayank Gupta, Gopal Jalwal, Anju Grewal DOI: https://doi.org/10.13107/ijra.2023.v04i01.067 Authors: Mayank Gupta [1], Gopal Jalwal [1], Anju Grewal [1] [1] Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India. Address of Correspondence Dr. Gopal Jalwal, Assistant Professor, Department of Anaesthesiology & Critical Care, AIIMS, […]

Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

May 10, 2023/4,750 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

Converting Regional Anaesthesia Database into Publication: A Step-based Approach

May 10, 2023/6,332 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

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Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

May 10, 2023/4,750 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

Vol 4 | Issue 1 | January-June 2023 | Page 29-30 | Chethana G. Mapari, Tuhin Mistry, Kartik B. Sonawane, Jagannathan Balavenkatasubramanian

DOI: https://doi.org/10.13107/ijra.2023.v04i01.072

Authors: Chethana G. Mapari [1], Tuhin Mistry [1], Kartik B. Sonawane [1], Jagannathan Balavenkatasubramanian [1]

[1] Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.

Address of Correspondence
Dr. Tuhin Mistry
Department of Anaesthesiology, Ganga Medical Centre & Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India.
E-mail: tm.tuhin87@gmail.com

Letter to Editor

To the Editor,

Perioperative pain management in spine surgeries poses a unique challenge to anesthesiologists. The severity of pain correlates with multiple factors, including the degree of trauma, level of injury, and complexity of the surgery. Various multimodal analgesia (MMA) strategies and regional analgesia options have been described to deal with such pain. However, the paucity of literature on pain management in traumatic sacral fractures and spinopelvic fixation surgeries warrants further exploration of various modalities. This report describes the application of the sacral multifidus plane block (SMPB) in spinopelvic fixation surgery as an adjunct to MMA. Consent was obtained for the publication of this correspondence.
An 18-year-old healthy male (weight 60 kg, height 160 cm) patient was brought to our hospital with an alleged history of falling from around 15 feet. Radiological investigations revealed comminuted type 1 sacrum fracture (bilateral zones 1, 2, and 3) extending to the left sacroiliac (SI) joint with kyphotic angulation at the fracture site without any anterior translation; comminution of S1, S2, and involvement of neural foramen, median sacral crest with diffuse marrow contusion (Figure 1a). His neuromuscular examination, other systemic examinations, and laboratory investigations were within normal limits. In the first stage, the patient had undergone emergency closed reduction and percutaneous SI joint screw fixation under general anesthesia (Figure 1b). After two days, the patient was scheduled for left L5-ilium spinopelvic fixation with decompression (Figure 1c). The anesthesia plan was discussed with the patient and his relatives and informed written consent was obtained.
In the operating room, standard monitors were attached, an 18G intravenous cannula was secured, and lactated ringer infusion was started. General anesthesia was administered using intravenous propofol 2 mg/kg, fentanyl 2 μg/kg, and rocuronium 0.6 mg/kg. The patient was mechanically ventilated following tracheal intubation, and anesthesia was maintained with nitrous oxide: oxygen (1:1) mixture and titrated desflurane. After turning the patient prone, an ultrasound-guided SMPB was performed as per the technical description by Mistry et al. [1] A high-frequency linear transducer was kept longitudinally next to the midline in the parasagittal plane (Figure 1d). After optimizing the image at the S2 level, a 23G Quincke’s spinal needle was advanced in an in-plane approach from the cephalad to the caudad direction. After hitting the underlying bone, 20 mL of local anesthetic (LA) solution (0.2% ropivacaine + 4 mg dexamethasone) was administered. An anechoic LA spread in the plane between the multifidus muscle (MFM) and the hyperechoic bony area (between the median and intermediate sacral crests) was confirmed. The craniocaudal spread of the LA in the same plane was also noted (Figure 1e). A similar procedure was repeated on the other side.
Intraoperatively, intravenous paracetamol 15 mg/kg, ketorolac 0.5 mg/kg, and 40 mg/kg magnesium sulfate were administered as a part of MMA. The patient remained hemodynamically stable and extubated uneventfully immediately after the surgery of two hours duration. Postoperatively, MMA was continued with intravenous paracetamol 15 mg/kg 6 hourly and oral pregabalin 75 mg once daily. The patient remained comfortable with pain scores of 0–3 on the numeric rating scale for 24 hours without requiring additional analgesics.
SMPB, a variant of the paraspinal plane block, has been used for various surgeries in the perineal and buttock region [1]. The innervation of the SI joint is complex and varies among individuals. It may arise from the ventral rami of L4 and L5, superior gluteal nerve, and dorsal rami of L5-S2 or almost exclusively from the sacral dorsal rami [2]. The dorsal rami also innervate the skin and the muscles in the adjacent region [3]. The lateral branches of the S1-S3 dorsal rami unite to form the medial cluneal nerve that innervates the skin overlying the posteromedial area of the buttock near the midline. The possible mechanism of action of SMPB includes blocking the terminal nerves directly by LA deposition in the myo-osseous plane and involving ventral rami, pudendal nerve (S2–S4), lumbosacral plexus, and sciatic nerve by anterior and craniocaudal spread through dorsal and ventral sacral foramina [4,5]. Postoperatively, we observed selective sensory loss in the L4-S3 dermatome without motor weakness. Being a fascial plane block, the analgesic coverage of SMPB is volume-dependent. However, unlike other fascial plane blocks, the LA spread in SMPB can be consistent due to the presence of the bony dorsal surface of the sacrum. Consistent drug spread across the sacral dorsal surface could include all procedure-specific innervations required to provide analgesia for sacral spine surgery. SMPB provided adequate analgesia in our patient, possibly because of this anatomical advantage. It also helped maintain intraoperative hemodynamic stability, reduce surgical blood loss, control opioid requirements, and facilitate postoperative enhanced recovery and mobilization.
We conclude that the inclusion of SMPB as a component of MMA can provide effective perioperative analgesia in spinopelvic fixation surgeries or sacral spine injuries. However, adequately powered studies with robust methodology are required in the future to establish the safety, and efficacy of this block, and also to determine the appropriate volume and concentration of local anaesthetic necessary for providing the desired effect.

References

[1] Mistry T, Sonawane K, Balasubramanian S, Balavenkatasubramanian J, Goel VK. Ultrasound-guided sacral multifidus plane block for sacral spine surgery: A case report. Saudi J Anaesth 2022; 16:236-9.
[2] Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology, and clinical significance. Pain Physician. 2006 Jan;9(1):61-7.
[3] Suganthy J, Irodi A, Prithishkumar IJ, Jacob TM. Cunningham’s Manual of Practical Anatomy. 16th ed. New York: Oxford University Press; 2017. pp. 279–92.
[4] Kukreja P, Deichmann P, Selph JP, Hebbard J, Kalagara H. Sacral erector spinae plane block for gender reassignment surgery. Cureus. 2020;12: e7665.
[5] Chakraborty A, Chakraborty S, Sen S, Bhatacharya T, Khemka R. Modification of the sacral erector spinae plane block using an ultrasound-guided sacral foramen injection: Dermatomal distribution and radiocontrast study. Anaesthesia. 2021; 76:1538–9.

How to Cite this Article: Mapari CG, Mistry T, Sonawane KB, Balavenkatasubramanian J | Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 29-30 | DOI: https://doi.org/10.13107/ijra.2023.v04i01.072

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Converting Regional Anaesthesia Database into Publication: A Step-based Approach

May 10, 2023/6,332 Comments/in Volume 4; Issue 1: January-June 2023/by Ijraijraadmin

Vol 4 | Issue 1 | January-June 2023 | Page 04-06 | Mayank Gupta, Gopal Jalwal, Anju Grewal

DOI: https://doi.org/10.13107/ijra.2023.v04i01.067

Authors: Mayank Gupta [1], Gopal Jalwal [1], Anju Grewal [1]

[1] Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India.

Address of Correspondence
Dr. Gopal Jalwal,
Assistant Professor, Department of Anaesthesiology & Critical Care, AIIMS, Bathinda, Punjab, India.
E-mail: gopaljalwal@gmail.com

Abstract

The article discusses the benefits of regional anaesthesia (RA) and the role of point-of-care ultrasound (POCUS) in enhancing its safety and efficacy. Conducting randomized controlled trials (RCTs) to establish the efficacy of RA remains a challenge due to resource constraints and ethical considerations. The author suggests that focusing solely on RCTs can be counterproductive and advocates for the importance of other forms of research, such as case series, practice audits, and prospective observational cohort studies. These forms of research can provide a background and rationale for designing future RCTs and can help broaden the scope of research beyond the idealistic RCT paradigm. The passage also includes a table highlighting the pros and cons of different study designs. Overall, the article emphasizes the importance of expanding the scope of research to improve the safety and efficacy of RA.
Keywords: Regional anaesthesia, Point-of-care ultrasound, Randomized controlled trials, Case series, Practice audits, Prospective observational cohort studies, Efficacy, Safety

References

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[2] Chin KJ, Mariano E, El-Boghdadly KE. Advancing towards the next frontier in regional anaesthesia. Anaesthesia 2021; 76(S1): 3–7.
[3] Shelley BG, Anderson KJ, Macfarlane AJR. Regional anaesthesia for thoracic surgery: what is the PROSPECT that fascial plane blocks are the answer? Anaesthesia 2022; 77(3): 252–256.
[4] Kearns RJ, Womack J, Macfarlane AJ. Regional anaesthesia research – where to now? Br J Pain. 2022 Apr;16(2):132-135. doi: 10.1177/20494637221091139.
[5] Dohlman LE, Kwikiriza A, Ehie O. Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings. Local Reg Anesth. 2020 Oct 22;13:147-158. doi: 10.2147/LRA.S236550.
[6] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344-9. doi: 10.1016/j.jclinepi.2007.11.008.
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[11] Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group*. The CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development. Glob Adv Health Med. 2013 Sep;2(5):38-43. doi: 10.7453/gahmj.2013.008.
[12] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344-9. doi: 10.1016/j.jclinepi.2007.11.008.
[13] Butcher NJ, Monsour A, Mew EJ, Chan AW, Moher D, Mayo-Wilson E, Terwee CB, Chee-A-Tow A, Baba A, Gavin F, Grimshaw JM, Kelly LE, Saeed L, Thabane L, Askie L, Smith M, Farid-Kapadia M, Williamson PR, Szatmari P, Tugwell P, Golub RM, Monga S, Vohra S, Marlin S, Ungar WJ, Offringa M. Guidelines for Reporting Outcomes in Trial Reports: The CONSORT-Outcomes 2022 Extension. JAMA. 2022;328(22):2252-2264.
[14] Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S. Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education. Cureus. 2017 Aug 7;9(8):e1546. doi: 10.7759/cureus.1546.

How to Cite this Article: Gupta M, Jalwal G, Grewal A | Converting Regional Anaesthesia database into Publication: A step-based approach | International Journal of Regional Anaesthesia | January-June 2023; 4(1): 04-06 | DOI:https://doi.org/10.13107/ijra.2023.v04i01.067

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Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

Converting Regional Anaesthesia Database into Publication: A Step-based Approach

Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

Converting Regional Anaesthesia Database into Publication: A Step-based Approach

Full Sized Blog Element (Big Preview Pic)

Sacral Multifidus Plane Block – A Way Forward to Provide Perioperative Analgesia for Spinopelvic Fixation Surgery

Authors: Chethana G. Mapari [1], Tuhin Mistry [1], Kartik B. Sonawane [1], Jagannathan Balavenkatasubramanian [1]

(Abstract Text HTML) (Download PDF)

Converting Regional Anaesthesia Database into Publication: A Step-based Approach

Authors: Mayank Gupta [1], Gopal Jalwal [1], Anju Grewal [1]

(Abstract Text HTML) (Download PDF)

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