Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery

Question 1

Innervation of the chest wall

Answer 1

• Segmental innervation from spinal nerves becoming the intercostal nerves: sensory from the dorsal root and motor from ventral root
• Suprascapular nerves
• Thoracodrsal nerve
• Long thoracic nerve
• Medial and lateral pectoral nerves
• Phrenic nerve

Question 2

The route of the intercostal nerve

Answer 2

Formed from the corresponding spinal nerve and sympathetic trunk
Initially runs in front of the parietal pleura and behind the transverse process of the spinal column
Mostly runs between the internal intercostal muscle and the innermost intercostal muscle
Branches off at the mid-axillary line to form the lateral cutaneous branch of the intercostal nerve
Ends with a medial and an anterior branch in front of the sternum

Question 3

Complications of acute pain after VATS/ Thoracotomy

Answer 3

• Ineffective breathing and coughing
• Reduced mobility
• Atelectasis
• Pneumonia
• PE
• Chronic post-surgical pain syndrome

Question 4

Regional anaesthetic options for thoracic surgery

Answer 4

• Thoracic epidural
• Paravertebral block
• Surgically placed intercostal block
• Erector spinae block
• Serratus anterior block

Question 5

Erector spinae block needle position

Answer 5

The needle tip is positioned in the plane between the erector spinae muscle and the intertransverse tissue complex (connective tissue between adjacent transverse processes)

Question 6

Serratus anterior block needle position

Answer 6

The needle tip is positioned in the plane between the lat dorse muscle and the serratus anterior muscle in the mid-axillary line