You are on page 1of 4

Journal of Anesthesia

https://doi.org/10.1007/s00540-017-2439-7

SHORT COMMUNICATION

Novel ultrasound‑guided inter‑semispinal plane block: a comparative


pilot study in healthy volunteers
Yuichi Ohgoshi1   · Ryo Nishizakura1 · Yuki Takahashi1 · Keisuke Takeda1 · Hirosuke Nakayama1 ·
Mariko Kawamata1 · Kiyoyasu Kurahashi1,2

Received: 25 August 2017 / Accepted: 15 December 2017


© Japanese Society of Anesthesiologists 2017

Abstract
We previously reported that a novel multifidus cervicis plane (MCP) block could anesthetize the dorsal rami of the cervical
spinal nerves. While MCP sonoanatomy is easily detectable in most patients, it is sometimes difficult to recognize the MCP
injection plane, especially in elderly patients. Thus, we proposed the inter-semispinal plane (ISP) block as an alternative
for the MCP block. The aim of this study was to evaluate the utility of the ISP block by evaluating the area and duration of
anesthesia, compared with that of the MCP block in eight healthy volunteers. Each participant underwent unilateral ultra-
sound-guided MCP block and ISP block. For each block, 20 ml of ropivacaine 0.2% was injected, and the area of anesthesia
was determined using the pinprick test. The anesthetic area ranged from C4 to T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (3/8;
37.5%) in the MCP block, and from C4 to T1 (1/8; 12.5%), T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (1/8; 12.5%) in the ISP
block. The mean (standard deviation) duration of sensory loss following MCP and ISP blocks was 329 (77) min and 349
(70) min, respectively. Thus, the ISP block may be a reliable alternative to the MCP block.

Keywords  Multifidus cervicis plane block · Inter-semispinal plane block · MCP block · ISP block · Analgesia

We have previously reported that the multifidus cervicis of MCP block, and thus provides a better detection of the
plane (MCP) block is an effective perioperative analgesic plane even in elderly patients. This modification is based
strategy for cervical spine surgery [1]. Since the multifidus on a previous anatomical study demonstrating the running
cervicis muscle is the deepest structure of the five-layered course of the dorsal rami of the cervical spinal nerve [2].
posterior cervical muscles, the MCP sonoanatomy is some- We hypothesized that the injection in both the MCP and ISP
times difficult to detect, especially in elderly patients, which blocks can spread and block the root of the dorsal rami of
may result in ineffective analgesia. To provide successful the cervical spinal nerves.
perioperative analgesia during cervical spine surgery, some In this study, we separately performed unilateral MCP
modifications are warranted in the MCP block. Here, we block and ISP block on each side in eight healthy volun-
proposed the inter-semispinal plane (ISP) block, which is teers and compared their analgesic effects. The purpose of
an anatomy-based modified approach that is performed by this comparative pilot study was to evaluate the utility of
a local anesthetic injection into the fascial plane between the ISP block by comparing the area and duration of anes-
the semispinalis cervicis and semispinalis capitis muscles. thesia compared with the original MCP block. This study
The injection of the ISP block is superficial relative to that was approved by the institutional ethics committee of the
International University of Health and Welfare (approval
number: 5-16-50), and was registered in the UMIN Clinical
* Yuichi Ohgoshi Trial Registry (UMIN 000027180).
ohgoshi22@gmail.com
We enrolled six men and two women, 20 to 39 years of
1
Department of Anesthesiology, International University age, with an American Society of Anesthesia physical status
of Health and Welfare Mita Hospital, 1‑4‑3 Mita, Minato‑ku, I. After receiving a detailed explanation of the procedure
Tokyo 108‑8329, Japan and its potential side effects, the participants provided writ-
2
Department of Anesthesiology and Intensive Care Medicine, ten informed consent for their participation. The eight vol-
International University of Health and Welfare, School unteers showed no significant differences in their baseline
of Medicine, Narita, Japan

13
Vol.:(0123456789)
Journal of Anesthesia

characteristics, with a mean [standard deviation (SD)] age of None of the volunteers experienced serious complica-
31.8 (4.8) years (range, 20–39 years), the mean (SD) height tions, but equilibrium disturbance caused by unilateral anes-
of 170.5 (8.4) cm (range, 154–181 cm), and mean (SD) thesia on the posterior cervical region occurred temporarily
weight of 61.4 (9.7) kg (range, 43–70 kg) (Table 1). The in all participants to a greater or lesser extent. The derma-
volunteers were allocated to two groups using an envelope tomal distribution of the maximum sensory loss obtained
method. In group 1 (n = 4), the MCP block was performed by the pinprick test and the duration of the blocks’ action
on the right side and the ISP block on the left side. In group indicated numerically (Table 1) or graphically (Fig. 1d, e).
2 (n = 4), the MCP block was performed on left side and Anesthetic area obtained by the pinprick test was confined
the ISP block on the right side. In addition, the order of the to the region innervated by the dorsal rami of the spinal
blocks was randomly assigned in each group. The second nerves. The upper border of the anesthetic area was C4 in
block was carried out on a different day to facilitate a com- the dermatome in all volunteers, and the third occipital nerve
plete recovery from the first block. and the greater occipital nerve were never blocked (Fig. 1d,
After establishment of the peripheral venous line and e; Table 1). The lower limit of the anesthetic area of the
standard non-invasive monitoring, each participant was MCP block was T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (3/8;
placed in a prone position, and the five-layered posterior 37.5%), while that of the ISP block was T1 (1/8; 12.5%), T2
cervical muscles were identified at the level of C5 with a (3/8; 37.5%), T3 (2/8; 25%), or T4 (1/8; 12.5%). The mean
6–15-MHz linear probe oriented in the transverse plane (SD) duration of sensory loss was 329 (77) min in the MCP
(S-Nerve, Fujifilm Sonosite, Tokyo, Japan) (Fig. 1a). The block and 349 (70) min in the ISP block. The region around
fifth cervical spine was counted from the C7 spinous process the dorsal midline was not colored (Fig. 1d, e) because it
with the probe sliding cranially. After aseptic preparation of corresponds to the area of the overlapping cutaneous inner-
the injection area, lidocaine 1% was used to anesthetize the vation of the bilateral medial branches. Therefore, unilateral
skin. Under continuous ultrasound guidance, the needle (22- block could not block the area around the dorsal midline;
G, 0.7 mm × 60 mm, Plexufix, B-BRAUN, Tokyo, Japan) thus, perioperative analgesia requires bilateral blocks.
was introduced in-plane through the skin and advanced into In the present study, we found interesting findings related
the fascial plane between the multifidus cervicis and semi- to the anatomical features. First, both procedures never
spinalis cervicis muscles for the MCP block (Fig. 1b), or blocked the third occipital nerve and the greater occipital
between the semispinalis cervicis and semispinalis capitis nerve in any of the participants. This finding indicated that
muscles for the ISP block (Fig. 1c). After negative aspira- the extension of local anesthetics injected at the C5 level into
tion for blood, 20 ml of ropivacaine 0.2% was injected for the MC- or IS-plane stemmed from a structure at approxi-
each block. The area of sensory loss was assessed carefully mately the C2-3 spinous process level. We hypothesize that
20 min after the block using the pinprick test. To assess the this structure could be a fascia of the semispinalis capitis
duration of the block, the pinprick test was first repeated at muscle or strong fascial connection between the semispinalis
10-min intervals, and subsequently at 1-min intervals in the capitis and inlying muscles. The fascia of the semispinalis
final phase until the effect of the nerve block disappeared. capitis muscle may hinder the spread of local anesthetics,
All injections were performed by one of the two investiga- thus disturbing the anesthesia of the third occipital nerve
tors (Y.O. or R.N.). and the greater occipital nerve existing above the fascia. As

Table 1  Dermatomal distribution of sensory loss obtained by the pin prick test and duration of action of the MCP and ISP blocks
Participants Age (years)/sex Height/weight MCP block ISP block
(cm/kg)
Area (upper–lower) Duration (min) Area (upper–lower) Duration (min)

Group 1
 1 38/M 170/70 C4(C2)-T3 252 C4(C2)-T2 380
 2 34/M 181/67 C4(C3)-T4 364 C4(C3)-T2 351
 3 30/M 175/70 C4(C3)-T2 354 C4(C3)-T1 402
 4 29/F 162/43 C4(C3)-T4 288 C4(C2)-T3 300
Group 2
 5 39/M 170/65 C4(C3)-T4 358 C4(C2)-T4 238
 6 27/M 180/65 C4(C2)-T2 495 C4(C3)-T2 484
 7 27/M 172/64 C4(C3)-T2 245 C4(C3)-T3 327
 8 26/F 154/47 C4(C2)-T3 277 C4(C2)-T4 311

M male, F female

13
Journal of Anesthesia

Fig. 1  a Transducer orientation and needle insertion point of both SCA semispinalis capitis muscle, SCE semispinalis cervicis muscle,
blocks. b, c Ultrasonographic transversal view of the MCP block (b) SP spinous process, SPL splenius capitis muscle, T trapezius muscle.
and ISP block (c) visualized at the level of the fifth cervical vertebra. d, e Area of sensory loss following MCP block (d) and ISP block (e)
The arrowhead indicates the needle. MC multifidus cervicis muscle, in eight volunteers

a result, the upper anesthetic area of the MCP or ISP blocks There are considerable limitations in this study. First, the
was confined to the epidermal region above the C2-3 spinous age group of the volunteers who were enrolled in the present
process (innervated by the medial branch of C4). study is not representative of the patients’ age group. The
Second, both blocks could anesthetize not only the cervi- volunteers are young, and as a result the discernibility of
cal region but also the thoracic region; the paralyzed area their five-layered posterior cervical muscles in sonography
was extended to the T1–T4 level. This result suggested that is easy. In contrast, the patients who undergo cervical spine
the local anesthetic placed by each block spread along the surgery are typically older and the visibility of the layers
semispinalis cervicis muscle into the thoracic region. may be worse, thus limiting the success of the block. In

13
Journal of Anesthesia

addition, the spread of the local anesthetics may vary with of Health and Welfare Mita Hospital for their assistance and support
age due to multiple factors including muscular degeneration during data collection.
and other anatomical changes. Second, we used 20 ml of
Funding None.
ropivacaine 0.2% for each block in the present study. When
applying MCP or ISP block for perioperative pain relief,
Compliance with ethical standards 
higher concentrations of local anesthetics may be used to
induce positive and long-term effects. These factors may Conflict of interest  All authors declare that they have no competing
cause alterations to the area or the duration of MCP and interests.
ISP blocks.
In summary, the fascial plane of the ISP block was more
superficial to that of the MCP block. Furthermore, the ISP References
block provided equivalent effects to the MCP block in block-
ing the multiple dorsal rami of the cervical spinal nerves; 1. Ohgoshi Y, Izawa H, Kori S, Matsukawa M. Multifidus cervicis
therefore, the ISP block may be a reliable alternative to the plane block is effective for cervical supine surgery. Can J Anesth.
2017;64:329–30.
MCP block. 2. Zhang J, Tsuzuki N, Hirabayashi S, Saiki K, Fujita K. Surgical
anatomy of the nerves and muscles in the posterior cervical spine:
Acknowledgements  The authors thank Dr. Yosuke Usui for his con- a guide for avoiding inadvertent nerve injuries during the posterior
tributions to the anatomical understanding of the block. The authors approach. Spine (Phila Pa 1976). 2003;28:1379–84.
also thank the staff of the operating room of International University

13