Anaesthesia 2021, 76 (Suppl. 1), 110–126 doi:10.1111/anae.

15276

Review Article

Ultrasound-guided fascial plane blocks of the chest wall: a

state-of-the-art review
K. J. Chin,1 B. Versyck2,3 and A. Pawa4

1 Professor, Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto,
Canada
2 Consultant, Department of Anaesthesia and Pain Medicine, AZ Turnhout, Belgium
3 Researcher, Department of Anaesthesia and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
4 Consultant, Department of Anaesthesia, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Summary
Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established
techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an
appealing safety profile. Many different techniques have been described, which can be broadly categorised
into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is
critical not only for block performance, but also to match block techniques appropriately with surgical
procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be
overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a
conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral
nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely
to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall
techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic
paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further
avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-
quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and
comparative studies to determine which of the myriad blocks currently on offer should be core competencies in
anaesthetic practice.

.................................................................................................................................................................
Correspondence to: K. J. Chin
Email: gasgenie@gmail.com
Accepted: 18 September 2020
Keywords: breast surgery; cardiac surgery; fascial plane block; postoperative analgesia; regional anaesthesia;
thoracic surgery; thoracic trauma
Twitter: @KiJinnChin; @BarbaraVersyck; @amit_pawa

Introduction adverse effects. The advent of ultrasound-guided regional

Until just over a decade ago, regional anaesthesia of the
chest wall was limited to thoracic epidural analgesia,
thoracic paravertebral blocks and intercostal nerve blocks,
all of which target thoracic spinal nerves at or close to their
origin. They are effective techniques, but widespread usage
was hampered by technical complexity, perceived risks and
anaesthesia led to the development of fascial plane chest
wall blocks, which are characterised by: injection of a
generous volume of local anaesthetic; injection into
musculofascial planes that contain nerves, rather than
around discrete nerves; and injection distant from critical
structures such as the spinal cord, major vessels or pleura

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Chin et al. | Fascial plane chest wall blocks
[1]. These techniques have burgeoned both in number and
popularity as safer and easier alternatives to thoracic
epidural anaesthesia and thoracic paravertebral blockade.
The pectoral nerve type-1 (PECS1) block was the first to be
described and was followed by the pectoral nerve type-2
(PECS2) block, the serratus anterior plane block and
parasternal blocks. These can all be categorised into an
anterolateral group of chest wall blocks (Table 1). More
recently, the erector spinae plane (ESP) block has sparked
interest in a posterior group of paraspinal-intercostal block
techniques that continues to evolve (Table 1). In this article,
we provide an overview of various chest wall block
techniques by reviewing the relevant clinical anatomy,
discussing their mechanisms of action and summarising the
available evidence for their clinical application.
Anatomy
Anatomical knowledge is not only critical to proper block
performance, but also to appropriate matching of block
technique and surgical procedure. This includes
understanding the anatomical course of target nerves as well
as the innervation of clinically-relevant anatomical tissues. We
often focus only upon the patterns of cutaneous innervation;
however, pain from trauma to muscles, ligaments, joints and
bone is just as significant. While the innervation of these
deeper tissues is less well described, a useful principle is that
of Hilton’s law, which states that nerves innervating the
muscles acting at or across a joint are also responsible for
sensory innervation of the articular soft tissues (joint capsule,
ligaments, synovium) [2]. Nerves traditionally regarded as
purely motor may, therefore, play a larger role in the
transmission of pain than previously thought [3, 4].
Anterolateral chest wall and axillary region
From superficial to deep, the anterolateral chest wall
consists of skin, subcutaneous fat, muscle layers and ribs.
The deepest muscle layer comprises the intercostal muscles
(external, internal and innermost) connecting adjacent ribs.
The serratus anterior muscle overlies the lateral aspect of
first to eighth ribs and intercostal muscles, originating as
multiple muscular slips running posteriorly from individual
ribs to merge and insert on the scapula and spine. This is an
important consideration during an ultrasound-guided
serratus anterior plane block, as the serratus anterior muscle
becomes progressively thicker and easier to identify in an
anterior-to-posterior direction. The serratus anterior muscle
is covered by the latissimus dorsi muscle and by the
pectoral muscles on its posterior and anterior aspect,
respectively (Fig. 1). Hence, a superficial serratus anterior
© 2020 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 110–126
plane block at the level of the fourth rib in the posterior or
mid-axillary line, and the deep (subpectoral) injection of the
PECS2 block are injections into the same plane.
The anterolateral chest and axillary region are
innervated by five groups of nerves: anterior cutaneous
branches and lateral cutaneous branches of the T2-T6
thoracic intercostal nerves; pectoral nerves; long thoracic
nerve; and supraclavicular nerves (Fig. 2). These originate
from three anatomically-distinct neural structures: the
neuraxis; brachial plexus; and cervical plexus.
The thoracic intercostal nerves are the continuations of
ventral rami of the respective spinal nerve roots. A complex
intercommunicating network of branches from each
intercostal nerve innervates the thoracic cage (Fig. 3) [5].
Multiple anastomoses between adjacent spinal nerves and
their branches result in a complex and non-segmental
pattern of sensory innervation [6]. In general, the terminal
anterior cutaneous branches of T2-T6 innervate the medial
half of the breast [7], while the lateral cutaneous branches of
T3-T6 innervate the lateral half. The lateral cutaneous
branches of T3-T6 arise from the main nerve trunk close to
the mid-axillary line [5], and ascend through intercostal and
serratus anterior muscles, before dividing further into
anterior and posterior branches that innervate the
anterolateral and posterolateral chest wall, respectively. The
lateral cutaneous branch of T2 is the intercostobrachial
nerve, which innervates the axilla and medial upper arm. In
the axilla, the intercostobrachial nerve often receives a
communicating branch from the brachial plexus and medial
brachial cutaneous nerve [8].
The pectoral nerves and the long thoracic nerve
originate from the brachial plexus. The lateral pectoral
nerve (C5-7) innervates the pectoralis major muscle. The
medial pectoral nerve (C7-T1) innervates pectoralis minor
muscle and the caudal part of pectoralis major. Both
pectoral nerves run lateral to the pectoral branch of the
thoracoacromial artery, and thus the PECS1 block should
ideally be performed near this artery. The long thoracic
nerve (C5-7) descends from the brachial plexus in a
posterolateral direction to innervate the serratus anterior
muscle. The role of these nerves in postoperative pain is
controversial and may be minor [9, 10]. Finally, the
supraclavicular nerves originate from the superficial cervical
plexus to innervate the skin of the superior part of the breast
(Fig. 2).
Anteromedial chest wall
The anteromedial chest wall (the area between the mid-
clavicular line and the sternum) comprises skin,
111
 112
Table 1 Overview of chest wall fascial plane block techniques
Block name Technical performance
Anterolateral chest wall blocks
Pectoral nerve type-1 Injection between pectoralis
(PECS1) block [6] major and minor muscles.
Pectoral nerve PECS1 block plus a second injection
type-2 (PECS2) deep to pectoralis major and
block [6] superficial to serratus anterior muscle.
Serratus anterior Injection superficial to serratus
plane block anterior muscle.
(superficial) [6] Injection can be performed anywhere
within a region bounded by the anterior
and posterior axillary line,
and the 3rd to 6th ribs.
Serratus anterior Injection deep to serratus anterior
plane muscle and superficial to ribs and
block (deep) [6] intercostal muscles.
Injection can be performed anywhere
within a region bounded by the anterior
and posterior axillary line,
and the 3rd to 6th ribs.
Anteromedial chest wall blocks
Transversus thoracis Injection deep to internal intercostal
plane block [126] muscle and superficial to transversus
thoracis muscle, lateral to the sternal edge.
Pecto-intercostal fascial Injection deep to pectoralis major
plane block [25] muscle and superficial to internal
intercostal muscle and ribs,
lateral to the sternal edge.
© 2020 Association of Anaesthetists
Neural targets of
primary interest Other comments
Lateral and medial The pectoral branch of the thoracoacromial artery is an
pectoral nerves. important landmark for locating the pectoral nerves, but also as a
structure to be avoided with needle puncture.
Lateral and medial The block is conventionally performed with the probe oriented in
pectoral nerves. an oblique orientation and placed between the clavicle and
Lateral cutaneous axilla, and a single-needle insertion trajectory from medial to lateral.
branches of T2-T6
intercostal nerves.
Anaesthesia 2021, 76 (Suppl. 1), 110–126
Lateral cutaneous The exact probe position and needle trajectory may be modified
branches of T2-T7 according to the desired area of coverage. The exact levels of
intercostal nerves. intercostal nerves that are blocked will depend on where the local
anaesthetic is deposited, and how it spreads.
Depending on where the probe is placed, the overlying muscle
layer may be pectoralis minor or latissimus dorsi.
Lateral cutaneous The exact probe position and needle trajectory may be modified
branches of T2-T7 according to the desired area of coverage. The exact levels of
intercostal nerves. intercostal nerves that are blocked will depend on where the
Main trunk of intercostal local anaesthetic is deposited and how it spreads.
nerves may also
be reached.
Anterior cutaneous This is currently the only described technique of injection into the
branches of T2-T6 deep parasternal-intercostal plane. The exact probe position
intercostal nerves. (transverse or parasagittal view) and needle trajectory may be
modified to optimise block performance.
Anterior cutaneous The pecto-intercostal fascial plane block is the term most
branches of T2-T6 commonly used in the current literature to describe the
intercostal nerves. technique of injection into the superficial parasternal-intercostal
plane.
Several similar blocks have been described with different names
and minor variations in technical performance: anterior thoracic
medial block [127], subpectoral interfascial plane block [46],
parasternal-intercostal block [26], parasternal PECS block [128].
(continued)
Chin et al. | Fascial plane chest wall blocks
 Table 1 (continued)
Block name Technical performance
Posterior chest wall blocks
© 2020 Association of Anaesthetists
Retrolaminar Injection in the plane between the bony
block [62, 129] vertebral lamina and the overlying muscle
(transversospinalis and erector spinae
muscle groups).
Erector spinae Injection in the plane between the bony
plane block [6] vertebral transverse processes and the
overlying erector spinae muscle (specifically,
longissimus thoracis).
Midpoint transverse Injection deep (anterior) to the posterior
process-to-pleura aspect of the vertebral transverse process
(MTP) block [15] but superficial to the superior costotransverse
ligament (i.e. the needle tip does not
enter the paravertebral space)
Paraspinal- Injection in the plane between the bony
intercostal ribs plus intercostal muscles and the
plane blocks overlying erector spinae muscle (specifically,
longissimus thoracis or iliocostalis depending
on how far lateral to the midline the
point of injection is).
Rhomboid intercostal First injection is into the plane between
subserratus plane the bony ribs plus intercostal muscles
(RISS) block [117] and the overlying rhomboid major muscle
plus erector spinae muscle. The second
injection is into the same plane at a site that is
more lateral and more inferior, where the
overlying muscle layer is now serratus
anterior muscle.
113
Neural targets of
primary interest
Dorsal and ventral rami
of spinal nerves, spanning
1-3 levels cranial and
caudal to the level of injection.
Dorsal and ventral rami
of spinal nerves, spanning
1-3 levels cranial and
caudal to the level of injection.
Dorsal and ventral rami
of spinal nerves, spanning
1-3 levels cranial and
caudal to the level of injection.
Lateral cutaneous
branches of T2-T7
intercostal nerves.
Lateral cutaneous branches
of T2-T7 intercostal nerves,
with potential extension
as far as the T10 dermatome.
Other comments
The extent of spread is volume dependent and subject to
inter-individual variability.
The extent of spread is volume dependent and subject to
inter-individual variability.
Chin et al. | Fascial plane chest wall blocks
The MTP block was the first published description of the technique
of injection into the intertransverse connective tissue complex,
superficial to the thoracic paravertebral space. Several similar
blocks have been described with different names and minor
variations in technical performance: costotransverse block [100],
multiple-injection costotransverse (MIC) block [99] and
subtransverse process interligamentary (STIL) block [101].
Several similar blocks have been described with different names:
these include the rhomboid intercostal block [116], continuous
intercostal nerve block [111], posterior paramedian
subrhomboidal block [113], intercostal/paraspinal block [114],
extrathoracic sub-paraspinal block [115].
All involve injection into the same fascial plane, with minor
variations in technical performance related to landmarks and
exact site of injection on the posterior chest wall.
The first injection is the rhomboid intercostal block, a
paraspinal-intercostal plane block performed at a very specific
point on the posterior chest wall (the anatomical ‘triangle of
auscultation’). The second injection (subserratus) is essentially
a deep serratus anterior plane block and is designed to extend
the spread to cover the territory innervated by lower
thoracic spinal nerves.
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Anaesthesia 2021, 76 (Suppl. 1), 110–126 Chin et al. | Fascial plane chest wall blocks

ISN
LSN
M
BC
N
IC MSN
BN
LP
N
MPN

LTN: long thoracic nerve

LSN: lateral supraclavicular nerve
II ISN: intermediate supraclavicular nerve
MSN: medial supraclavicular nerve
LTN

LPN: lateral pectoral nerve

III MPN: medial pectoral nerve
II
III-VI lateral cutaneous branches of the thoracic intercostal nerves
III III-VI anterior cutaneous branches of the thoracic intercostal nerves
IV
ICBN: intercostobrachial nerve
IV MBCN: medial brachial cutaneous nerve
V
V
VI
VI

Figure 1 Innervation of the axilla, anterolateral and anteromedial chest wall. This is derived from several sources. The lateral,
intermediate and medial supraclavicular nerves (purple) are branches of the superficial cervical plexus. The medial brachial
cutaneous nerve (blue) and lateral and pectoral nerves (black) are branches of the brachial plexus. The intercostobrachial nerve
(blue) is a branch of the T2 intercostal nerve that supplies the skin of the axilla together with the medial brachial cutaneous nerve.
The lateral cutaneous branches (green) and anterior cutaneous branches (red) of the T2-T6 intercostal nerves are otherwise
responsible for most of the cutaneous innervation. (Reproduced with permission from Dr B. Versyck).

subcutaneous fat, pectoralis major muscle, internal Posterior chest wall

intercostal and transversus thoracis muscles, ribs and
sternum. Its innervation is derived from the T2-6 intercostal
nerves [5], which travel in the intercostal space bounded by
internal and innermost intercostal muscles. Adjacent to the
lateral edge of the sternum, the innermost intercostal
muscles transition to slips of the transversus thoracis muscle
which connect the posterior aspect of the sternum to the
ribs (Fig. 4). The intercostal nerves terminate here in
anterior cutaneous branches which ascend through the
intercostal and pectoralis major muscles to innervate the
superficial tissues of the parasternal region [11]. The
anterior branches of intercostal nerves can, therefore, be
targeted in two fascial planes in the parasternal region:
deep to pectoralis major and superficial to intercostal
muscles (the superficial parasternal-intercostal plane); and
deep to intercostal muscles but superficial to transversus
thoracis muscles (the deep parasternal-intercostal plane;
Fig. 4) [12].
The posterior chest wall extends from the posterior axillary
line to the thoracic spinous processes. Multiple different
muscle groups overlie the bony thoracic cage in a complex
arrangement and the exact muscle layers seen during any
ultrasound-guided block will depend on where the probe is
placed. The latissimus dorsi muscle is the most superficial
layer in the inferior portion of the posterior thorax, covering
the erector spinae muscle from the T7 spinous process
downwards and extending out to the lateral thoracic wall.
The most superficial muscle layer in the superior portion is
the trapezius, which covers rhomboid major and minor
muscles as well as the scapula and its associated muscles.
These, in turn, overlie the erector spinae muscle, a collective
term for the spinalis, longissimus thoracis and iliocostalis (in
order from medial to lateral) muscles that run longitudinally
between the cervical and lumbar regions. The erector
spinae muscle is the main component of the paraspinal
muscles that stabilise the torso, but there is also a

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Excised Pectoralis
Major muscle

Pectoralis major
muscle
Pectoralis minor
muscle

Subcutaneous
breast organ

Intercostal muscles

Latissimus dorsi
muscle

Serratus anterior
muscle

Figure 2 Muscles of the pectoral and axillary region. The most superficial layer in the anterior chest is the pectoralis major
muscle. Pectoralis major has been cut away on the left side to show the wedge-shaped pectoralis minor muscle that overlies the
serratus anterior muscle. Serratus anterior is composed of multiple slips of muscle that originate from the ribs and run posteriorly
to merge and insert on the scapula and spine. In the lateral aspect of the chest, serratus anterior is covered by the latissimus dorsi
muscle. The deepest layer of muscles comprises the intercostal muscles spanning adjacent ribs; these are subdivided further
into external, internal and innermost intercostal muscles. (Reproduced with permission from Dr B. Versyck).

transversospinalis muscle group which lies deep to spinalis
and immediately adjacent to the bony vertebrae, and
includes multifidus, rotatores and intertransverse muscles.
The rotatores and intertransverse muscles, together with
several ligamentous structures such as the superior
costotransverse ligament, span the gap between adjacent
vertebral transverse processes. This ‘intertransverse tissue
complex’ [13] constitutes a permeable posterior boundary
for the paravertebral space. Local anaesthetic spread
through this layer is the postulated mechanism of action for
analgesia in the distribution of the ventral rami observed
with the retrolaminar, ESP and midpoint transverse process
to pleura (MTP) blocks [14–15]. Lateral to the transverse
processes, the erector spinae muscle overlies the ribs and
intercostal muscles, and the plane between these two layers
is continuous with the plane deep to the serratus anterior
muscle in the anterolateral thorax [16].
The posterior thoracic wall is innervated by branches of
the dorsal rami of thoracic spinal nerves. The dorsal ramus
arises from the main spinal nerve root once it emerges from
the intervertebral foramen, and divides into medial,
intermediate and lateral branches that ascend through the
muscle layers to the superficial tissues [18, 19]. The
posterolateral chest wall is also innervated by the posterior
divisions of the lateral cutaneous nerve branches that arise
from the intercostal nerves.
Mechanisms of action
The primary mechanism of analgesia for chest wall blocks is
the conduction blockade of sensory afferents. Local

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Figure 3 Stylised representation of the course of a typical thoracic intercostal nerve within the chest wall (based on the work of
Sakamoto et al. [5]). As each thoracic spinal nerve root arises from the spinal cord, it divides into a dorsal ramus and a ventral
ramus within the paravertebral space (dashed box). The ventral ramus continues as the intercostal nerve, running in the
intercostal space between internal and innermost intercostal muscles (dotted box). Lateral to the sternal edge, the innermost
intercostal muscles give way to the transversus thoracis muscle (see Fig. 4). A lateral cutaneous branch arises from the main
intercostal nerve close to the mid-axillary line and pierces the internal and external intercostal muscles, as well as the overlying
muscle layer (which may be serratus anterior or external oblique depending on the intercostal space in question), ascending and
branching to innervate the superficial tissues of the anterolateral chest wall. The main trunk of the intercostal nerve also gives rise
to multiple branches (darker green arrows) that innervate the ribs and muscle layers, and anastomose with branches from
adjacent intercostal nerves. The intercostal nerve terminates in the anterior cutaneous nerve which ascends through the
parasternal muscle and tissue layers to innervate the anteromedial chest wall. (Reproduced with permission from KJ Chin
Medicine Professional Corporation).

anaesthetic spreads within the fascial plane of injection to
reach nerves running within the plane [20–26], but there is
also diffusion into the surrounding muscles and fascia
where it may have a local effect on peripheral nociceptors.
The ribs, associated joints and connective tissues are
similarly important sources of pain, and are innervated by
the multiple branches that arise from the intercostal nerves
along their course (Fig. 3) [5]. The paths of these perforating
nerve branches and accompanying vessels provide
potential channels for physical spread of local anaesthetic,
and this is enhanced further by tissue disruption in trauma or
surgery [27, 28]. The clinical efficacy of techniques such as
the deep serratus anterior plane block or paraspinal-
intercostal blocks in rib fractures and thoracic surgery may,
therefore, be explained by diffusion into the intercostal
space as well as local analgesia of traumatised muscles [27].
A larger volume of injection generally contributes greater
spread and nerve involvement, although this is still subject
to anatomical constraints. For example, serratus anterior
plane block injections rarely, if ever, reach the pectoral
nerves [20, 21].
Posterior chest wall blocks, such as the ESP block, differ
from the anterolateral blocks in that the primary targets are
not nerves passing through the plane of injection (these
being dorsal rami of spinal nerves innervating the back) but
nerves in an adjacent anatomical compartment – namely,
the ventral rami in the paravertebral and intercostal space.
Although this has been disputed, the weight of available
evidence points to this as the primary mechanism of action
[14].
Another proposed mechanism of action is via systemic
absorption and elevated plasma concentrations of local
anaesthetic, like the analgesia associated with intravenous
(i.v.) lidocaine infusion [29]. There are presently no
pharmacokinetic data from chest wall fascial plane blocks,
but data from abdominal wall blocks using similar local
anaesthetic volumes and concentrations indicate that
therapeutic plasma concentrations can be achieved [30,

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Figure 4 Parasternal-intercostal anatomy and sonoanatomy. With the ultrasound probe placed in a transverse orientation
between adjacent ribs and next to the sternum, three muscle layers are visible (upper ultrasound image). These are, from
superficial to deep: pectoralis major muscle; internal intercostal muscle; and transversus thoracis muscle. The inset sketch of the
interior surface of the thorax illustrates the oblique course of the various slips of transversus thoracis muscle that connect the
sternum and ribs. The intercostal space between innermost and internal intercostal muscles is continuous with the plane
between transversus thoracis and internal intercostal muscles. The terminal anterior cutaneous branches of the intercostal
nerves travel in this plane and gradually ascend to innervate the superficial tissues in the parasternal area. They may be
anaesthetised by local anaesthetic injection (green ovals) in the plane that lies either deep to the internal intercostal muscle, or
deep to the pectoralis major muscle. An alternative ultrasound view may be obtained with the probe rotated 90° into a
parasagittal view (lower ultrasound image). The costal cartilages are visible in cross-section, and can be used as a backstop for
needle insertion into the plane deep to pectoralis major muscle. (Reproduced with permission from KJ Chin Medicine
Professional Corporation).

31]. However, these plasma concentrations are not bupivacaine and ropivacaine (the most commonly used
sustained after single-injection blocks, falling significantly local anaesthetics) have similar systemic analgesic efficacy
over 3–4 h [30]. It has also not been established if compared with lidocaine. Currently, this is likely to be a

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Anaesthesia 2021, 76 (Suppl. 1), 110–126
minor contribution to the clinical efficacy of fascial plane
blocks.
Clinical application
The profusion of chest wall blocks has increased the
accessibility of regional anaesthesia but also introduced the
dilemma of choice. To assist with decision-making, we have
summarised the current evidence related to common
clinical applications for each technique.
Anterolateral chest wall and axillary region
The PECS1 block [22] was intended originally as an
alternative to thoracic paravertebral blockade or thoracic
epidural anaesthesia for breast surgery, specifically
insertion of breast expanders and subpectoral prostheses.
The PECS2 block combined PECS1 with a second injection
deep to pectoralis minor to provide axillary and intercostal
nerve coverage and increase the scope of application in
breast surgery [23]. Two separate meta-analyses published
in 2019 reviewed the available randomised controlled trials
(RCT) in breast surgery comparing the PECS2 block with
either systemic analgesia alone, or with thoracic
paravertebral blockade, and arrived at similar findings [32,
33]. There was no significant difference in pain scores, time
to first analgesic request or 24-h opioid consumption
between patients who received PECS2 or thoracic
paravertebral blockade. Compared with systemic analgesia
alone, the PECS2 block produced a significant reduction in
pain scores and postoperative opioid consumption (by
13.6 mg oral morphine, 95%CI -21.2–6.1, in one study [32]
and 30.5 mg, 95%CI -42.2 to -18.8, in the other [33]) within
the first 24 postoperative hours. These analgesic benefits
were confirmed by a third, more recent meta-analysis which
undertook a broader comparison of PECS1, PECS2 and
serratus anterior plane block alone or in combination vs.
control (block or sham injection) [34]. In addition, there was
less pain irrespective of whether multimodal analgesics
were administered or not, and the risk of postoperative
nausea and vomiting was also reduced, even in patients
receiving routine anti-emetic prophylaxis.
One criticism of these reviews relates to the
heterogeneity of included surgical procedures, which
ranged from mastectomy to more minor surgery (e.g.
lumpectomy with or without axillary node dissection). This
has been addressed by another three meta-analyses
focusing specifically on mastectomy patients. Two of them
compared PECS1 or PECS2 blocks vs. systemic analgesia
and found that overall, PECS blocks significantly reduced
24-h postoperative opioid consumption (by up to 5 mg i.v.
morphine, 95%CI -7.9 to -2.1) with modest reductions (< 1
118
Chin et al. | Fascial plane chest wall blocks
point) in postoperative pain scores at 6 and 24 h [35, 36].
The third study found that a PECS2 block or serratus anterior
plane block produced similar analgesic outcomes
compared with thoracic paravertebral blockade [37]. There
was a statistically significant mean difference of 0.4 (95%CI
-0.7 to -0.1) in rest pain 2 h postoperatively in favour of
fascial plane blocks, but this is not a clinically meaningful
difference.
Regarding the comparison between anterolateral and
posterior chest wall blocks in breast surgery, there are only
three published RCTs comparing PECS2 block with an ESP
block at the T4 level, all for modified radical mastectomy
surgery [38-40]. Intra-operative opioid doses and
haemodynamic parameters were similar in all three studies;
however, PECS2 resulted in superior postoperative
analgesic outcomes (24-h opioid consumption, time to first
opioid request and pain scores). This may be due to better
coverage of the axilla and T2 dermatome [38]. The recently-
published PROSPECT guidelines on pain management for
oncological breast surgery [41] concluded that there was
strong evidence for PECS2 as an alternative to thoracic
paravertebral blockade, but insufficient evidence for any
recommendations regarding posterior chest wall blocks at
this time.
The component of PECS2 blockade involving injection
into the plane deep to pectoralis minor and superficial to
serratus anterior muscle was described subsequently as a
separate technique, the serratus anterior plane block [24].
This was modified further according to whether injection
occurs superficial or deep to the serratus anterior muscle,
and its exact location on the chest wall. There is evidence
that a serratus anterior plane block alone, without the
PECS1 component, can provide clinically useful chest wall
analgesia. A recent meta-analysis reviewed 19 RCTs
comparing serratus anterior plane block with either
systemic analgesia alone or thoracic paravertebral
blockade, in both breast (13 studies) and thoracic surgery
(six studies) [42]. The addition of a serratus anterior plane
block significantly reduced pain scores during the first 24
postoperative hours, with a mean difference ranging from
1.3–1.7 at 0–6 h (p < 0.001) to a more modest 0.7–0.9
(p < 0.001) at 12–24 h. Similar magnitudes of effect were
seen on sub-group analyses of breast vs. thoracic surgery,
superficial vs. deep serratus anterior plane block and
studies at low risk of bias. Serratus anterior plane block was
also associated with decreased 24-h opioid consumption,
prolonged time to first analgesia, and reduced rates of
postoperative nausea and vomiting and pruritus. There
were five studies comparing serratus anterior plane block
with thoracic paravertebral blockade, four of which were in
© 2020 Association of Anaesthetists
Chin et al. | Fascial plane chest wall blocks
breast surgery. As with the PECS2 block in other meta-
analyses [32, 33, 37], the serratus anterior plane block was
equivalent to thoracic paravertebral blockade regarding
almost all analgesic outcomes, except for higher pain scores
in the immediate postoperative period (< 2 h) in the
serratus anterior plane block group (mean difference 1.0,
95%CI 0.6–1.4, p < 0.001) [42].
Further evidence for the effectiveness of serratus
anterior plane block (and to a lesser extent, PECS blocks) to
treat acute thoracic pain comes from a systematic review of
the literature involving cardiac surgery, thoracic surgery and
trauma [1]. Study heterogeneity (a mix of RCTs, cohort
studies and case series) precluded meta-analysis, but a
qualitative summary of the evidence suggests that serratus
anterior plane block and PECS blocks consistently
improved postoperative thoracic analgesia compared with
systemic analgesia alone, with greatest analgesic benefit
occurring within the first 4–6 h. The potential benefit of
serratus anterior plane block in traumatic rib fractures was
highlighted further by a longitudinal cross-sectional study of
354 patients who received either serratus anterior plane
block, thoracic paravertebral blockade or thoracic epidural
anaesthesia as part of analgesic management [43]. All three
groups demonstrated clinically significant improvements in
inspiratory volume and pain scores, with no significant
difference observed between them.
Anteromedial chest wall
Parasternal-intercostal blocks target the anterior cutaneous
branches of the thoracic intercostal nerves, which innervate
the sternum and anteromedial thorax. Injection is
performed into either a deeper plane between transversus
thoracis and internal intercostal muscles (the transversus
thoracis plane block [44, 45]), or a more superficial plane
between the ribs and internal intercostal muscles (Fig. 4).
Several descriptions of the latter approach exist under
different names (Table 1), the most common being the
pecto-intercostal fascial block. The main advantages of the
superficial approach are that the fascial plane is further away
from the pleura and is easier to identify.
Parasternal-intercostal blocks have been used primarily
to provide peri-operative analgesia for midline sternotomy
and are an attractive option, as the risk of bleeding
complications is low. There are also isolated reports of their
use for sternal fracture [46], pericardiocentesis [47] and
implantable cardiac defibrillator insertion [48]. Research is
still at a preliminary stage but it appears safe and effective in
reducing early post-sternotomy pain [49]. A pilot RCT of
transversus thoracis plane blocks performed in ICU before
© 2020 Association of Anaesthetists
Anaesthesia 2021, 76 (Suppl. 1), 110–126
extubation reported a significant reduction in pain scores at
12 h postoperatively [50]. The pecto-intercostal fascial
plane block has similarly been described as a post-
extubation rescue strategy for intractable acute post-
sternotomy pain [51]. A small RCT of surgically-
administered parasternal-intercostal blocks in 30 paediatric
patients demonstrated shorter times to extubation in
conjunction with reduced pain scores [52]. However, a more
recent RCT of pecto-intercostal fascial plane blocks in adult
cardiac surgical patients did not demonstrate meaningful
benefit vs. placebo, indicating the need for further
investigation into its role in enhanced recovery pathways
[53].
Parasternal-intercostal blocks may also augment the
analgesia provided by PECS2 blocks in breast surgery,
particularly if the surgical site extends into the medial half of
the breast. The combination of PECS2 block plus
transversus thoracis plane block in a RCT of modified
radical mastectomy resulted in lower pain scores at rest and
movement up to 24 h, and fewer patients requiring rescue
analgesia compared with PECS2 block alone [54].
Posterior chest wall
Paraspinal fascial plane blocks are designed to produce
local anaesthetic spread to the paravertebral and intercostal
spaces without inserting the needle tip into these spaces,
hence the moniker ‘paravertebral-by-proxy’ [55]. Several
different techniques have been described and the scientific
evidence supporting their role in clinical practice is still
evolving.
The retrolaminar block was the first paraspinal fascial
plane block to be described and is notable for its simplicity –
the needle is inserted to contact the thoracic lamina and
local anaesthetic is injected between the bony surface and
the overlying paraspinal muscles, with subsequent spread
through the intertransverse connective tissue complex into
the paravertebral space [56–59]. A catheter may also be
inserted, and two early studies in breast surgery indicated
that continuous retrolaminar block provided satisfactory
analgesia comparable with continuous thoracic
paravertebral blockade [60]. There may, however, be
limited benefit from single-injection blocks. A RCT in 122
patients undergoing breast surgery with axillary dissection
found that a bilevel (T2 and T4) retrolaminar block lowered
pain scores in the first two postoperative hours and more
than doubled the median time to first analgesic request
(161 vs. 64 min, p < 0.001), but there was no significant
difference in analgesic outcomes compared with the sham
block group beyond this [61]. The most likely explanation
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Anaesthesia 2021, 76 (Suppl. 1), 110–126
for the short duration of effect is that only a small fraction of
injected local anaesthetic penetrates the paravertebral
space. The retrolaminar block remains a little-studied
technique, and the evidence base for the ultrasound-
guided approach is limited to case reports in thoracic
trauma and surgery [57, 58, 62].
The erector spinae plane block was first described in
2016 [63], and has generated intense clinical and academic
interest in ultrasound-guided paraspinal fascial plane
blocks. Much of its popularity stems from simplicity of
execution, with the transverse processes acting as a readily-
identifiable landmark for local anaesthetic injection into the
fascial plane between them and the overlying erector
spinae muscle. The ESP block is also the paraspinal
technique with the largest evidence base to date, including
numerous RCTs as well as several narrative and systematic
reviews [64–67]. Although originally described for thoracic
analgesia, its scope of clinical application has expanded to
include abdominal, upper limb and lower limb analgesia,
which is not discussed here.
A comprehensive systematic review by Leong et al. of
RCTs investigating ESP blocks in breast surgery identified
13 studies involving 861 patients published before
February 2020 [67]. Of the 13 studies, seven compared ESP
with no block, four compared ESP with thoracic
paravertebral blockade and three compared ESP with
PECS2 blocks. One trial had three arms – ESP, thoracic
paravertebral blockade and no block [68]. All but one study
[69] involved only patients undergoing modified radical
mastectomy. Patients who received an ESP block had
superior analgesic outcomes compared with systemic
analgesia alone, with reductions in 24-h opioid
consumption (mean difference of 21.6 mg oral morphine,
95%CI -32.6 to -10.5, p < 0.001) and decreased pain scores
at all time-points up to 24 h postoperatively. The reduction
in pain scores was most marked in the early postoperative
period (mean difference ranging from 1.63, 95%CI -3.0 to
-0.3, p = 0.020, at 0–2 h and 0.90, 95%CI -1.5 to -0.3,
p = 0.003, at 6 h), decreasing to a mean difference of
approximately 0.5 at 12 and 24 h, 95%CI -0.7 to -0.3,
p < 0.001). Although the pooled incidence of postoperative
nausea and vomiting was 18.7% vs. 31.1% in the ESP vs. no
block group, this did not achieve statistical significance.
Compared with thoracic paravertebral blockade,
patients who received an ESP block had higher pain scores
in the immediate (0–2 h) postoperative period (mean
difference 1.7, 95%CI 1.3–2.2, p < 0.001) but not at other
reported time-points [67]. There was also no significant
difference in 24-h opioid consumption. Notably, the pooled
incidence of pneumothorax in the thoracic paravertebral
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Chin et al. | Fascial plane chest wall blocks
blockade group was 2.58% vs. 0% in the ESP group. The ESP
block was found in one study to be easier for novice
practitioners to perform successfully [70]. However,
compared with the PECS2 block, the pooled evidence
indicated that analgesia is inferior to the ESP block. Twenty-
four hour opioid consumption was higher (mean difference
14 mg oral morphine, 95%CI 3.9–24.1, p = 0.007) and pain
scores were higher at time-points up to 12 h
postoperatively, albeit by only a small mean difference
ranging from 0.32, 95%CI 0.01–0.63, p = 0.040 at 0–2 h to
0.50, 95%CI 0.09–0.90, p = 0.020 at 12 h, and with no
significant difference observed in pain scores at 24 h [67].
The authors attributed this to coverage of the
intercostobrachial and pectoral nerves with the PECS2
block.
Another systematic review by Huang et al. [71]
comparing ESP with no block or thoracic paravertebral
blockade in both breast and thoracic surgery searched the
literature up to March 2020 but only included a total of eight
studies in breast surgery. Although they failed to identify
several relevant RCTs included in the meta-analysis by
Leong et al. [67], they reached similar conclusions regarding
the analgesic superiority of ESP blocks compared with
systemic analgesia alone in breast surgery, and analgesic
equivalence with thoracic paravertebral blockade. The ESP
block has also been used successfully for surgical
anaesthesia for modified radical mastectomy as described
in a case report [72] and series of 30 patients [73].
Huang et al. [71] identified six RCTs in thoracic surgery
comparing ESP with either systemic analgesia alone (two
studies [74, 75]) or with thoracic paravertebral blockade
(four studies [76–79]). Only one study [76] involved patients
undergoing thoracotomy, and the other five were in video-
assisted thoracoscopic surgery. Sub-group analysis of
thoracic surgical patients found that 24-h opioid
consumption was reduced in the ESP group compared with
systemic analgesia alone (mean difference 14.9 mg i.v.
morphine, 95%CI -21.2 to -8.4, p < 0.001) and was
equivalent in ESP and thoracic paravertebral blockade
groups. The authors did not attempt to analyse pain scores
by surgical sub-groups; however, the three studies included
in the meta-analysis of pain scores on movement or
coughing were all in thoracic surgery and showed no
difference between ESP and thoracic paravertebral
blockade groups at time-points up to 24 h postoperatively.
The ESP block has been compared with serratus
anterior plane block in three RCTs [80–82]. Both serratus
anterior plane block and ESP blocks resulted in low
postoperative pain scores following video-assisted
thoracoscopic surgery but there were significant differences
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in favour of the ESP block in all three trials. Opioid combination of ESP and MTP blocks to provide surgical
consumption up to 48 h postoperatively was lower in the anaesthesia in a group of three patients with multiple rib
ESP group [80, 82] with longer time to first analgesic request fractures undergoing surgical stabilisation; all three patients
[81, 82] and fewer instances of rescue analgesia [80]. The had previously-sited thoracic epidurals that were
most recent study by Finnerty et al. [82] is notable for its inadequate for this purpose [92].
focus on patient-centred outcomes. Patients who received Peri-operative anticoagulation in cardiac surgery has
an ESP block had superior quality of recovery (measured by traditionally limited the use of regional anaesthesia;
QoR-15) and a lower overall rate of postoperative however, the perceived safety profile of the ESP block with
complications (measured by the Comprehensive regard to bleeding complications has rekindled interest.
Complication Index), including pneumonia. Case series and reports describe its use for postoperative
The ESP block has also been compared with multilevel analgesia following midline sternotomy [93, 94] as well as
intercostal nerve blocks in two RCTs [77, 83]. Chen et al. thoracotomy for minimally invasive approaches [95] and left
found that a single-injection ESP block resulted in similar ventricular device implantation [96], with no reports of any
postoperative analgesia compared with a six-level complications to date. There have been two RCTs of
ultrasound-guided intercostal nerve block, in terms of 24- bilateral ESP blocks in cardiac surgery via midline
and 48-h opioid consumption, and pain scores in the first sternotomy. In the first, single-injection ESP blocks were
8 h following video-assisted thoracoscopic surgery [77]. compared with systemic analgesia and this resulted in
Fiorelli et al. studied patients undergoing a 13–15 cm mini- significantly lower pain scores and analgesic outcomes up
thoracotomy at the fifth intercostal space and compared a to 12 h postoperatively, as well as improved recovery
single-injection ESP block with surgically-performed five- outcomes that included faster time to oral intake and
level intercostal blocks performed at the time of incision. ambulation [97]. In the second RCT, continuous ESP blocks
Patients receiving ESP block had lower pain scores, higher were compared with thoracic epidural anaesthesia, and
satisfaction scores and required fewer rescue analgesic outcomes including incentive spirometry, total intra-
doses, which was associated with better preservation of operative fentanyl consumption, ventilator duration and ICU
postoperative respiratory capacity [83]. Finally, continuous length of stay were similar between the groups. The ESP
ESP was compared with continuous thoracic paravertebral group even demonstrated superior pain scores at rest and
blockade in a RCT of video-assisted thoracoscopic during coughing for up to 48 h postoperatively. A dramatic
lobectomy and was found to be non-inferior with regard to improvement in analgesia with bilateral continuous ESP
resting pain scores 24 h postoperatively [78]. catheters was also reported in a non-randomised
There has been much interest in the ESP block as an comparative study of a fast-track programme which utilised
alternative to thoracic paravertebral blockade and thoracic a historical control group receiving only systemic analgesia
epidural anaesthesia in chest trauma. Its simplicity has [98]. The median (IQR) morphine consumption in the first
contributed to its use by non-anaesthetists and in out-of- 48 h was virtually nil in the ESP group and much more in the
theatre settings, including the emergency department [84] control group, 0 (0–0) vs. 40 (25–45) mg, p < 0.001. The ESP
and pre-hospital retrieval [85, 86]. Apart from case reports group also had a shorter time to chest tube removal, earlier
[84–87] and small series that demonstrate the effectiveness mobilisation and lower pain scores 1 month after surgery.
of both single-injection and continuous ESP blocks for rib The MTP block was based on the clinical
fracture analgesia [88, 89], the current literature also observation that ultrasound-guided local anaesthetic
includes two retrospective cohort studies. The first injection into the intertransverse muscular layer posterior
examined 79 patients who received an ESP block for rib to the superior costotransverse ligament still resulted in
fracture analgesia and found a meaningful improvement in pleural depression, signifying spread into the
incentive spirometry and pain scores in the first 3 h paravertebral space [15]. Conceptually, it is midway
following block performance [90]. The benefit appeared to between an ESP block and a true thoracic paravertebral
be greater for continuous vs. single-injection ESP blocks. block in terms of needle-tip location. Since its
Another study compared 66 patients receiving either an ESP description, there have been several publications of
block or systemic analgesia alone, and matched patients for identical block techniques with different names,
age, number of fractured ribs and other injuries. Patients in including: the multiple-injection costotransverse block
the ESP group had significantly lower daily opioid [99]; the costotransverse notch (or foramen) block [100];
consumption, mean (SD) of 37.5 (30.9) mg vs. 60.8 (52.6) mg and the subtransverse process interligamentary plane
oral morphine, p = 0.038 [91]. There is also a report of a block [101] (Table 1). Some of these have been

© 2020 Association of Anaesthetists 121

Anaesthesia 2021, 76 (Suppl. 1), 110–126
characterised as variants of the ESP block, but they all
involve injection into the intertransverse tissue complex
[13], with minor differences in described landmarks for
block performance. Cadaveric studies suggest that these
blocks may be more effective at producing paravertebral
spread compared with the ESP block, by the simple fact
that injection is occurring closer to the paravertebral
space [102]. However, the only supporting clinical
literature at present consists of small case series and
case reports. Most of the reports relate to the MTP
block, which has been utilised successfully in breast
surgery [103–105], thoracic surgery [106–108] and
thoracic trauma [109]. Both single-level and multi-level
injection approaches have been used, and a continuous
catheter technique also appears promising for providing
extended analgesia [105, 108, 109].
‘Paraspinal-intercostal plane block’ is a collective
term encompassing all posterolateral approaches to the
fascial plane that lies superficial to the ribs and
intercostal muscles [110] (Table 1). The first described
technique involved surface landmark-guided insertion of
a tunnelled multi-orifice catheter into this plane, to
provide ‘continuous intercostal nerve’ blockade for rib
fractures [111, 112]. The same technique (under a
different name) was used in another non-randomised
comparative study of rib fractures which demonstrated
equivalent analgesia compared with thoracic epidural
anaesthesia [113]. Several similar ultrasound-guided
approaches to the same fascial plane have since been
described and include the intercostal/paraspinal block
[114], the extrathoracic sub-paraspinal block [115] and
the rhomboid intercostal block [116]. The latest of these
is the rhomboid intercostal and subserratus plane block,
which combines the rhomboid intercostal block with a
deep serratus anterior plane block to increase
dermatomal coverage on the basis that they are both
injections into the same fascial plane, just at different
locations on the posterolateral thoracic wall [117].
Most of the literature on paraspinal-intercostal plane
blocks to date is comprised of case reports and small case
series. Single-injection and continuous rhomboid
intercostal and rhomboid intercostal and subserratus plane
blocks have been described for use in thoracic surgery,
including thoracotomy [118, 119], rib fractures [120] and
breast surgery [121–123]. One RCT has compared single-
injection rhomboid intercostal block with systemic
analgesia alone in modified radical mastectomy with
axillary dissection [124]. Patients who received the block
had significantly better QoR-40 scores and lower 24-h
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Chin et al. | Fascial plane chest wall blocks
opioid consumption, median [IQR] of 5 [4–7] vs. 10 [8–13]
mg i.v. morphine, p < 0.001.
Conclusions and future directions
The fascial plane blocks described in this state-of-the-art
review represent a significant step forward for regional
anaesthesia of the chest wall. They are attractive alternatives
to thoracic epidural anaesthesia and thoracic paravertebral
blockade due to their safety profile and relative simplicity,
and the positive evidence to date for their efficacy. Yet
many avenues for future research remain to be pursued, if
their full potential is to be realised. There are clearly roles
for them in diverse settings beyond the operating room,
including the emergency department, chronic pain service
and pre-hospital environment, that are worthy of further
investigation. Given that these are large-volume blocks,
research into optimal dosing regimens (i.e. local
anaesthetic volume and concentration) will help in
balancing the considerations of block onset and duration
vs. the risk of local anaesthetic systemic toxicity. The role of
local anaesthetic additives and continuous catheter
techniques in prolonging the duration of analgesic benefit
also requires further study.
When considering whether to offer regional
anaesthesia, and which specific technique to employ, the
focus should always be centred on the patient in question,
and the balance between expected benefit vs. risk.
Continued research is warranted, therefore, to define their
impact on postoperative pain more accurately in specific
surgical procedures and populations. The paediatric
patient population stands to benefit, as these blocks are
eminently suited to performance under general
anaesthesia. A further priority is to establish if these blocks
have a meaningful impact on patient-centred outcomes
beyond pain scores and opioid consumption, and how they
can be effectively integrated into clinical care pathways.
One more critical issue to be addressed is the multiplicity of
described techniques, many of which are similar in
performance and targeted endpoints. There is a real risk of
intimidating would-be practitioners of regional anaesthesia
with needless complexity and choice [125]. An authoritative
attempt at reaching a consensus on simplified and rational
nomenclature, as well as technical descriptions, will go a
long way towards mitigating this. Finally, further head-to-
head studies comparing these different techniques with
each other, as well as against the more-established
techniques of thoracic paravertebral block and epidural
analgesia, will guide clinicians in making the best possible
choice for their patients.
© 2020 Association of Anaesthetists
Chin et al. | Fascial plane chest wall blocks
Acknowledgements
The authors wish to thank R. Chin for her invaluable
assistance with the illustrations. No competing interests
declared.
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