581 Full

Special article
Reg Anesth Pain Med: first published as 10.1136/rapm-2021-102506 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on April 4, 2022 at The Chinese University of Hong Kong.
Anatomical basis of fascial plane blocks
Ki Jinn Chin ‍ ‍,1 Barbara Versyck ‍ ‍,2,3 Hesham Elsharkawy ‍ ‍,4,5
Maria Fernanda Rojas Gomez,6 Xavier Sala-Blanch,7,8 Miguel A Reina ‍ ‍9
►► Prepublication history and Abstract gradient). There may also be a secondary effect
additional material is published Fascial plane blocks (FPBs) are regional anesthesia resulting from systemic absorption of local anes-
online only. To view please visit
the journal online (http://dx. techniques in which the space (“plane”) between two thetic.1 The primary objective of this article is to
doi.org/10.1136/rapm-2021- discrete fascial layers is the target of needle insertion present key fundamental anatomical concepts rele-
102506). and injection. Analgesia is primarily achieved by local vant to the performance and effect of FPBs, with
1
Department of Anesthesiology anesthetic spread to nerves traveling within this plane a focus on blocks of the torso. It is not intended
and Pain Medicine, Toronto and adjacent tissues. This narrative review discusses key to be a detailed description of the anatomy or
Western Hospital, University fundamental anatomical concepts relevant to FPBs, with technique of individual blocks, for which several
of Toronto, Toronto, Ontario, a focus on blocks of the torso. Fascia, in this context, excellent reviews already exist.2–5 FPBs are a
Canada constantly evolving topic of intense clinical interest
2 refers to any sheet of connective tissue that encloses
Department of Anaesthesia
and Pain Medicine, Catharina or separates muscles and internal organs. The basic and research, and this article is merely a snapshot
Ziekenhuis, Eindhoven, North composition of fascia is a latticework of collagen fibers of our current understanding of their anatomical
Brabant, The Netherlands filled with a hydrated glycosaminoglycan matrix and basis. Nevertheless, our hope is that it will assist
3
Department of Anaesthesia infiltrated by adipocytes and fibroblasts; fluid can cross practitioners in interpreting the present and future
and Pain Medicine, AZ Turnhout,
Turnhout, Belgium this by diffusion but not bulk flow. The plane between literature, in matching the appropriate clinical
4
Outcomes Research fascial layers is filled with a similar fat-glycosaminoglycan applications with the different FPBs, and in opti-
Consortium, Cleveland Clinic, matric and provides gliding and cushioning between mizing the clinical utility, efficacy and safety of the
Cleveland, Ohio, USA structures, as well as a pathway for nerves and vessels. techniques.
5
Department of Anesthesiology,
The planes between the various muscle layers of the
Case Western Reserve
University, MetroHealth Pain thorax, abdomen, and paraspinal area close to the
Protected by copyright.
and Healing Center, Cleveland, thoracic paravertebral space and vertebral canal, are General anatomical concepts
Ohio, USA popular targets for ultrasound-guided local anesthetic Anatomy of fascia
6
Anesthesiology, Clinica injection. The pertinent musculofascial anatomy of these The current anatomical definition of fascia is “a
Cirulaser Andes, Bogotá, sheath, a sheet, or any other dissectible aggrega-
Colombia regions, together with the nerves involved in somatic and
7
Anesthesiology, Hospital Clinic visceral innervation, are summarized. This knowledge tions of connective tissue” that “attach, enclose, and
de Barcelona, Barcelona, Spain will aid not only sonographic identification of landmarks separate muscles and other internal organs.”6 Fascia
8
Human Anatomy and and block performance, but also understanding of the can be classified as superficial, deep, or visceral.
Embryology, University of Visceral fascia is the connective tissue component
potential pathways and barriers for spread of local
Barcelona Faculty of Medicine,
anesthetic. It is also critical as the basis for further of the serous membranes lining the thoracic and
Barcelona, Spain
9
Department of Anesthesiology, exploration and refinement of FPBs, with an emphasis on abdominal cavities and enclosing internal organs.7
Madrid-Monteprincipe improving their clinical utility, efficacy, and safety. Superficial fascia is the thin membranous layer(s)
University Hospital, CEU-San- of connective tissue below the dermis, composed
Pablo University School of of loosely organized bundles of collagen and elastic
Medicine, Madrid, Spain
fibers, that give the fat-filled subcutaneous tissue
Introduction its loculated appearance (figure 1).8 9 Deep fascia is
Correspondence to
Dr Ki Jinn Chin, Department Fascial plane blocks (FPBs) are regional anesthesia the denser layer that invests musculoskeletal struc-
of Anesthesiology and Pain techniques in which local anesthetic is injected into tures, and is most pertinent to the performance of
Medicine, Toronto Western the space (“plane”) between two layers of fascia FPBs. From a functional perspective, fascia serves a
Hospital, University of Toronto, rather than attempting to locate a specific nerve role in force transmission and stabilization during
Toronto, Ontario, Canada, M5T
2S8; g asgenie@gmail.c om or plexus. The earliest FPBs were surface anatom- movement.6 The deep fasciae investing all muscu-
ical landmark-guided techniques and entry into the loskeletal structures, such as muscle epimysium and
Received 13 January 2021 plane was inferred from tactile “pops” of needle periosteum of bone, blend and fuse via aponeu-
Revised 29 January 2021 penetration through fascial layers. Ultrasound guid- roses and ligaments. As a result, the demarcations
Accepted 30 January 2021
ance is now almost always used instead for greater between fascial entities are not always clear-cut.
precision and accuracy. It has also spurred the At the microscopic level, fascia is a sheet of
development of FPBs, especially of the thoracic and connective tissue composed of one or more layers
abdominal wall where individual terminal nerves of a lattice-like network of collagen fibers mixed in
are generally too small to otherwise locate. with a smaller amount of elastin fibers (figure 2).10
© American Society of Regional
Anesthesia & Pain Medicine The mechanisms of FPBs are discussed in-depth The spaces within this collagen-rich scaffolding are
2021. No commercial re-use. elsewhere1 but in brief, the main aim is to produce filled by ground substance (a hydrated gel-like extra-
See rights and permissions. conduction block of nerves that traverse fascial cellular matrix of hyaluronic acid and other proteo-
Published by BMJ. planes and compartments. Local anesthetic reaches glycans), adipocytes, and fibroblasts.9 10 Fascia is
To cite: Chin KJ, Versyck B, these nerves, which may be relatively distant from therefore permeable to molecules in aqueous solu-
Elsharkawy H, et al. the injection site, by a combination of bulk flow tion.11 The exact composition and thickness of
Reg Anesth Pain Med (particle movement along a pressure gradient) and fascia varies depending on its location and function.
2021;46:581–599. diffusion (solute dispersion along a concentration For example, the epimysium of pectoralis muscles
Chin KJ, et al. Reg Anesth Pain Med 2021;46:581–599. doi:10.1136/rapm-2021-102506 581
Special article
for force transmission. It is over twice as thick at 680 μm, and
composed of up to three sublayers.13 By comparison, a 22-gage
needle commonly used in ultrasound-guided regional anesthesia
measures 718 μm in its outer diameter. This provides some
perspective on the challenges of precise injection into a fascial
plane. It is not unusual to see multiple fascial separations open
up during ultrasound-guided hydrodissection (figure 3).
Fascial planes
In regional anesthesia, the term “fascial plane” describes the
space separating two deep fascial layers. These layers are usually
the investing fascia (epimysium) of two apposing muscles (eg,
internal oblique and transversus abdominis in the transversus
abdominis plane (TAP) block), or epimysium and periosteum in
locations where a muscle runs over a bony structure (eg, serratus
anterior muscle and rib in the deep serratus anterior plane (SAP)
block). Fascial planes serve as a passageway for nerves and
vessels (figure 4). They are filled with adipocytes and various
other fixed and migratory cells (eg, fibroblasts, macrophages), as
well as elastin and reticulin fibers, all embedded in an aqueous
matrix of ground substance that serves to cushion and lubricate
the gliding of muscles and organs over each other.9 10
Apposing fascial layers are connected by collagen fibers that
Figure 1 Illustration of deep fascia investing the anterior aspect of
provide transversal strength and tension but these are relatively
rectus abdominis. The subcutaneous layer of fat-filled loose connective
fragile and are readily separated by blunt dissection during
tissue and superficial fascia has been retracted superiorly. The inset
surgery or by fluid injection (hydrodissection) in FPBs (figures 1
image illustrates the transversal elements that connect the superficial
and 3).8 9 At the same time, these transversal fibers and points of
and deep fascia and divide the subcutaneous space to give it its areolar
attachment will constrain the bulk distribution of injected local
appearance.
anesthetic within the plane. Therefore, although some fascial
planes are theoretically continuous throughout large regions of
is approximately 300 μm thick and consists of a single layer of the body,14 different patterns and areas of macroscopic spread
collagen fibers with a relative abundance of elastic fibers.12 This will result from different injection sites into the same plane, and
is consistent with its function as an enclosure for muscles that this may in turn produce significantly different clinical effects.
expand and contract. In contrast, an aponeurotic fascial layer, For example, a TAP injection at the mid-axillary site will not
such as the thoracolumbar fascia (TLF), is primarily an anchor spread into the anterior subcostal TAP location even if the
Figure 2 Histological cross-section of human fascia at 100× magnification. Fascia is primarily composed of a permeable lattice-like network
of interwoven collagen fibers organized into bundles (green). The intervening spaces are filled in the living subject with an aqueous matrix of
glycosaminoglycans (ground substance), which provides a cushioning and lubricating function, as well as a medium for cells and molecules to move
through. Fascia is thus a barrier to bulk flow of fluid but not to diffusion of molecules in solution. Adipocytes (purple) are a significant component of
the inter-fascial compartment and also infiltrate fascia itself. Fascia is richly innervated (nerves in yellow) and well-vascularized (vessels in red). The
image has been color-enhanced for clarity using Adobe Photoshop. (Reproduced with permission of Dr Miguel A Reina.)
582 Chin KJ, et al. Reg Anesth Pain Med 2021;46:581–599. doi:10.1136/rapm-2021-102506
Special article
Figure 3 Example of an interpectoral (PECS1) block. It can be difficult to appreciate injection into the “true” fascial plane between two muscles
as tiny adjustments in needle tip position during injection can result in hydrodissection of different planes. The outer diameter of the 22-gage needle
shown here is 718 μm. The epimysium of the pectoralis major (PM) muscle is approximately 300 μm. (A) Here the initial injection is probably within
the epimysium of pectoralis major and does not appear to be splitting the hyperechoic fascia between the two muscles (arrows). (B) A slightly deeper
insertion opens up another plane that is more clearly splitting this fascia. However, this is not always easy to appreciate. LA, local anesthetic; Pm,
pectoralis minor; SA, serratus anterior.
injectate volume is doubled.15 It may also be difficult to discern proprioceptive feedback for muscular coordination. Fascia
what constitutes an appropriate fascial plane injection in areas is also innervated by polymodal free nerve endings of unmy-
where multiple fascias coalesce and fuse (eg, at the intersection elinated (C) and thinly myelinated (A- delta) neurons, which
between quadratus lumborum, internal oblique, and transversus respond to mechanical, thermal, and chemical inputs.16–18 These
abdominis). primarily serve a mechanosensory function but can also signal
noxious stimuli, especially if sensitized by local inflammation.19
Fascial innervation As a result, fascia can itself be a source of pain if it is subjected
As with most body tissues, fascia is innervated by sensory nerve to potentially injurious forces or trauma,20 in which case local
endings (figure 2), the density and type of which varies to serve anesthetic action injected in this area can contribute to anal-
its primary function.13 Specialized mechanosensory neurons gesia. However, fascial innervation has no direct bearing on the
respond to stretch and pressure and are critical in providing sensory innervation of distant structures by nerves traveling in or
Figure 4 (A) Histological cryosection through the lateral abdominal wall (see inset image) showing the muscle layers (purple) of external oblique
(EO), internal oblique (IO), and transversus abdominis (TA). The collagenous fascia and adipocytes separating them are colored green and pale yellow,
respectively. Note that there are fascial planes between the epimysium of different muscles, as well as planes within muscle that separate bundles
of fascicles. This is most evident in the external oblique muscle in this particular histological section. (B) Detail of the three muscle layers showing
their organization into bundles of fascicles, with each fascicle itself a bundle of muscle fibers. Endomysial and perimysial fascia (arrows) surrounds
fibers and fascicles, respectively. Intramuscular terminal nerves are visible (dark yellow). (C) The epimysial fascial layer is composed of multiple
parallel bundles of collagen fibers (colored green) and thicker than intramuscular collagenous septae (which have not been colored). The fascial plane
(transversus abdominis plane) between internal oblique (IO) and transversus abdominis (TA) muscles is filled with adipocytes (pale yellow) and, in
the living subject, the hydrated proteoglycan matrix of ground substance. Blood vessels (red) and nerves (dark pink) run through this plane—in this
case, these are branches of the ilioinguinal and iliohypogastric nerves. Intramuscular terminal nerves (dark yellow) and blood vessels are also seen. All
images have been color-enhanced for clarity using Adobe Photoshop. (Adapted and reproduced with permission of Dr Miguel A Reina.)
Special article
Figure 5 Illustration of the sensory and motor pathways for nerve conduction. The dorsal rootlets carry purely sensory neurons (green) to the dorsal
horn of the spinal cord, and the ventral rootlets carry the motor neurons (yellow) from the ventral horn. Distal to the dorsal root ganglion, the sensory
and motor neurons mix within the spinal nerve. The autonomic neurons and sympathetic ganglia are not shown. The spinal nerve divides into (1)
a dorsal ramus, which transmits sensory, motor and autonomic innervation to the posterior torso and (2) a ventral ramus which transmits sensory,
motor, and autonomic innervation to the anterolateral torso, viscera, and all limbs. similarly, nerves innervating a particular tissue or organ are almost
all mixed nerves that contain a combination of sensory, motor and autonomic neurons, depending on its function. Nociceptive blockade of sensory
neurons by fascial plane blocks occurs at the level of the tissue nociceptors, peripheral nerves, or at the level of the dorsal and ventral rami, depending
on the specific technique. A systemic effect from vascular absorption of local anesthetic is believed to have effects at the level of the dorsal root
ganglion, dorsal horn, or supraspinal sites such as the thalamus. (Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
through fascial planes; the latter remain the primary therapeutic mediates visceral pain. However, visceral sensory afferent and
targets in FPBs. sympathetic neurons are functionally distinct and separate.
Sympathetic neurons are purely efferent and have no role in
Anatomical concepts governing the role of FPBs in somatic visceral sensory or nociceptive signaling.21 27 28 Visceral and
and visceral analgesia somatic sensory afferents eventually converge within the spinal
Appropriate selection of FPBs hinges not only on understanding nerve and both project to the dorsal horn of the spinal cord
the anatomical course of target nerves, but also the innervation (figure 8). This viscerosomatic convergence is responsible for the
of clinically relevant anatomical tissues and etiology of pain phenomenon of referred pain.28
(figure 5). Somatic and visceral pain have different character- An illustrative example follows. The PECS2 block targets
istics and even psycho-physiological responses, and these are lateral cutaneous branches of intercostal nerves which transmit
discussed in detail elsewhere.21 FPBs are most often employed to superficial somatic pain, as well as pectoral nerves respon-
manage somatic pain, since peripheral nerves innervating cuta- sible for deep somatic pain from pectoral muscle stimulation,
neous and musculoskeletal tissues travel through the targeted providing analgesia in breast surgery.29 30 However, it will not
fascial planes. Note that “motor” nerves supplying muscles are block thoracic visceral afferents, since these course within the
actually mixed nerves, with up to one-third of the fibers serving thoracic cavity and only merge with somatic afferents in the
a sensory function.22 These are responsible for nociception not paravertebral space. On the other hand, paraspinal FPBs such
only from the muscle itself, but also from the articular soft tissues as the erector spinae plane (ESP) or midpoint transverse process
(joint capsule, ligaments, synovium) of the joint that the muscle to pleura (MTP) blocks, could potentially block both somatic
acts on (Hilton’s law of innervation).23 Nerves with a primarily and visceral pain and may therefore be better choices in thoracic
motor function may therefore have a greater role in nociception surgery. The same considerations apply to abdominal FPBs. Any
than previously assumed.24 25 visceral analgesic effects ascribed to more peripheral FPBs (eg,
Visceral pain emanating from thoracic, pelvic, or abdominal TAP blocks31) may be mediated instead by a systemic effect of
internal organs, on the other hand, is transmitted via spinal local anesthetic.
sensory afferent neurons, which are primarily responsible for Even paraspinal FPBs may not always block referred visceral
mechanosensation and nociception.26 These share the same pain, however. For example, patients receiving a T4-T5 ESP or
anatomical conduit as sympathetic neurons—they travel in the MTP block for video-assisted thoracoscopic surgery may still
same nerves, pass through the same intrathoracic and intra- experience shoulder pain due to irritation of diaphragmatic,
abdominal plexuses and sympathetic ganglia, and only diverge pleural, or mediastinal tissues that are innervated by the phrenic
when the spinal nerves split into dorsal and ventral roots nerve. This visceral pain maps to the C3-C5 nerve roots, which
(figure 6).27 28 This physical association leads to a common serves both the phrenic nerve as well as the shoulder region
but erroneous assumption that the sympathetic nervous system innervated by the supraclavicular nerves, and can only be
Special article
Figure 6 Simplified illustration of the abdominal visceral innervation. cell bodies of sympathetic neurons (green) are located in the anterolateral
horn of T1-L2 spinal cord segments. Efferent fibers (cholinergic) pass by way of the ventral root to a white ramus communicans and then to the
paravertebral sympathetic ganglia. They continue via splanchnic nerves (greater, lesser, and least) to prevertebral ganglia (eg, celiac ganglia). From
here, multiple branches form autonomic plexuses (eg, celiac plexus) that supply terminal efferent fibers to the viscera. Adrenergic vasomotor efferents
also leave the sympathetic ganglia to innervate blood vessels. Sensory afferent neurons from the viscera (blue) travel in the reverse direction along
the same pathway as sympathetic efferent neurons but are functionally separate. The visceral sensory neurons enter the spinal nerve via white rami
communicantes and converge with somatic sensory neurons. They both project onto second-order neurons in the dorsal horn of the spinal cord,
and this viscerosomatic convergence is responsible for the phenomenon of referred pain. Visceral pain sensation may be blocked at the level of the
celiac ganglion or plexus, or at the level of the spinal nerve and cord. However, blocking the latter site will also interrupt motor and somatic sensory
function, which is generally undesirable. There are also afferents carried in branches of the vagus nerve; these neurons (pathway not shown in full)
have their cell bodies within the superior and inferior (nodose) ganglia located within the jugular foramen and project to the solitary nucleus in the
medulla oblongata. DRG, dorsal root ganglion. (Reproduced with permission from KJ Chin Medicine Professional Corporation.)
blocked at this level. The precise pathway of any visceral pain is while the dorsal rami innervate the intrinsic muscles of the back
thus an important consideration in formulating an analgesic plan and cutaneous tissues of the posterior torso.
that incorporates FPBs. Each dorsal ramus branches off the spinal nerve, turns
posteriorly, and divides into medial and lateral branches, 32
with a third intermediate branch described by some
General anatomy of the torso authors. 33 In the thoracic spine, this division occurs as the
Innervation of the torso dorsal ramus pierces the posterior boundary of the paraver-
The thorax and abdomen derive their innervation mainly from
tebral space.32 The medial branch innervates the transverso-
the T2-T12 spinal nerve roots. Each spinal nerve is formed by
spinalis group of muscles adjacent to the spinous processes,
the union of ventral and dorsal rootlets arising from the spinal
as well as the skin of the midline (figure 8). The intermediate
cord (figure 7). Ventral rootlets transmit efferent motor neurons
and lateral branches supply the longissimus, iliocostalis, and
and preganglionic autonomic neurons. The latter synapse with
other intrinsic back muscles and overlying skin.
post-ganglionic autonomic neurons in the sympathetic ganglia.
Macroscopically, the sympathetic ganglia are connected to spinal Each ventral ramus is continuous with its respective inter-
nerves by rami communicantes. Dorsal rootlets transmit sensory costal nerve which runs forward in the intercostal space
afferent neurons from visceral and somatic tissues and their cell (figure 8). Numerous branches arise from each intercostal
bodies are contained in the dorsal root ganglion (DRG) located at nerve along its course to supply the various muscles and
the intervertebral foramina of the vertebral column (figures 7 and connective tissues that constitute the lateral and anterior
8). The dorsal and ventral rootlets converge immediately beyond thoracoabdominal wall (figure 9).34 The intercostal nerves
the DRG to form the spinal nerve proper. In the adult, the spinal also innervate the ribs and associated joints, parietal pleura,
nerve extends for approximately 2 cm before it divides into a and peritoneum. All of these structures may be sources of
dorsal and ventral ramus. Note that the dorsal and ventral rami pain following surgery or trauma.
each contain motor, sensory, and autonomic neurons (figure 8). The major cutaneous branches of the intercostal nerves
The ventral rami innervate the anterior and lateral walls of the are the lateral cutaneous and anterior cutaneous nerves. The
torso as well as the intrathoracic and intra-abdominal organs, lateral cutaneous branch arises from the main nerve trunk
Special article
Figure 7 Detail of the neuronal synapses at the level of the spinal cord and nerve. This governs the characteristics of the neural block that can be
expected from local anesthetic action at a specific site. Each spinal nerve and its respective dorsal and ventral ramus (not shown) contain sensory,
motor, and autonomic neurons. All somatic and visceral sensory afferents, including nociceptors, have their cell bodies within the dorsal root ganglion,
and all the axons are contained within the dorsal rootlets that connect to the dorsal column of the spinal cord. The sympathetic ganglion is the site
of synapses between preganglionic and postganglionic autonomic efferent neurons that are responsible for sympathetically mediated phenomena.
Motor efferents have their cell bodies in the ventral horn of the spinal cord, and exit the spinal canal via ventral rootlets that converge with
sensory neurons distal to the dorsal root ganglion to form the spinal nerve. Note that the neural pathway of visceral innervation is not shown here.
(Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
close to the mid- axillary line, ascends obliquely through However, there are several others, including the intertrans-
intercostal and serratus anterior muscles, and divides into verse, laminotransverse, and lateral (posterior) costotrans-
anterior and posterior branches that innervate the skin over verse ligaments, and levatores costarum muscles. 32 38 39 The
the anterolateral and posterolateral torso (figure 9). Each porosity of this intertransverse connective tissue complex
intercostal nerve (except for T1) terminates in anterior has been demonstrated by radiological evidence of injectate
cutaneous branches that innervate the anteromedial thorax spread from the fascial plane deep to transversospinalis and
and midline. Overlapping midline innervation from contra- erector spinae muscles into the paravertebral and intercostal
lateral intercostal nerves is the rule rather than the excep- spaces in both cadaveric and patient studies. 40–43 In partic-
tion, 35 and may lead to parasternal sparing with unilateral ular, the free medial edge of the SCTL borders an aperture
blocks. Intersegmental connections between adjacent inter- that transmits the dorsal ramus and accompanying dorsal
costal nerves are also common 34 and partly explain the vari- branch of the intercostal artery and vein—the costotrans-
ability and overlap of classically described dermatomes that verse foramen. 43 This is a potential passageway for injectate
is observed in practice.36 37 to flow into the paravertebral space following paraspinal
FPBs. 43 Furthermore, while these connective tissues are
Costovertebral angle largely impermeable to particulate injectates such as India
The anatomy of the costovertebral junction or angle is ink and latex solutions,44 their microscopic architecture
important in the ESP block and other paraspinal FPBs. Note of collagen fibers permits diffusion of local anesthetic and
that the length of the transverse processes, a key landmark other small molecules down a concentration gradient.11
in the ESP block, becomes progressively shorter at the lower
thoracic vertebrae. A connective tissue complex of over- Thoracic paravertebral space
lapping ligaments and muscles spans the gap between adja- The paravertebral space is bounded anteriorly by endo-
cent transverse processes and ribs (figure 10). The superior thoracic fascia and parietal pleura, and posteriorly by the
(or anterior) costotransverse ligament (SCTL) is the most transverse processes, ribs, and the intertransverse connec-
well-known of these as it is often highlighted as the chief tive tissue complex described earlier (figure 10). Medially, it
landmark to be pierced in a thoracic paravertebral block. communicates with the epidural space via the intervertebral
Special article
Figure 8 A typical thoracic spinal nerve is formed by the union of ventral and dorsal rootlets that arise from the spinal cord. The dorsal rootlets
converge into the dorsal root ganglion (DRG) which contains the cell bodies of the primary sensory afferent neurons; the DRG is located at or
just outside the intervertebral foramen. The spinal nerve divides into a ventral and dorsal ramus. The dorsal ramus branches to innervate the bony
vertebrae, the intrinsic muscles of the back (erector spinae and transversospinalis), and cutaneous tissues of the posterior torso. The ventral ramus
becomes the intercostal nerve. The posterior intercostal artery and vein and their branches accompany the nerves. Note that the exact arrangement of
back muscles will vary at different vertebral levels. (Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
foramina. The spinal nerves emerge here and immediately paravertebral space, transitioning into intercostal nerves
divide into dorsal and ventral rami. As mentioned, dorsal and intercostal space, respectively. The paravertebral, inter-
rami and accompanying vessels exit the paravertebral space costal, and epidural space are therefore anatomically contin-
through the intertransverse connective tissue complex. uous compartments through which injectate can disperse
The ventral rami continue into the lateral aspect of the freely by bulk flow. Each can be accessed from the other,45–48
Figure 9 Transverse cross-section of the various muscles of the anterolateral chest wall. Each intercostal nerve gives off multiple branches to
innervate the ribs, intercostal muscles, and other intrinsic muscles of the thoracoabdominal wall. The lateral cutaneous branch arises close to the
mid-axillary line, pierces the internal and external intercostal and serratus anterior muscles, and divides into an anterior and posterior branch that
innervates the superficial tissues over the lateral torso. Local anesthetic injection into the planes superficial or deep to serratus anterior muscle will
therefore block the lateral cutaneous branches of the intercostal nerves. (Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
Special article
Figure 10 Illustration of the intertransverse connective tissue complex and the boundaries of the thoracic paravertebral space (red dashed triangle)
and intercostal space (blue dashed rectangle). The superior costotransverse ligament (SCTL) connects the superior aspect of the rib neck to the inferior
aspect of the transverse process (TP) of the vertebra above. The inferior costotransverse ligament (ICTL) connects the inferior aspect of the rib neck to
the TP of its corresponding vertebra. The lateral costotransverse ligament (LCTL) connects the tubercle of the rib to the lateral tip of its corresponding
TP. The intertransverse ligament (ITL) connects the lateral ends of adjacent TPS. Ishizuka et al32 have also described a laminotransverse ligament (LTL)
connecting the lateral border of the upper vertebral lamina and the TP of the lower vertebra. the ventral ramus (intercostal nerve) and intercostal
vessels pass anterior to the SCTL; the dorsal ramus turns almost 90° to travel in a posterolateral direction through the gap bounded by the TPS above
and below, the medial edge of SCTL, and the lateral edge of the lamina and LTL, and divides into its component branches. All nerves are accompanied
by their respective branches of the segmental spinal artery and vein (not shown). (Reproduced with permission of KJ Chin Medicine Professional
Corporation.)
and spread into all three has been demonstrated for a variety on one side by external and internal intercostal muscles, and on
of paraspinal FPBs. 40 41 49 50 the other by the innermost intercostal muscle layer and pleura.
The endothoracic fascia blends caudally into transversalis The external and internal intercostal muscles normally prevent
fascia, sheathing the psoas major and quadratus lumborum bulk flow of fluid from the fascial plane between the ribs and
muscles as they travel from their insertions on the T12 serratus anterior into the intercostal space,59 unless they are
vertebra and 12th rib, respectively, under the medial and disrupted by surgery or trauma.60 However, starting at a point
lateral arcuate ligaments of the diaphragm. The continuity anterior to the midpoint of the ribs, the intercostal nerves may
of these fasciae provides a potential pathway for fluid to run in and among the fibers of the internal intercostal muscles.57
travel from the thoracic paravertebral space to the celiac This, together with local anesthetic diffusion through the muscle
ganglion 51 and into the lumbar paravertebral region. 52 layers, may partly explain the analgesic effect of deep SAP blocks
Note however, that there is no true paravertebral space at in thoracic surgery and trauma.61 62
the lumbar level. The region anterior to lumbar transverse
processes is occupied instead by psoas major and quadratus
Anatomy of the posterior torso
lumborum; the ventral rami of L1-L 5 spinal nerves enter into
The posterior chest wall (extending from posterior axillary line
psoas major and unite within it, forming the lumbar plexus.
to thoracic spinous processes) and lumbar region of the back are
An anatomical pathway between the fascial planes around
composed of a complex multi-layered arrangement of different
the quadratus lumborum muscle and the thoracic paraver-
muscle groups (figure 12; online supplemental table 1). The
tebral area is the current basis for explaining the abdom-
exact muscle layers and intervening fascial planes visualized
inal analgesia reported with the quadratus lumborum block
during any ultrasound-guided FPB will depend on where the
(QLB).4 This was demonstrated in cadavers 53–55 although a
probe is placed over the posterior torso. A simplified anatomical
recent MRI study in patients was unable to find evidence of
description encompassing the key muscular landmarks pertinent
similar spread.56
to FPBs follows.
Intercostal muscles and space
The deepest layer of the chest wall comprises the intercostal Extrinsic back muscles
muscles (external, internal, and innermost) connecting adja- Latissimus dorsi is the most superficial muscle in the inferior
cent ribs and is lined on its inner aspect by the parietal pleura. portion of the posterior torso; it overlies serratus posterior infe-
The anatomical arrangement and sonographic appearance of rior and extends out to the lateral thoracic wall. Trapezius is
the three intercostal muscles varies along the length of the ribs the most superficial muscle in the superior portion; it overlies
(figure 11).57 58 The main intercostal nerve trunk and accom- serratus posterior superior, levator scapulae, rhomboid major,
panying vessels run in the fat-filled intercostal space, bounded and minor muscles. These, in turn, overlie the intrinsic back
Special article
Figure 11 Intercostal muscles and spaces at different locations of the thorax. (A) Anterior parasternal intercostal space. Costal cartilages (CC)
transmit ultrasound waves, so the line of the pleura is visible beneath them. The muscle layers from superficial to deep are: pectoralis major (PM),
internal intercostal muscle (IIM), and transversus thoracis muscle (TTM). The external intercostal muscle has transitioned into the aponeurotic external
intercostal membrane lying between pectoralis and internal intercostal muscles, and the innermost intercostal muscle has transitioned into the
transversus thoracis muscle. The intercostal nerve runs in the space between internal intercostal and transversus thoracis muscles, and its terminal
anterior cutaneous branch ascends to innervate the superficial parasternal tissues. There are two potential fascial planes for local anesthetic injection:
the deeper plane (large arrowhead) is the target of the transversus thoracis plane block, and the more superficial plane (dashed arrow) is the target
of the pecto-fascial plane/parasternal intercostal plane block. (B) Lateral intercostal space in the mid-axillary line. The “curtain sign” of the pleural
edge is visible where it meets the diaphragm. The intercostal muscle layers of external intercostal (EIM), IIM, and innermost intercostal (InIM) are
thin, closely apposed, and difficult to distinguish clearly. The inferior corner of the intercostal space (triangle) is just visible at the inferior edge of the
rib, with most of it shielded from view within the intercostal groove on the inner aspect of the rib. The deep serratus anterior plane is indicated by
the arrowheads and is a target for fascial plane injection of local anesthetic. The lateral cutaneous branches of the intercostal nerve are anesthetized
as they pass through this plane. Local anesthetic diffusion to the intercostal nerve is also plausible given its proximity. (C) Posterior intercostal space
medial to the angle of the ribs. The trapezius (TM) and rhomboid major (RMM) muscles lie superficial to the ribs and the intercostal muscles. EIM and
IIM muscles are visible, however, the innermost intercostal muscle is a largely insubstantial layer in this location. The corner of the intercostal space
containing the intercostal artery (IA), vein, and nerve is visible at the inferior edge of the rib (triangle). The plane superficial to the rib and external
intercostal muscle (arrowheads) is the target for local anesthetic injection in the rhomboid intercostal plane and paraspinal intercostal plane blocks.
Local anesthetic diffusion to the intercostal nerve is plausible given its proximity. (Adapted and reproduced with permission of Dr Maria Fernanda
Rojas Gomez.)
muscles that occupy the bony paravertebral gutter. More later- The deepest layer of muscles include the interspinales, inter-
ally, beyond the angle of the ribs and the lateral border of ilio- transversarii, and levatores costarum. The next deep layer is
costalis, the lateral edge of the rhomboid muscles covers the collectively referred to as transversospinalis (or transverso-
external intercostal muscles and ribs. The fascial plane deep to spinales) and occupies much of the bony gutter formed by the
the rhomboids is the target of the rhomboid intercostal block, vertebral laminae. It comprises the multifidus, rotatores, and
which aims to block the lateral cutaneous branches of intercostal semispinalis muscles. Multifidus (lumborum) is especially well
nerves passing through this plane.63 developed in the lumbar spine, where the entire transversospi-
nalis group is often referred to simply as “multifidus.”64 The
Intrinsic back muscles superficial layer is the erector spinae muscle, a collective term for
The intrinsic back muscles are a complex collection of muscles three muscle groups running longitudinally between the cervical
organized in layers from deep to superficial (figure 12; online and lumbosacral regions: spinalis, longissimus, and iliocostalis
supplemental table 1). The muscles that constitute these layers muscles (in order from medial to lateral). The entire group of
are subdivided according to their insertion onto a particular intrinsic back muscles are invested by the TLF.65
aspect of the axial skeleton and named with the appropriate
suffix for example, capitis, cervicis, thoracis, and lumborum. Aspects relevant to thoracolumbar paraspinal FPBs
Although detailed knowledge of these muscles is not essential The ESP block involves contacting the tip of the thoracic trans-
for block performance, it is useful in understanding the spread verse process with the needle and injecting fluid to hydrodissect
patterns that can be obtained by injecting at different paraspinal the plane deep to erector spinae muscle. However, resistance to
locations. injection is sometimes encountered, with associated difficulty
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Figure 12 Extrinsic and intrinsic back muscles. These are organized in a complex arrangement of multiple overlapping layers, which determines
the fascial planes visible on ultrasound imaging at different locations. The bony insertion points of these muscles and associated fascia constitute
potential lines of fusion that may limits to bulk spread of injectate. Only the more prominent muscles have been shown here for simplicity and clarity.
Note that “erector spinae muscle” is a collective term for spinalis, longissimus, and iliocostalis muscles; and “transversospinalis” is a collective term
for the smaller paraspinal muscles including multifidus, rotatores, and semispinalis. D, deltoid; EO, external oblique; IL, iliocostalis; IS, infraspinatus; It,
intertransversarii; LC, longissimus cervicis; LeC, levatores costarum; LD, latissimus dorsi; LS, levator scapulae; LT, longissimus thoracis; MF, multifidus;
QL, quadratus lumborum; R, rhomboid major and minor; S, spinalis thoracis; SA, serratus anterior; SpC, splenius capitis; SPI, serratus posterior inferior;
SS, supraspinatus; SsC, semispinalis cervicis; SsT, semispinalis thoracis; Tr, trapezius. (Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
in obtaining a clean separation of muscle from bone. A closer planes between the lumbar paraspinal muscles (figure 15).67 68
examination of the muscle architecture provides a possible The lumbar erector spinae muscle only comprises longissimus
explanation. Longissimus and iliocostalis muscles are each orga- and iliocostalis, and the medial component of the paraspinal
nized into two overlapping groups of fascicles, distinguished musculature is represented instead by multifidus lumborum.64
by a suffix according to their spinal insertions (“thoracis” vs The fascial plane between multifidus lumborum and longissimus
“lumborum”).64 The muscle fascicles of longissimus thoracis is the injection target in the original TLIP block.67 A modified
have tendinous insertions onto the tip of each transverse process. (lateral) TLIP block has been described in which injection is
At T5-T12, this is usually a single tendon but at T1-T4 the muscle performed instead into the fascial plane between iliocostalis
belly is attached to each transverse process by 3–4 tendons and longissimus.69 When attempting to identify these planes on
(figure 13).64 In targeting the tip of the transverse process, the ultrasound, it is important to note that their location and conti-
needle may embed itself within the tendon rather than the fascial nuity are not consistent throughout the lumbar spine. The plane
plane, resulting in difficulty with injection and achieving the between longissimus and iliocostalis can only be identified in the
desired pattern of spread. A possible solution is to aim slightly upper lumbar spine as the tendons of both muscles merge into an
lateral to the transverse process and contact the tubercle of the aponeurosis below L3 and attach to the iliac crest.70 The plane
rib instead, thus avoiding the longissimus tendons.66 However, between multifidus and longissimus is present from L1 to S1, but
this contact point should not be too far lateral to the tubercle, is located progressively lateral to the midline in a caudal direc-
as a second series of longissimus thoracis fascicles inserts onto tion (ranging between 0.8 cm at L1-L2 and 3.5 cm at L5-S1) due
the posterior aspect of each rib in its proximal portion.64 Alter- to the increasing thickness of multifidus.70
natively, the needle tip may be placed into the intertransverse
connective tissues rather than on the transverse process itself, as
described for the MTP block.49 Cervical paraspinal muscles
Similar considerations also apply to the lumbar ESP block, The intrinsic paraspinal muscles in the cervical spine have a more
as the fascicles of longissimus lumborum attach strongly to the complicated arrangement. This varies depending on the specific
medial three-quarters of the lumbar transverse processes, while axial plane, but the general configuration in the infrahyoid region
lumbar fascicles of iliocostalis lumborum attach to the lateral is illustrated in figure 16. The medial layers from superficial to
quarter.64 Hydrodissecting lumbar erector spinae muscle cleanly deep are splenius cervicis and capitis, semispinalis cervicis and
off the lumbar transverse processes may therefore be challenging capitus, and multifidus cervicis. More laterally, longissimus and
if the needle tip is placed onto bone. The fascial plane between iliocostalis cervicis insert on cervical transverse processes and are
erector spinae muscle and quadratus lumborum or psoas major is adjacent to levator scapulae. All are encased by the deep cervical
usually quite evident and it is reasonable to attempt to place the fascia, which defines the perivertebral space, and blends caudally
needle tip directly into this plane instead (figure 14). with the TLF. The fascial planes between these muscles are an
The thoracolumbar interfascial plane (TLIP) block seeks to evolving area for FPBs designed to block cervical dorsal rami for
block the branches of the lumbar dorsal rami by injection into analgesia in cervical spine surgery.71 72 There also appears to be
Special article
SAP block. The fascial planes superficial and deep to serratus
anterior are targeted in FPBs of the same name. Serratus anterior
is covered on its posterior aspect by latissimus dorsi, and on its
anterior aspect by pectoralis major and minor (figure 9). Hence,
a superficial SAP block at the level of the fourth rib in the ante-
rior or mid-axillary line and the deep injection under pectoralis
minor of the PECS2 block are injections into the same fascial
plane. Similarly, a deep SAP block may be performed anywhere
on the lateral chest wall from the medial margin of the scapula
(as in the rhomboid intercostal subserratus plane block63) to the
origins of the serratus anterior muscle along the anterior axil-
lary line. Despite the theoretical continuity of these planes, the
spread pattern and area of coverage will vary depending on the
site of injection. In a cadaveric study of both superficial and deep
SAP blocks, a 20 mL injection at the level of the fifth rib in the
mid-axillary line did not spread cranial to the third rib. Instead,
spread to the first rib and axilla was only achieved with a second
injection at the level of the third rib in the anterior axillary line.77
The primary nerve targets in anterolateral FPBs are the
lateral cutaneous and muscular branches of T3-T10 intercostal
nerves.63 77 These arise from the main nerve trunk close to the
mid-axillary line,78 and ascend through intercostal and serratus
anterior muscles before dividing further into anterior and poste-
rior branches that innervate the anterolateral and posterolateral
torso, respectively (figure 9). 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.79 Other nerves of the
thorax arising from the brachial plexus include the lateral and
medial pectoral nerves (C5- C6), thoracodorsal nerve (C6-8),
and long thoracic nerve (C5-7) which innervate the pectoralis
major and minor, latissimus dorsi, and serratus anterior muscles,
respectively. While these are all primarily motor nerves, they also
transmit sensory afferents from the muscles they supply,22 24 and
are therefore relevant targets if there is muscle trauma or spasm
contributing to pain. Finally, the supraclavicular nerves (C3-C4),
which are branches of the superficial cervical plexus, contribute
to cutaneous innervation of the suprascapular and infraclavic-
ular regions of the posterior and anterior thorax, respectively
(figure 17).
Figure 13 Cadaveric dissection illustrating the tendinous attachments The pectoralis major and minor muscles are key landmarks in
of longissimus thoracis (pars thoracis) muscle. One series of fascicles the PECS1 and PECS2 FPBs. Pectoralis minor has a broad origin
attaches to the transverse processes (TP) of thoracic vertebrae and from the anterior surface of the costal cartilages of the third to
another series inserts more laterally onto the ribs. fifth ribs and narrows to insert on the coracoid process, giving it
a wedge-shaped appearance. Unlike the larger pectoralis major
muscle which covers the entire anterior chest wall from sternum
communication with fascial planes between the more anterior and clavicle to its insertion on the humerus, pectoralis minor will
cervical flexor muscles of longus capitis, longus colli, and scalene not be visualized on ultrasound if the probe is placed inferior to
muscles. Injectate spread into the vicinity of brachial plexus the fourth rib and lateral to the anterior axillary line, or medial
roots has been reported with ESP blocks at C7-T2 levels,73 74 to the midclavicular line (figure 18). Injectate spread in these
and may partly explain the analgesia of the shoulder girdle that FPBs is also influenced by the clavipectoral fascia, a complex
is achieved.73 75 76 multilamellar structure that defines the three-dimensional pyra-
midal space of the axilla and separates it from the pectoral
Anatomy of the thorax muscles.80 From its attachments to the clavicle, coracoid process,
Anterolateral chest wall and sternal end of the first to second ribs, the clavipectoral fascia
Serratus anterior overlies the lateral aspect of first to eighth extends to split and envelop the subclavius and pectoralis minor
ribs and intercostal muscles. It originates as multiple slips of muscles. This creates a fascial plane between the deep aspect of
muscle attached to the approximate mid-point of the first 10 pectoralis minor and the fat-filled compartment of the axilla.
ribs (corresponding roughly to the anterior axillary line). These The thickened caudal edge of the anterior layer of clavipectoral
slips expand and merge as they run posteriorly to insert on the fascia is referred to as the suspensory ligament of the axilla
anterior surface of the scapula. Serratus anterior thus increases (Gerdy’s ligament) and corresponds to the surface landmark of
in thickness in an anterior-to-posterior direction, an important the anterior axillary fold. The clavipectoral fascia reflects over
fact when identifying the muscle during an ultrasound-guided serratus anterior, forming the medial boundary of the axilla, and
Special article
Figure 14 (A) Parasagittal ultrasound view of the L3 and L4 transverse processes (TP) close to their tips. The parallel fibers of erector spinae muscle
(ESM) are clearly visible as they swoop in to insert on the transverse processes. The medial edge of quadratus lumborum muscle (QLM) is adjacent
to the tips of the transverse processes, and thus may be seen deep to ESM. There are two obvious fascial planes—one between ESM and QLM
(dashed arrows) and one between QLM and psoas major (solid arrows). (B) Transverse oblique view of the L3 vertebra in an inter-transverse plane
corresponding to the dotted line in (A). The fascial plane between ESM and QLM (dashed arrows), and between QLM and psoas major (solid arrows)
is evident in the lateral aspect. These two planes converge at the medial edge of QLM, and erector spinae muscle also converges as a tendon onto the
transverse process (not visible in this cut) and thus the plane is less distinct (broad arrow). AP, articular process; MF, multifidus; SP, spinous process; VB,
vertebral body.
binds the long thoracic nerve to the muscle’s surface.81 Poste- of pectoralis minor, to emerge into the interpectoral fascial
riorly, it is apposed to latissimus dorsi, and similarly binds the plane.83 The lateral pectoral nerve runs in this plane for about
thoracodorsal nerve and vessels to this muscle’s surface.81 1 cm before ascending into pectoralis major and innervating the
The targets in the interpectoral plane are the medial and lateral clavicular and sternal portions of this muscle.82–84 The lateral
pectoral nerves. The lateral pectoral nerve arises from the ante- pectoral nerve also gives rise to 1–2 articular branches that inner-
rior divisions of the superior and middle trunks of the brachial vate the acromioclavicular joint and occasionally contribute to
plexus.82 It is closely associated with the pectoral branch of the the anterior aspect of the glenohumeral joint. These branches
thoracoacromial artery and both pierce the clavipectoral fascia travel along the inferior edge of the clavicle, passing superior
just inferior to the clavicle and medial to the coracoid insertion to the coracoid process to reach the joint capsules in question.85
Figure 15 Transverse cross-sectional illustration, T2-weighted MRI, and ultrasound images of lumbar paraspinal muscles and planes in the upper
lumbar spine. The solid arrow indicates the fascial plane between multifidus (MF) and longissimus thoracis (LT) that is the target of the thoracolumbar
interfascial plane (TLIP) block. The dotted arrow indicates the fascial plane between longissimus thoracis and iliocostalis lumborum (IL) that is the
target of the modified TLIP block. These fat-filled planes show up as white on the MRI scan. Both blocks are intended to block the lumbar dorsal rami
and their branches that travel through these planes to innervate the lumbar paraspinal region. The thoracolumbar fascia investing the erector spinae
and quadratus lumborum (QL) muscle is visible on MRI and ultrasound (white arrowheads). Note that the plane between LT and IL will disappear
below L3 as the two muscles merge into a common aponeurosis that attaches to the iliac crest. AP, articular process; SP, spinous process; VB, vertebral
body.
Special article
Figure 16 Idealized representation of the paraspinal muscles of the lower cervical spine. The exact arrangement and prominence of the various
muscles will vary at different cervical levels. Fascial plane block techniques targeting the dorsal rami of spinal nerves have been described in this
area. The course and branches of the dorsal ramus have not been shown in full. The continuation of longissimus into this region provides a potential
pathway for cranial spread from high thoracic erector spinae plane blocks. (Reproduced with permission of Dr Maria Fernanda Rojas Gomez.)
The medial pectoral nerve arises from either the anterior divi- Some of these branches pierce pectoralis minor and innervate
sion of the inferior trunk or the medial cord of the brachial it, before emerging into the interpectoral plane to innervate the
plexus.82 It travels inferior to the axillary artery and vein through costal portion of pectoralis major muscle. Other branches reach
the infraclavicular fossa before dividing into several branches. pectoralis minor by passing around the lateral edge of pectoralis
minor rather than through it.82 84 86
These anatomical details have important implications for
PECS1 and PECS2 blocks.83 86 Transversal collagen fibers within
the interpectoral plane create points of attachment between the
fascial layers that constrain the dispersion of fluid, and thus
the site and direction of needle insertion determines the spread
pattern obtained. The pectoral branch of the thoracoacromial
artery is a readily identifiable ultrasonographic landmark in the
interpectoral plane—injection lateral to it in the region around
the anterior axillary line and the third to fourth ribs will reli-
ably anesthetize all branches of the lateral and medial pectoral
nerves.83 86 Larger volumes of injected solution (20 mL vs 10 mL)
will spread even further into the loose areolar connective tissue
of the axilla and reach the intercostobrachial nerve (figure 19).83
Conversely, injection medial to this artery, in the region of the
midclavicular line and over the second to third ribs, may miss the
more lateral branches of the medial pectoral nerve and may not
spread to the axilla.83 86 The deep injection of the PECS2 block
Figure 17 Cutaneous innervation of the anterior chest. The lateral should be performed in the anterior axillary line, over the third
portion is supplied by the lateral cutaneous branches of T2-T6 and the to fourth ribs. This will spread to the posterior axillary line and
medial portion is supplied by the terminal anterior cutaneous branches over the third to seventh ribs, anesthetizing the lateral cutaneous
of these same intercostal nerves. The superior portion (clavicular and branches of the corresponding intercostal nerves and the long
infraclavicular areas) is innervated by branches of the superficial thoracic nerve.83 However, the clavipectoral fascia may prevent
cervical plexus—the supraclavicular nerves. T2 also supplies the injectate distribution into the axilla (figure 19).
intercostobrachial nerve that innervates the axilla together with the
medial brachial cutaneous nerve from the brachial plexus (not shown). Anteromedial chest wall
LPN, lateral pectoral nerve; MPN, medial pectoral nerve. (Reproduced The anteromedial chest wall from the mid-clavicular line to the
with permission of Dr Maria Fernanda Rojas Gomez.) sternum comprises skin, subcutaneous tissue, pectoralis major,
Special article
Figure 18 The clavipectoral fascia is shown as a translucent white layer in the anterior–posterior projection (pectoralis major has been removed)
and as a green line in the cross-sectional representation. It attaches cranially to the clavicle and coracoid process, and splits to envelop the subclavius
(Sc) and pectoralis minor (Pm) muscle. It defines the boundaries of the fat-filled compartment of the axillary space, and its caudal edge is the
suspensory (Gerdy’s) ligament of the axilla. Note that different arrangements of the muscle layers are visible on ultrasound at different locations
on the anterior chest. Ic, intercostal muscles; PM, pectoralis major; SA, serratus anterior. (Reproduced with permission of Dr Maria Fernanda Rojas
Gomez.)
intercostal and transversus thoracis muscles, ribs and costal carti- The intercostal nerves terminate in the parasternal region as
lages, and pleura. Pectoralis major is the only muscle superficial anterior cutaneous branches which ascend through the intercostal
to costal cartilages and intercostal muscles in the parasternal area and pectoralis major muscles to innervate the superficial tissues.
(figure 20). The intercostal nerves travel in the intercostal space In doing so, they pass through two fascial planes (figure 20). The
bounded by internal and innermost intercostal muscles. Adja- first is located between transversus thoracis and internal inter-
cent to the lateral edge of the sternum, the innermost intercos- costal muscles (the deep parasternal-intercostal plane), and is the
tals blend with slips of transversus thoracis which extend from target of the transversus thoracis plane block.5 The second is the
the posterior aspect of the second to sixth costal cartilages to plane superficial to internal intercostal muscle and costal carti-
insert on the deep surface of the sternum. Note that transversus lages and deep to pectoralis major; this is the target of several
thoracis does not span the intercostal space between first and technically similar blocks with different names, including pecto-
second ribs. intercostal fascial block and parasternal (intercostal) block.87 88
Figure 19 Dye injected into the interpectoral plane between pectoralis major (PM) and minor (Pm) spreads into the compartment of the axillary
fossa defined by the clavipectoral fascia, and can thus reach the intercostobrachial nerve (ICBN). Dye injected into the plane deep to pectoralis
minor (Pm) spreads over the surface of serratus anterior muscle (SA) and the ribs, and is confined and prevented from spreading by bulk flow into
the axillary fossa by the clavipectoral fascia (CPF). Local anesthetic may still cross by diffusion, however. (Reproduced with permission of Dr Barbara
Versyck.)
Special article
Figure 20 Musculofascial anatomy in the parasternal region. Pectoralis (Pec) major overlies the costal cartilages. External intercostal muscle
has tapered into the external intercostal membrane which is part of the fascial layer separating pectoralis major and internal intercostal muscles.
Innermost intercostal muscle has transitioned into transversus thoracis muscle, which is composed of multiple muscular slips connecting the inner
aspect of the sternum and ribs. The oblique orientation of these slips contributes to the slender triangular appearance of transversus thoracis muscle
in the transverse intercostal ultrasound view. The terminal branches of the intercostal nerves run in the fascial plane between transversus thoracis
and internal intercostal muscles and ascend through the layers to innervate the muscles, bone, and skin of the parasternal region. Injection of local
anesthetic can be performed either superficial or deep to internal intercostal muscle (green circles). (Adapted and reproduced with permission of Dr
Maria Fernanda Rojas Gomez.)
The internal mammary (or thoracic) artery and vein run in the project onto the dorsal horn of the T7-T12 segments, whereas
deep parasternal-intercostal plane and must be identified and the pelvic viscera and anorectal gastrointestinal tract project onto
avoided when performing these parasternal FPBs. lumbosacral segments (L1-S4).90 91 The transmission of abdom-
With the exception of pectoralis major, most of the anterome- inal visceral pain can therefore only be interrupted by targeting
dial chest wall (ribs, costal cartilages, sternum, and intercostal the following sites: (1) prevertebral plexuses (eg, celiac plexus
and transversus thoracis muscles) is innervated by branches of block), (2) splanchnic nerves (eg, surgical splanchniectomy), (3)
T2-T6 intercostal nerves. The cutaneous tissues have a more sympathetic chain or spinal nerves in the paravertebral space, (4)
complicated sensory innervation (figure 17). The territories of DRGs in the intervertebral foramina, (5) nerve roots and spinal
the lateral and anterior cutaneous branches of the T2-T6 inter- cord within the vertebral canal. FPBs will only provide mean-
costal nerves overlap in the region of the mid-clavicular line. The ingful visceral analgesia if there is local anesthetic penetration
infraclavicular region is innervated by the supraclavicular nerves into the paravertebral space and intervertebral foramina, or via a
which are branches of the superficial cervical plexus. Finally, the systemic local anesthetic effect mediated by vascular absorption.1
skin close to the midline usually receives sensory contributions
from anterior cutaneous branches of the contralateral intercostal
nerves.35
Anterolateral abdominal wall
The anterolateral abdominal wall is bounded superiorly by
the costal margin of the 7th–10th ribs and xiphoid process of
Anatomy of the abdomen the sternum; and inferiorly by the iliac crests, inguinal liga-
The abdominal wall is a cylindrical myofascial structure that
ment, pubic crest, and symphysis. From superficial to deep, it
attaches to the thoracic cage superiorly, the pelvic girdle infe-
comprises skin and subcutaneous tissue, the abdominal muscles,
riorly, and the spinal column posteriorly. A useful conceptual
transversalis fascia, extraperitoneal fat, and parietal peritoneum.
framework in the context of regional anesthesia is to arbitrarily
Three flat muscles (external oblique, internal oblique, trans-
divide the abdominal wall into anterolateral and posterior
versus abdominis) are arranged in concentric overlapping layers
sections separated by the posterior axillary line, and to further
(figure 21). All three taper into aponeuroses that fuse to form
divide the anterolateral abdominal wall into supraumbilical and
the tendinous rectus sheath encasing rectus abdominis muscle.
infraumbilical areas (figure 21). The anatomy of the area has
These aponeuroses blend in the midline to form the linea alba
been reviewed in detail elsewhere,2 4 65 89 and only the most
that divides the rectus sheath into a pair of separate compart-
important aspects relevant to FPBs are discussed here.
ments. This musculofascial anatomy and its relevance to regional
Clinical application of FPBs must take into account the distinc-
anesthesia is described in detail elsewhere.2
tion between somatic and visceral innervation of the abdomen.21
Somatic innervation pertains to the musculocutaneous abdom-
inal wall, which is supplied by sensory and motor neurons of the Innervation of the anterolateral abdominal wall
T7-L1 intercostal nerves. Abdominal visceral sensory afferents, The anterior abdominal wall is innervated by ventral rami of the
on the other hand, travel alongside sympathetic efferent fibers lower seven thoracic spinal nerves (T6-T12) via the respective
through the prevertebral plexuses, ganglia, splanchnic nerves, intercostal nerves. The inguinal and suprapubic regions of the
and sympathetic trunk to reach the respective thoracic spinal abdominal wall and iliac crest are innervated by the ilioinguinal
nerves.27 28 The hepatobiliary, renal, and gastrointestinal tract and iliohypogastric nerves, which are branches of the ventral
Special article
Figure 21 The abdominal wall can be divided into anterolateral and posterior sections on either side of the posterior axillary line (PAL). The
composition and innervation of the anterolateral abdominal wall differs in different locations. The different arrangement of muscular layers and
their aponeuroses is evident on ultrasound imaging. lateral cutaneous branches arise from intercostal nerves in the mid-axillary line (MAL) and
innervate the region lateral to the mid-clavicular line (MCL). These do not enter the transversus abdominis plane (TAP). The region medial to the MCL
is innervated by anterior cutaneous branches from nerves that travel through the tap. The supraumbilical region receives innervation from the T6-T9
intercostal nerves, which only enter the TAP medial to the MCL. The infraumbilical region is innervated by the T10-L1 nerves, which enter the TAP at
the anterior axillary line (AAL). However, any given area has multisegmental innervation due to branching and anastomoses between nerves in the
TAP and rectus sheath. EOM, external oblique muscle; IOM, internal oblique muscle; IL, iliocostalis; LD, latissimus dorsi; LT, longissimus thoracis; MF,
multifidus; PM, psoas major; QL, quadratus lumborum; RAM, rectus abdominis; SPI, serratus posterior inferior, TAM: transversus abdominis muscle;
USG, ultrasound-guided. (Illustrations adapted and reproduced with permission of Dr Maria Fernanda Rojas Gomez and the American Society of
Regional Anesthesia and Pain Medicine.)
ramus of the L1 spinal nerve. All the thoracoabdominal nerves abdomen.94 Regardless of the technique, injection in the TAP
branch and communicate within both the TAP and rectus sheath will not anesthetize the lateral cutaneous branches that innervate
to form plexuses.92 The innervation of the abdominal wall is the skin lateral to the mid-clavicular line.94 However, prelimi-
therefore multisegmental rather than organized into well- nary cadaveric investigation suggests that injection into the plane
demarcated dermatomes as is often illustrated.36 37 between external oblique and the lower costal cartilages (the
The lateral cutaneous branches of the intercostal nerves arise external oblique FPB) may achieve this.95
in the mid-axillary line and ascend to enter the subcutaneous The terminal anterior cutaneous branches of the thoracoab-
tissues along the anterior axillary line. These branches innervate dominal nerves exit the TAP to enter the posterior rectus sheath
the skin of the lateral abdominal wall as far anteriorly as the at its lateral margin. They travel deep to the posterior surface
mid-clavicular line. The muscles themselves are innervated by a of rectus abdominis for a short distance (1.6 cm–2.6 cm) before
complex network of nerve branches, which arise independently ascending to the subcutaneous layer,96 where they further divide
from the main intercostal nerve trunks in the case of internal to innervate the skin between midclavicular line and midline.
oblique (T10-L1) and transversus abdominis (T6-L1), and from The optimal injection site for a rectus sheath block is thus within
the lateral cutaneous branches in the case of external oblique the lateral half of the posterior rectus sheath plane.
muscle (T5-T12).93
The intercostal nerves subsequently emerge from the costal
margin and enter the TAP between internal oblique and trans- Posterolateral abdominal wall
versus abdominis. The T6-T9 nerves supplying the supraumbil- The posterolateral abdominal wall can be defined as the area
ical area only enter the TAP medial to the anterior axillary line, extending from the L1- L5 spinous processes to the poste-
while the T10-T12 nerves enter it more laterally (figure 21).92 rior axillary line, and bounded by the costal margin cranially
Meanwhile, the iliohypogastric and ilioinguinal nerves run over and iliac crests caudally. Muscles in this region comprise the
the anterior surface of quadratus lumborum and transversus lumbar paraspinal muscles (multifidus, longissimus, and iliocos-
abdominis, and enter the TAP superior to the anterior third of talis), serratus posterior inferior, latissimus dorsi, psoas major,
the iliac crest, where they can be most consistently located on and quadratus lumborum; as well as the posterior portions of
ultrasound.2 Although the TAP is theoretically continuous across external oblique, internal oblique, and transversus abdominis
the hemi-abdomen, in clinical practice injectate spread behaves (figures 21 and 22).
as though there are separate supraumbilical and infraumbil- The first FPB described in this region was the landmark-guided
ical compartments, and a single injection in one area will not TAP block performed at the triangle of Petit.2 This has evolved
reach the other.15 Instead, multiple injections along an oblique into a heterogeneous group of ultrasound-guided posterolateral
subcostal line extending from xiphoid process to anterior supe- FPBs based around the quadratus lumborum muscle and associ-
rior iliac spine are required for complete coverage of the anterior ated fasciae. This is an active area of investigation and much of
Special article
Figure 22 Illustration of the anatomy of the posterior abdominal wall and the three-layer model of thoracolumbar fascia (TLF) at the L2-L3
level. The anterior TLF (aTLF) is a composite of transversalis fascia (pink) and epimysium (dashed line) of quadratus lumborum (QL). The middle TLF
(mTLF) is a composite of QL epimysium, common aponeurosis (green line) of transversus abdominis (TA) and internal oblique (IO), and the investing
fascia of erector spinae muscle (ESM). The fascia that envelops all of ESM is also called the paraspinal retinacular sheath. The posterior TLF (pTLF)
is a composite of the paraspinal retinacular sheath and a collagenous layer derived from the investing fascia of latissimus dorsi (LD) and serratus
posterior inferior (SPI). The lumbar interfascial triangle (LIFT) is a fat-filled compartment defined by the splitting of the aponeurosis of TA and IO, and
the paraspinal retinacular sheath. Note that this is an idealized representation of the fascial anatomy, and that the precise arrangement will vary at
different vertebral levels. In the inset MRI, the block arrow points to the fused aponeurosis of the abdominal wall muscles and LD fascia that splits to
define the lift. PM, psoas major. (Reproduced with permission from KJ Chin Medicine Professional Corporation.)
the ongoing debate stems from the fact that the only nerves trav- composed of the anterior portion of this paraspinal sheath and
eling within the fascial planes of the posterolateral abdominal the epimysium of quadratus lumborum together with an inter-
wall are the T12 subcostal nerve, iliohypogastric and ilioinguinal vening sublayer of collagen fibers derived from the aponeurosis of
nerves, and dorsal rami of L1-L5 spinal nerves (which innervate internal oblique and transversus abdominis.65 89 The middle TLF
the paraspinal muscles and skin over the posterior torso and hip). is the target in the posterior QLB. It does not contain any major
For posterolateral FPBs to effect blockade of the T7-T11 ventral nerves and is a plane of dissection for certain surgical approaches
rami that innervate the anterolateral abdominal wall, local to the lumbar spine.70 The posterior and middle TLF fuse again
anesthetic must spread from these fascial planes cranially into lateral to the paraspinal muscles and merge with the aponeu-
the T7-T11 paravertebral or intercostal spaces. Another possi- roses of internal oblique and transversus abdominis.65 89 Both
bility is anterolateral spread into the TAP or internal–external clinical imaging and cadaveric dissection studies have observed
oblique plane, which may block the anterior or lateral cutaneous that following a posterior QLB targeting the lateral aspect of the
branches, respectively, of the lower thoracoabdominal nerves. muscle, cranial spread is usually limited by its attachment to the
12th rib.54 56 This might reflect the fact that injection is tending
Thoracolumbar fascia to occur within the investing fascia of quadratus lumborum. A
The TLF is an important landmark in posterolateral FPBs. It more medial injection site between erector spinae and quadratus
is a complex structure formed by the confluence and blending lumborum muscles was shown to result in greater cranial
of several different muscular aponeuroses and fasciae.65 89 The spread,54 possibly because the fluid is now more likely to track
TLF anchors the abdominal wall and paraspinal muscles to the along or within the paraspinal sheath, and thus follow longis-
spine, providing core stability, and is thus vital to the biome- simus and iliocostalis muscles to their attachments on the lower
chanics of movement. From the regional anesthesiologist’s thoracic transverse processes and proximal ribs.
perspective, however, it is primarily of interest in governing local The anterior TLF is the target for anterior QLB approaches and
anesthetic spread. Tracing it laterally from its attachments to the is comprised of quadratus lumborum epimysium and transversalis
thoracic and lumbar spinous processes, the TLF splits to encase fascia. Transversalis fascia is a thin layer of areolar connective tissue
the paraspinal and quadratus lumborum muscles. There is an that lines the abdominal cavity and separates the muscular abdom-
unresolved discussion among anatomists as to whether the TLF inal wall from the parietal peritoneum. Cranially, it bifurcates into
should be defined in terms of two or three layers with regard to one layer that blends with the investing fascia of the diaphragm, and
this split.65 This is relevant to FPBs only insofar as it aids clarity another layer that enters the thorax with quadratus lumborum and
of communication. We will use the three-layer terminology in psoas major. Here, it blends with the endothoracic fascia, creating
further discussion. a potential pathway for fluid spread from the thoracic paraverte-
At a microscopic level, these TLF layers are composed of bral space into the fascial plane anterior to the quadratus lumborum
multiple sublayers or laminae with different origins.13 65 The muscle,52 and vice versa.53 55 The recognition that thoracic paraver-
posterior TLF consists of at least three sublayers,13 the deepest tebral spread is probably essential for the efficacy of the anterior
of which is termed the paraspinal retinacular sheath and encases QLB has generated various modifications. The earliest described
the intrinsic back muscles (figure 22).89 The middle TLF is approach (the transmuscular QLB) was originally performed at
Special article
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Acknowledgements The authors wish to thank Rachel Chin for her invaluable
27 Farmer AD, Aziz Q. Mechanisms of visceral pain in health and functional
contributions to the illustrations.
gastrointestinal disorders. Scand J Pain 2014;5:51–60.
Contributors KJC contributed to the conception, research, writing, illustration, and 28 Schwartz ES, Gebhart GF. Visceral pain. Curr Top Behav Neurosci 2014;20:171–97.
editing of the paper. BV contributed to the conception, research, writing, and editing 29 Versyck B, van Geffen G-J, Chin K-J. Analgesic efficacy of the PecS II block: a
of the paper. HE contributed to the conception, research, writing, and editing of the systematic review and meta-analysis. Anaesthesia 2019;74:663–73.
paper. MFRG contributed to the conception, writing, illustration, and editing of the 30 Hussain N, Brull R, McCartney CJL, et al. Pectoralis-II myofascial block and analgesia
paper. XS-B contributed to the illustration and editing of the paper. MAR contributed in breast cancer surgery: a systematic review and meta-analysis. Anesthesiology
to the illustration and editing of the paper. 2019;131:630–48.
Funding The authors have not declared a specific grant for this research from any 31 Smith DI, Hawson A, Correll L. Transversus abdominis plane block and treatment of
funding agency in the public, commercial or not-for-profit sectors. Viscerosomatic abdominal pain. Reg Anesth Pain Med 2015;40:731–2.
32 Ishizuka K, Sakai H, Tsuzuki N, et al. Topographic anatomy of the posterior ramus of
Competing interests None declared. thoracic spinal nerve and surrounding structures. Spine 2012;37:E817–22.
Patient consent for publication Not required. 33 Saito T, Steinke H, Miyaki T. Analysis of the posterior ramus of the lumbar spinal
nerve: the structure of the posterior ramus of the spinal nerve. Anesthesiology
Provenance and peer review Commissioned; externally peer reviewed. 2013;118:88–94.
34 Sakamoto H, Akita K, Sato T. An anatomical analysis of the relationships between the
ORCID iDs intercostal nerves and the thoracic and abdominal muscles in man. I. Ramification of
Ki Jinn Chin http://orcid.org/0000-0002-8339-3764 the intercostal nerves. Acta Anat 1996;156:132–42.
Barbara Versyck http://o rcid.org/0000-0003-3368-8959 35 Capek S, Tubbs RS, Spinner RJ. Do cutaneous nerves cross the midline? Clin. Anat.
Hesham Elsharkawy http://orcid.org/0000-0002-0836-1404 2015;28:96–100.
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