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Transducer position
- Select the target transverse process for the block.
- Place the transducer in a paramedian sagittal orientation, approximately 2 cm away from the midline (spinous processes).
| Essential fact: |
|---|
| At higher thoracic levels, e.g., above T5; trapezius, rhomboid major and erector spinal muscles can be identified as three layers superficial to the transverse processes. In the lower and mid-thoracic levels, only trapezius and erector spinae muscles can be seen. |
Scanning
- Visualize the transverse process.
| Common problems and solutions: |
| If the transducer is placed too medial, the thoracic laminae will be visualized as flat hyperechoic lines (A). To fix: Slowly slide the transducer laterally (B). |
| When the transducer is placed too lateral, ribs will be visualized as rounded acoustic shadows with an intermediate hyperechoic pleural line (C). To fix: Slowly slide the transducer medially (B). |
| Tips |
| At higher thoracic levels, e.g., above T5; trapezius, rhomboid major, and erector spinae muscles can be identified as three layers superficial to the transverse processes. |
| In the lower and mid-thoracic levels, only trapezius and erector spinae muscles can be seen. |
| Typically the rib-transverse process complex can be identified as a flat squared hyperechoic line with an acoustic shadow behind. |
| Also, note that the pleura should not be visualized at the level where the block is performed. |
Needle insertion
- Insert the needle in-plane from a cranial to caudad direction until the needle tip contacts the transverse process.
Inject 1-3 mL of local anesthetic to confirm proper injection plane by visualization of a spread deep to the erector spinae muscles and superficial to the transverse process.
Complete the block with 20-30 mL of local anesthetic.
Let’s review the block:
