Method
Cadaveric examination in one cadaver was performed following approval from Istanbul Medipol University Ethics and Research Committee (Date: 13/04/2022, No: 327). The same committee also approved (Date: 11/05/2022, No: 437) the retrospective evaluation of five patients that underwent SPSIP between 15/04/2022 and 11/05/2022. All patients gave written informed consent for inclusion of their data in this study.
Description of SPSIP block
Although we prefer the prone position for the block, it can also be performed in the sitting position. To lateralize the scapula, the patient is instructed to grip the opposing shoulder with the hand on the side where the block is to be performed or to put the affected arm into adduction and internal rotation. A high frequency (4-12 MHz) linear transducer (B-Braun, Philips, Xperius, USA) is placed at the spinae scapula level in the transverse plane, and the upper medial border of the scapula, the trapezius muscle, Rm, SPSM and the second and third ribs are visualized. The ultrasound probe is rotated 90 degrees in a parasagittal orientation from the posterior aspect of the supraclavicular fossa to identify the first rib. After its identification, the second and third ribs are confirmed. The linear transducer is then rotated so that an oblique visualization is obtained (inferomedial-superolateral) with the upper medial border of the scapula in the sonographic view (Figure1A ). The needle (Stimuplex® Ultra 360®, B-Braun, Melsungen, Germany) is then advanced immediately medial to the scapula, aiming for the area between the second and third ribs in order to reach the fascial plane between the SPSM and intercostal muscles, either in the in-plane (caudal to cephalad) or out of the plane technique. After contact of the needle with the rib gently, 1-2mL of saline is used to confirm the correct plane, and a total of 30 mL of local anesthetic (LA) agent is administered to the superficial to the intercostal muscle. The LA should be visible, spreading cephalad and caudad over successive ribs in the interfascial plane (Figure 1B ). Schematic illustration at the level of third rib demonstrating needle/probe position and injectate spread during SPSIP is seen in Figures 1C , D.
Anatomic study of the SPSIP block
Bilateral SPSIP block was performed to an unembalmed cadaver. There were no surgical incisions or scars in the paraspinal region and thorax/neck/shoulder/upper abdominal regions of the cadaver, nor were there any anatomical deformities on inspection. The cadaver was maintained at room temperature for 12 hours prior to block application. Thirty mL of methylene blue 0.5% was administered to each side using the in-plane technique (ST-HAA). One hour after administration, an experienced anatomist (AF) began dissection. Beginning at C7 and proceeding dorsally to T10, the skin, and fascia were dissected from the midline. Both sides were simultaneously dissected and compared with each other. The trapezius muscle, latissimus dorsi, rhomboids, and erector spinae muscles were dissected and evaluated for the presence of dye. After dissecting the rhomboid muscles away from the midline, the scapula and its superficial and deep muscles were shifted laterally without making a transverse incision in order to analyze the distribution of dye along the intercostal muscles. The intercostal muscles were subsequently dissected in the sagittal plane to assess the presence of dye within the muscles. To evaluate dye distribution, the deep fascia of the trapezius muscle was traced to the scapula. To define the anterior boundary of dye spread, vertical incisions were made at the posterior, middle, and anterior axillary lines.
Case series
Considering the cadaveric findings, the SPSIP block application was chosen for eligible individuals who were likely to benefit from this new block technique. All of these patients were selected from patients who were diagnosed with myofascial pain syndrome (MPS), which causes complaints in the cervical and interscapular region, according to MPS diagnostic criteria, and who had previously been treated with medications, physiotherapy, and neural therapy for this, but could not provide sufficient pain relief.
After informing patients of the risks, benefits, and alternatives of this procedure, all patients provided informed written consent. The block was performed in the prone position under sterile conditions and after administration of 2% lidocaine for local anesthetic infiltration of the skin. Dermatomal evaluation was performed 40 minutes after block administration using the cold test.
Cadaveric examination in one cadaver was performed following approval from Istanbul Medipol University Ethics and Research Committee (Date: 13/04/2022, No: 327). The same committee also approved (Date: 11/05/2022, No: 437) the retrospective evaluation of five patients that underwent SPSIP between 15/04/2022 and 11/05/2022. All patients gave written informed consent for inclusion of their data in this study.
Description of SPSIP block
Although we prefer the prone position for the block, it can also be performed in the sitting position. To lateralize the scapula, the patient is instructed to grip the opposing shoulder with the hand on the side where the block is to be performed or to put the affected arm into adduction and internal rotation. A high frequency (4-12 MHz) linear transducer (B-Braun, Philips, Xperius, USA) is placed at the spinae scapula level in the transverse plane, and the upper medial border of the scapula, the trapezius muscle, Rm, SPSM and the second and third ribs are visualized. The ultrasound probe is rotated 90 degrees in a parasagittal orientation from the posterior aspect of the supraclavicular fossa to identify the first rib. After its identification, the second and third ribs are confirmed. The linear transducer is then rotated so that an oblique visualization is obtained (inferomedial-superolateral) with the upper medial border of the scapula in the sonographic view (Figure
Anatomic study of the SPSIP block
Bilateral SPSIP block was performed to an unembalmed cadaver. There were no surgical incisions or scars in the paraspinal region and thorax/neck/shoulder/upper abdominal regions of the cadaver, nor were there any anatomical deformities on inspection. The cadaver was maintained at room temperature for 12 hours prior to block application. Thirty mL of methylene blue 0.5% was administered to each side using the in-plane technique (ST-HAA). One hour after administration, an experienced anatomist (AF) began dissection. Beginning at C7 and proceeding dorsally to T10, the skin, and fascia were dissected from the midline. Both sides were simultaneously dissected and compared with each other. The trapezius muscle, latissimus dorsi, rhomboids, and erector spinae muscles were dissected and evaluated for the presence of dye. After dissecting the rhomboid muscles away from the midline, the scapula and its superficial and deep muscles were shifted laterally without making a transverse incision in order to analyze the distribution of dye along the intercostal muscles. The intercostal muscles were subsequently dissected in the sagittal plane to assess the presence of dye within the muscles. To evaluate dye distribution, the deep fascia of the trapezius muscle was traced to the scapula. To define the anterior boundary of dye spread, vertical incisions were made at the posterior, middle, and anterior axillary lines.
Case series
Considering the cadaveric findings, the SPSIP block application was chosen for eligible individuals who were likely to benefit from this new block technique. All of these patients were selected from patients who were diagnosed with myofascial pain syndrome (MPS), which causes complaints in the cervical and interscapular region, according to MPS diagnostic criteria, and who had previously been treated with medications, physiotherapy, and neural therapy for this, but could not provide sufficient pain relief.
After informing patients of the risks, benefits, and alternatives of this procedure, all patients provided informed written consent. The block was performed in the prone position under sterile conditions and after administration of 2% lidocaine for local anesthetic infiltration of the skin. Dermatomal evaluation was performed 40 minutes after block administration using the cold test.
Free full text: Click here
