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Mid-point transverse process to pleura (MTP) block: clarity or confusion?

Last post 05 Dec 2018, 4:09 PM by Ioana Costache. 1 replies.
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  •  27 Nov 2018, 12:00 AM 2696

    Mid-point transverse process to pleura (MTP) block: clarity or confusion?

     Costache et al.  have attempted to standardise the nomenclature of newer posterior truncal blocks in the paraspinal area [1]. We found the schematic illustration in their editorial especially useful. However, we think the schematic representation of the mid-point transverse process to pleura (MTP) block (as described by Costache et al. [2]) is inaccurate, and invite the authors to clarify their injection point.

    In their original description, Costache et al. described the injection point of the MTP block to be at the midpoint between the transverse processes and pleura, just superficial to the superior costotransverse ligament (SCTL). The SCTL consists of the anterior and posterior layers that connects the crest of the rib and the transverse process but it does not extend beyond the lateral edge of the transverse process, where it merges with the internal intercostal membrane [3].

    In the schematic diagram in the editorial, we notice that the SCTL is seen extending beyond the lateral edge of the transverse process and consequently, the injection point is represented lateral to the transverse process. We understand that schematic diagrams are not accurate representations of anatomical structures, but in an area where a small change in needle placements have been described as completely different blocks with different local anaesthetic spread patterns (e.g., retro-laminar block and erector spinae block) [4], we fear that the schema can mislead or confuse the reader.

    M. Narayanan

    Frimley Health NHS Foundation Trust,

    Frimley, UK.

    A. Venkataraju

    Hampshire Hospitals NHS Trust,

    Winchester, UK

    Email: madan.narayanan@gmail.com


    No external funding and no conflicts of interest declared.


    References

    1. Costache I, Pawa A, Abdallah FW. Paravertebral by proxy - time to redefine the paravertebral block. Anaesthesia 2018; 73: 1185-8.
    2. Costache I, de Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, McCartney CJL. The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anaesthesia 2017; 72: 1230-6.
    3. Krediet AC, Moayeri N, van Geffen GJ, Bruhn J, Renes S, Bigeleisen PE, Groen GJ. Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology 2015; 123: 459-74.
    4. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Regional Anesthesia and Pain Medicine 2018; 43: 756-62.
  •  05 Dec 2018, 4:09 PM 2700 in reply to 2696

    Mid-point transverse process to pleura (MTP) block: clarity or confusion? A reply

    We thank Drs Narayanan and Venkataraju for their comments on our editorial [1].

    In no way have we attempted to standardise the nomenclature of newer posterior truncal blocks in the paraspinal area. This would require a much wider discussion and consensus than presented in our editorial. We have merely questioned what truly defines a paravertebral block and introduced the reader to the concept that both these newer blocks and traditional landmark paravertebral blocks may achieve paravertebral block via indirect spread, or by proxy [1].

    We commend the authors on their detailed knowledge of anatomy of the superior costotransverse ligament (SCTL). As they quite correctly state, our schematic diagram is intended to help visualise the concepts discussed in the editorial, rather than to be an accurate anatomical illustration. We disagree that this will confuse the reader, and hope that our description of the MTP block [2] reinforces the needle endpoint and technique of insertion. In or orginal description, we defined the mid-point between the transverse process and the pleura as our endpoint – the SCTL does not need to be visualised during block insertion, which is one of the benefits of the MTP block. In our experience, injection lateral to the transverse process and posterior to the internal intercostal membrane produces a block with similar effect to the MTP and generates pleural displacement. Our schematic merely highlighted the various needle endpoints to the true paravertebral space, rather than acting as a road-map for needle insertion, and we apologise if that was not clear.

    I. Costache

    F. W. Abdallah

    The Ottawa Hospital,

    Ottawa, Canada.

    A. Pawa

    Guy's and St.Thomas' NHS Foundation Trust,

    London, UK.

    Email: icostache@toh.on.ca

     

    No external funding and no conflicts of interest declared.

     

    References

    1. Costache I, Pawa A, Abdallah FW. Paravertebral by proxy - time to redefine the paravertebral block. Anaesthesia 2018; 73: 1185-8.

    2. Costache I, de Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, McCartney CJL. The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anaesthesia 2017; 72: 1230-6.

     

     

     

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