Ultrasound-Guided Regional Anesthesia and Pain Medicine by Bigeleisen Paul E. & Gofeld Michael & Orebaugh Steven L

Author:Bigeleisen, Paul E. & Gofeld, Michael & Orebaugh, Steven L.
Language: eng
Format: epub
ISBN: 9781451173338
Publisher: LWW
Published: 2015-03-09T04:00:00+00:00

In this chapter, anatomical aspects relevant for ultrasonography of the TPV space are highlighted. Correlations between high-frequency ultrasound scans with high-resolution digitized anatomy are discussed in depth. This enables practitioners of regional anesthesia to appraise the spatial orientation of landmarks for TPV blockade on cross-sectional images that correspond to ultrasound images in clinical practice.

The anatomical images were obtained by slicing blocks of tissue from a human cadaver in transversal sections (interval: 78 µm) using a heavy-duty sledge cryomicrotome. The surface of each section was photographed at high resolution. Thousands of digitized photographs were thus obtained and then digitally stacked on top of each other using self-developed software to reconstruct the three orthogonal planes (sagittal, coronal, and transversal). The technique is described in detail elsewhere.11

Review of thoracic paravertebral (TPV) space anatomy

The TPV space is wedge-shaped.12 Figure 36.1 shows the TPV space in transverse, sagittal, and coronal cross sections at the level of T7. The base of the wedge is formed by the vertebral body, the intervertebral disk, and the intervertebral foramen medially. Laterally, the space tapers and proceeds as the intercostal space. The anterior boundary is formed by the parietal pleura (T2–T9/T10), the diaphragm (T9/T10–T12), and the mediastinum. Posteriorly, the transverse process, the superior costotransverse ligament (SCTL), and the paraspinal musculature confine the TPV space. The SCTL runs from the superior crest of the neck of the rib toward the anterior-inferior surface of the transverse process superior to it. The TPV space is filled with adipose and loose connective tissue and furthermore contains the spinal nerve, the sympathetic trunk, and the intercostal vessels. It communicates with the epidural space medially, the intercostal space laterally, adjacent TPV spaces cranially and caudally, the prevertebral space anteriorly, and with adipose tissue posterior to the SCTL (Figs. 36.2 to 36.7).

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