---
title: 'Regional Blocks in Spine Surgery'
type: 'lesson'
url: 'https://doc.social/courses/awake-spine-hybrid-course/regional-blocks-in-spine-surgery'
course: 'Awake Spine Hybrid Course'
course_url: 'https://doc.social/courses/awake-spine-hybrid-course'
position: '3 of 15'
author: 'Alok Sharan, MD MHCDS'
transcript: 'yes'
---

# Regional Blocks in Spine Surgery

## Summary

_This lesson is a recording without a written summary._

## Transcript

3,579 words · 20 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:08] Speaker 1: That was a good question. That was a good presentation on the why. And I, I really thank you for presenting all the, uh, the data around that. It's, it's an evolution. And I think that there's still going to be a lot of debate out there about why. I still get the question of why, and that's OK. Like any kind of new Innovation, there's always going to be questions about why we do what we do. But today, the goal is to sort of move forward and move beyond the why and then I wanted to discuss the how. So
[0:31] Speaker 1: We're really fortunate we have Doctor Michael Bullock uh with us today from Duke, who heads up one of their regional anesthesia programs. Him and his partner, Jeff Gatson have really been pushing the needle, um, a lot in terms of the introduction of regional anesthesia and Spine Surgery. So, um, Mike is going to come up here and then speak about that. For all the um individuals who are connected to us via Zoom.
[0:55] Speaker 1: Um, if you can put your questions into the chat box, we have breakpoints, and then we'll put the questions together and have the speakers come up and answer the questions at that point. OK? So thanks, Mike.
[1:05] Speaker 2: Thank you.
[1:07] Speaker 2: I'm really honored to be here today to be able to speak about regional anesthesia and to be part of this collaborative effort. I think that you're gonna hear the, the theme throughout the day is collaboration. We can't do this without each Other. So, um, let's get to talking a little bit here, uh, about regional anesthesia for wake Spine Surgery.
[1:24] Speaker 2: Um, I think the, the real power is gonna come in the labs and the stimulation later that you guys get to see the, the scanning techniques and figure out how to, how to use the Ultrasound and, uh, be able to put a needle to where it needs to be in order to, uh, get the results that we want. Um, and that's really gonna be important because, uh, as Kinsley spoke about, as anesthesiologists, I don't want to give patients a ton of medication. I would rather give them the minimal amount of what they
[1:49] Speaker 2: Uh, need in order to achieve our goal. So spinal anesthetics are fantastic, uh, as are some of the nerve blocks that I'll be talking about today.
[1:58] Speaker 2: So first off, with disclosures, I do, uh, I'm on speaker's bureau for Pasirra. I do consult for Pasirra Pharmaceuticals, and I will touch on liposomal bupivacaine, uh, in the talk, but I'm not gonna, I'm also talk about some Other, um, modalities.
[2:11] Speaker 2: By the way, this is a beautiful center that they have here and uh we're, we're lucky to be able to, to use this.
[2:17] Speaker 2: Uh, so the objectives today, I'm gonna talk about some of the blocks, and I'm gonna focus on kind of the main use blocks that are, are important for Spine Surgery. Um, we'll talk about some of the data, but more specifically some of the procedures, and then some of the pros and cons, um, advantages and challenges that, that come along with these blocks.
[2:36] Speaker 2: So, um, uh, with the theme of searching PubMed, I looked at PubMed to see what regional anesthesia and Spine Surgery in general kind of, uh, fell in, specifically awake Spine. And you see that the majority of the work has been done over the past 10 years with an increase tremendously last year. Um, some of this stuff back in the 1980s was actually, uh, erroneous search, but, um, all the stuff in the past 10 years is, is focusing on regional anesthesia and awake Spine. Uh, and as Kingsley pointed out, the majority of it is spinal anesthesia.
[3:03] Speaker 2: So, we'll talk about spinal anesthesia just briefly, um, but the, which is a fantastic modality, and I think that, uh, we use it, um, a lot at our main hospital. But we're starting to move to Other modalities at our ambulatory center as well. Touch on the TLL block, uh, briefly, and I'll talk about the erectrospinal plane block, which has been kind of a godsend type of block for anesthesiologists and surgeons in, in general over the past few years, um, because it has so much variety and so many applications. Um,
[3:33] Speaker 2: And it can be used for post-op analgesia for surgical anesthesia for a variety of different, different uh modalities.
[3:40] Speaker 2: So first off, spinal anesthetic. I'm just gonna go into it briefly since Kingsley did such a great job, uh, talking about it a second ago. Um, obviously, needles direct into the intrathecal space and local anesthetic is injected. Uh, I do want to say the nice part about a spinal is that you can actually, uh, uh, vary the length of the spinal. So, um, as, as Kingsley said, 12.5 to 15 mg of isobaric epivacaine. We've been using 45 to 60 mg of methpivacaine if you want to get, uh, a shorter spinal, time-limited, be able to see motors earlier.
[4:08] Speaker 2: Um, or 10 mg of, uh, of buppivacaine, 80 mg of lidocaine, despite the previous reports of transient neurologic symptoms, um, with our multimodal Protocols, I think those are pretty much gone by the wayside.
[4:21] Speaker 2: Uh, so we do use lidocaine as well. So, again, it kind of, you can tailor it to what you're, uh, what you're really looking for in terms of, of time.
[4:29] Speaker 2: Uh, recent 2001 meta-analysis with spinal anesthetic showed that it's just favorable across the board, and this is for, um, discectomies, laminectomies, fusions, but there's decreased length of stay, there's decreased, uh, operative times, anesthesia times, decreased complication rates, VAS scores are less, postoperative analgesics are less, uh, costs are less, and there's less blood loss.
[4:52] Speaker 2: Less blood loss with spinals, it's across the board, not just for Spine. We do it in uh all of our orthopedic procedures for total hips and knees. Uh, it, it's actually a fantastic modality if we can avoid general aesthetic and go to spinals.
[5:06] Speaker 2: So, pretty much any anesthesiologist can perform this. If they can't, I'm, I'm sorry, that's, uh, that's terrible, but, uh, any anesthesiologist can perform this now. I'm not saying it's gonna be easy, especially with Spine patients, it can be difficult, but, uh, anybody can perform. Uh, it's a single shot, and you can use a low volume of local anesthetic, um, versus say a peripheral nerve block. Um.
[5:26] Speaker 2: You can even put a catheter in if you want to put a catheter in, but I guess uh that would be in your surgical field and that wouldn't be the, the most desirable thing to do. Um, some considerations for this is it's only gonna be in the lumbar and sacral regions. Um, there is, uh, a thought of hypotension with dilation of the, excuse me, dilation of the splenic vessels. Um, so that may need to be taken into account depending on the patient's comorbidities.
[5:51] Speaker 2: Uh, the length, uh, again, since it's a single shot, can't be extended in length, um.
[5:56] Speaker 2: You can't, um, you can vary your local anesthetic to, to get a particular length, but you can't prolong it for days, and of course, we wouldn't want to do that. Uh, it's only a surgical anesthetic, you can't use it for Postoperative Pain control, uh, and you have to take into account anticoagulation status, especially with our aging population, patients with increasing comorbidities.
[6:16] Speaker 2: So that's where peripheral nerve blocks come into play. And I think, uh, either in combination with the spinal or solely by themselves, uh, works very well. So, the T-lip block, which uh uh Doctor Sharon um is gonna teach later and um uses frequently, is a Injection of local anesthetic, uh, in between the multifious and longissimus muscles in the lumbar Spine. Um, there's a, a fascial plane in between and you get, um, some of the nerve roots coming out from the dorsal rami.
[6:45] Speaker 2: And get really good dense um coverage on the back.
[6:52] Speaker 2: Uh, it was introduced by, uh,
[6:54] Speaker 2: Uh, William Hand in 2015, um, you see here kind of a schematic of where the needle would Approach, uh, from lateral to medial, in between, uh, multifitous and longissimus.
[7:05] Speaker 2: Um, and it's thought to be able to spare the dorsal rami a little bit more, yet provide the analgesia that's, uh, that's intended.
[7:14] Speaker 2: There's an Ultrasound image over there with the arrow pointing at the fascial plane in between multifous and longissimus.
[7:22] Speaker 2: Needle approaches from lateral to medial. Local anesthetic is injected once that uh plane is entered. You see the local anesthetic on the left side is starting to be injected, and you see on the right side, it's fully injected right there in that little triangle. So you want to see that that spread open like any sort of tissue plane block you wanna see uh a little bit of zippering and opening.
[7:44] Speaker 2: 20 to 30 mLs per side is pretty good. I think with any sort of fascial plane block, 20 to 30 mLs of local anesthetic is, is good. People use varying amounts of local anesthetic in different concentrations. I think if you want to achieve a surgical type block, 0.5% ropivacaine or bupivacaine is gonna be good for, for that, uh, that effect. If it's for Postoperative Pain control, 0.2% ropivocaine.
[8:08] Speaker 2: Uh, it's good, um.
[8:11] Speaker 2: Or Other mixtures. So here's a a video of a a tea lip.
[8:17] Speaker 2: See the needle coming in from the right side.
[8:20] Speaker 2: Entering that plane, first intramuscular Injection there into multitivious.
[8:25] Speaker 2: Needle is withdrawn slowly.
[8:29] Speaker 2: Hydrolocation with saline, and then finally you start to see that spread and spreads down um anterior on the patient, lower believe in that fascial plane between uh longissimus and multifitous.
[8:44] Speaker 2: So the advantages of this block is it's safe. It's a safe block, uh, and it can be extended. Um, I don't know if anybody's ever placed a catheter in there, but liposom bupivacaine could be used, uh, to help extend this block for uh post-operative Pain control.
[8:57] Speaker 2: The considerations of the length of the block can be potentially shorter than the block I'm gonna talk about next, the rector Spine and plane block, um, and this is only going to be applicable in lumbar regions.
[9:09] Speaker 2: So the rectors spinal plane block, like I said, this is the new, the new darling. This is the new thing in regional anesthesia, and the publications are just coming out more and more about uh the rector Spine and plane block. And they're mainly centered around um abdominal and uh chest wall surgeries. However, it's applicable for Spine surgeries as well, and I'll get into that in just a second.
[9:29] Speaker 2: Uh, Essentially with the rector Spine plane block, this is showing a, um, thoracic view where, uh, you have your trapezius rhomboids, and the rector Spine. The needle is brought in a, uh, caudad cephalo to caudad direction, uh, in a semi-transverse, um, orientation. The transverse process is contacted and local anesthetic is injected to spread along the error spinal flame.
[9:55] Speaker 2: This was introduced in 2016 by Ferrero, uh, and, um, a group in Toronto, and they showed that this was done on chronic Pain patients. This was for post-op, uh, or for chronic Pain control, um, in patients that were just refractory to Other, uh, modalities. And they were getting good results, and they showed that this gentleman here that they achieved this sort of spread with their uh erectro spinal plane block with a single shot.
[10:20] Speaker 2: Now,
[10:21] Speaker 2: That's nice. I've never seen that happen before. Uh, I've never gotten spread like that before, and whatever they did, I'd love to know.
[10:30] Speaker 2: What we're seeing is more along these lines, and that's OK. This is actually perfect for Awake spine surgery. What we're seeing is that we're getting a very dense patch where the local anesthetic is injected.
[10:41] Speaker 2: And so if we inject local anesthetic in the lumbar regions, if we're doing lumbar Spine Surgery, we're gonna get a really dense patch of skin and tissue. And we've been doing this with uh Doctor Abdelbar at Duke and in our uh ambulatory center using just a rectorspinal plane block without a spinal uh to achieve surgical anesthesia, and patients have been doing great.
[11:05] Speaker 2: The nice part is it also provides post-operative Pain control as opposed to uh a timelimited spiral.
[11:11] Speaker 2: So for this block can be done in a variety of different ways. Either block the TLlip or the erectros spinal plane block. You can have the patient supine, you can have them upright, or you can have them in decubitus position. Now, decubitus position is very difficult to do unless you're a master with a needle and Ultrasound, so I, I recommend doing it in an upright position.
[11:28] Speaker 2: Hike the bed up a little bit, uh, get the probe on, uh, entry is from, uh, sorry, cephalite to cotad.
[11:39] Speaker 2: So again, a thoracic view here, um, the upper left panel shows, uh, the transverse processes, uh, your trapezius, your rhomboids, and your rector Spine, uh, they're labeled over there on, uh, the upper right panel. The needle comes in from cephala de cauda, and local anesthetic, once the needle has, uh, contacted the transverse process, local anesthetic is injected.
[12:00] Speaker 2: Now, it's fairly easy to do, but when you inject a local anesthetic, what you want to see is you want to see what we call a breathing sign. You want to see, as you inject the tissue planes open, and as you stop injecting, say after 5 mLs, you want to see them close back up a little bit. And what that's doing is it's showing that you're in an interfascial plane and that the local anesthetic is spreading.
[12:19] Speaker 2: If you inject and you see what looks like just a rise, that's generally intramuscular, that's the posterior part of the muscle, and so you wanna readjust your needle in order to get into the proper plane.
[12:30] Speaker 2: Again, 20 to 30 mLs per side is uh is the appropriate amount for these types of blocks.
[12:39] Speaker 2: Talked about 0.5% repivacaine, 0.5% buppivacaine for these uh blocks as well for surgical anesthesia. Um
[12:47] Speaker 2: We tend to use ropivacaine if we're doing it for, for, uh, surgical anesthesia. Uh, like I said, if you wanted to prolong it, you could prolong it with, uh, a catheter or with liposomal buppivacaine, just depending how you want to do that. Uh, we can talk about that in a sec. Um, so this is an erector Spine block, uh, in a lumbar level.
[13:06] Speaker 2: You're gonna see the the needle Approach from cephala to cauder.
[13:11] Speaker 2: It's Approaching from the right side, right side, cephalite.
[13:19] Speaker 2: Most importantly, you see the transverse process on the bottom part of the screen.
[13:27] Speaker 2: I promise you there's a needle coming.
[13:48] Speaker 2: Needle approaching.
[13:50] Speaker 2: Approaching, approaching.
[13:53] Speaker 2: Context transverse process.
[14:00] Speaker 2: Uh, and the video stops there. Now, um, if he was to inject, what you want to see again is you want to see expansion of the, the interfascial plane, um.
[14:09] Speaker 2: And uh you wanna see that that breathing sign that we talked about. Now, if you come directly on top of the transverse process with the bevel up, um, unfortunately, you're gonna get a lot of intramuscular Injection. I think if you come to um areas such as
[14:26] Speaker 2: A little bit um caught out or a little bit cephalad right before or after the transverse process, you can get into that um erector spineal plane better and have a more effective block.
[14:40] Speaker 2: So once this is learned, it's actually a pretty easy block to do, very basic block. Um, most people can do this block, it's got a high safety margin, um, as long as you can see your needle, and I think when you talk about Ultrasound, seeing the needle is important, but it's got a very high safety margin.
[14:56] Speaker 2: It can be performed as a surgical anesthetic or as a post-op analgesic or both. Um, the bony contact is easy even with difficult visualization. Um, our, you know, young residents can do this block fairly effectively, uh, just by following those, uh, procedures. It can be done anywhere on the Spine. Um, people talk about doing a rector Spine and cervical regions. Definitely do it in thoracic regions a lot. Uh, we do it for breast Surgery, we do it for, uh, any sort of chest wall, uh, analgesia, uh, and in lumbar areas.
[15:26] Speaker 2: Like I said, it can be extended. Cathheters have been placed in the rector Spine, um, plane, and we use, um, we have used liposomal bupivacaine before for these applications.
[15:36] Speaker 2: Uh, the considerations, the functional anatomy is still being worked out. There's a lot of debate in our literature as to where the local anesthetic actually goes. Does it get to the paravertebral space? Is this kind of a back door to the paravertebral space? Um, does it just stay at the dorsal ramus?
[15:51] Speaker 2: We don't know yet. The, the majority of the data seems to say that it stays at the dorsal ramus and does not get to the paravertebral space. However, there are some studies, specifically cadaver studies that show that it does get to the paravertebral space, um, but I think in most, um,
[16:05] Speaker 2: Uh, um, studies where they've done actually live uh imaging that it stays, um, away from the paravertebral space.
[16:12] Speaker 2: Um, and it does take a higher volume of local anesthetic to achieve our goal. So if you have a very small patient, you want to take that into consideration.
[16:22] Speaker 2: There are Other block techniques that have been described for Spine Surgery and maybe some that need to be looked at further. Uh, the multifitous cervices block has been described as the ESP block for the, uh, for the neck. Um, I'm not gonna get into that too much cause I, I don't think that's gonna be so applicable at this point. Um, superficial cervical plexus blocks, again, similarly, um, for the neck, it's very difficult to do those. I think you have to have the correct patient to be able to do neck Surgery.
[16:48] Speaker 2: Uh, awake, doing an awake carotid endarterectomy is one of the most difficult procedures to do because patients, um, even though they're numb, don't like to tolerate being awake with a surgeon and, uh, procedures right by their face.
[17:01] Speaker 2: The transverse abdominous plane block has been used as well for Postoperative analgesia.
[17:06] Speaker 2: Um, uh, and I know it's been used in, um, in T lift and X lift procedures as well. It's kind of falling out of favor more for the quadratus lumbarum block, and I think the quadratus lumbarum block actually has a, a role, uh, as well. It's more difficult to do, so I think the error spinal plane is, is gonna be the block that's gonna actually carry us forward, but the quadratus lumbarum block, um, which, uh, the transmuscular version, uh, Injection of local anesthetic between the quadratus lumbarum muscle and the psoas muscle.
[17:35] Speaker 2: Um, gets you really good dense analgesia and surgical anesthesia as well.
[17:42] Speaker 2: So in summary, the, the advantages are that this is a really feasible, easy to, to do, um, modality, all of these things. The spinal anesthetic, adding on a rector Spine if you want to do that for post-op Pain control, or doing the rector Spine blocks, TLlip blocks, um, by themselves for surgical anesthesia. Um, it can be done. It's, it's fairly easy to do. The block techniques are simple, um, and they are effective.
[18:06] Speaker 2: I think the challenges come in with the, with the patients. You have to have the right patient. Patient coming in and asking for Awake spine surgery, perfect candidate. Uh, a patient coming in that's super anxious and doesn't like needles, maybe not the best candidate. Um, somebody with extreme comorbidities, great candidate comorbidities because we're decreasing our amount of local anesthetic, uh, we're decreasing our anesthesia in general, and we're keeping them, um, uh, more hemodynamically stable.
[18:31] Speaker 2: Of course, the procedure and there are block specific considerations to take into account, um, anticoagulation and Other things which not not as applicable with the TLI and the ESP blocks.
[18:43] Speaker 2: The biggest challenges so far though with regional anesthesia and awake Spine is that we do not have any data. We do not have any randomized controlled trials. There are plenty of case reports, but with, with regional anesthesia and Awake spine surgery, PubMed showed 0, so we need to get on that.
[19:00] Speaker 2: Now, despite that,
[19:02] Speaker 2: We're here to teach this to you. This is why we're here.
[19:06] Speaker 2: So I hope we can do this effectively, and we're gonna be able to go to the lab and, and take a look at these uh techniques.
[19:13] Speaker 2: So, talked about spinal, talked about ESPs, talked about TLlips, talked about some of the Other stuff that's not maybe not as applicable, but uh the, the major three right there I think are, are key. So, we'll open up questions later. Um, in the meantime,
[19:27] Speaker 2: If you guys have a QR reader, this is our uh Duke website where we have regional and um anesthesia videos. They're short videos, 5 to 7 minutes, um, and we do have ESPs on there. Um, we have a variety of different, uh, blogs if you're interested in anything else. Um, but the ESP is on there and it's a fantastic resource.
[19:49] Speaker 2: Thank you.

## In this course

- [Previous: Why Awake Spine Surgery?](https://doc.social/llms/courses/awake-spine-hybrid-course/why-awake-spine-surgery.md)
- [Next: Awake TLIF](https://doc.social/llms/courses/awake-spine-hybrid-course/awake-tlif.md)
- [All lessons: Awake Spine Hybrid Course](https://doc.social/llms/courses/awake-spine-hybrid-course.md)