A case of extensive epidural anesthesia with ultrasound-guided thoracolumbar interfascial plane block technique.

Sir,

The ultrasound-guided thoracolumbar interfascial plane (TLIP) block, which can be used for the analgesia for patients undergoing lumbar vertebra surgery, was first reported in 2015.[1] The injection of local anesthetic (LA) into the fascial plane between the multifidus and longissimus muscles at the level of the third lumbar vertebra (L3) can block the adjacent dorsal rami of the spinal nerves. As a new technology, its indications and contraindications have not been clearly defined. In this report, we present one case with extensive epidural anesthesia after the TLIP block.

A 52-year-old male underwent posterior midline approach for lumbar decompression and fusion at L4-S1, and he had done nucleus pulposus extraction in a small incision 10 years before. After identifying the multifidus muscle and the longissimus muscle at approximately the level of L3 using a low-frequency curvilinear ultrasound probe, 0.5% ropivacaine 40 mL in total (20 mL injected into each side) were injected into the fascial plane between the multifidus and longissimus muscles. We did not test the loss of sensation after block application, and the general anesthesia was performed using total intravenous anesthesia (propofol, remifentanil, and rocuronium). Anesthesia was maintained with 50–60 ug/kg/min propofol and 0.10–0.15ug/kg/min remifentanil. About 30 min after the block, persistent hypotension occurred, and norepinephrine 0.02–0.05 ug/kg/min was pumped all through the operation, which lasted for 6 h. After the operation, the administration of intravenous drugs was stopped, and the blood pressure returned to normal. The patient was able to breathe spontaneously, the tidal volume was more than 250 ml, and the tracheal tube was removed. However, the patient presented with myasthenia of limbs and the decreased sensation of the skin below the clavicle. The sensation and motor function of the patient began to recover 10 h after the block. Then, the patient was transferred to the Intensive Care Unit, and his sensation and motor function were fully recovered in 24 h after the block.

Through this case, we think we should not do the conventional TLIP block on the patients after lumbar surgery, because a large dose of LA may enter the spinal canal through the changed anatomical structure and cause extensive epidural anesthesia. The modified approach may be a safe and alternative way for these patients.[2] The LA is injected at the fascial plane between the iliocostalis muscle and longissimus muscle. Compared with conventional TLIP block, the modified TLIP block may have a decreased risk of extensive epidural anesthesia and infection.[3]

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Conflicts of interest

There are no conflicts of interest.