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Perioperative Pain Management for Chest Wall Procedures 421

7 Retrolaminar Block

Technique

The retrolaminar block (RLB) was ﬁrst described by Voscopoulous et al. in 2013 [27].

This block is similar to the ESP block as it is still anterior to the erector spinae muscles

but is placed more medial to the transverse process and posterior to the lamina of the

vertebrae. The same patient positioning and ultrasound scanning technique is used

for the RLB as with the ESP block. The lamina of the desired vertebrae is identiﬁed

on ultrasound by locating the deeper and ﬂatter bony structure between the spinous

process and the transverse process. This block targets a similar anesthetic distribution

as the ESP (Fig. 3).

Indications and Recent Research

The RLB has demonstrated an ability to provide effective analgesia for rib fractures

and breast surgery. The utility of the RLB in thoracic surgery and pediatric patients

undergoing cardiac surgery has also been observed.

A double-blinded RCT studying the efﬁcacy of bilateral RLB in pediatric patients

undergoing cardiac surgery with median sternotomy revealed that patients who

received an RLB required less intraoperative fentanyl (6.9 ± 2.1 mcg/kg vs. 9.3

± 1.2 mcg/kg, p < 0.001) and less fentanyl in the ﬁrst 24 hours after extubation (12.5

± 1.4 mcg/kg vs. 16.6 ± 2.8 mcg/kg, p < 0.001). The block group also demonstrated

a shorter time to extubation (2. vs. 6 hours, p < 0.001), longer time to rescue analgesia

after extubation (7 vs. 2 hours, p < 0.001), and lower modiﬁed objective pain scores

at 0, 2, 4, 9, 12, and 16 hours after extubation (p < 0.05) [28].

In a randomized study comparing an RLB with a PVB in adult patients undergoing

uniport VATS for lung cancer, it was found that NRS scores both at rest and while

coughing were lower in patients who received PVB (p < 0.05). Total postoperative

sufentanil consumption was also lower in the PVB group (p < 0.001) while the

incidence of postoperative nausea was higher in the RLB group (8 patients vs. 1

patient, p < 0.05) [ 29].

As the RLB is very similar to the ESP block, Sotome et al. conducted a randomized

study comparing the two in patients undergoing unilateral mastectomy with sentinel

lymph node biopsy. The investigation revealed there was no signiﬁcant difference in

median time to rescue analgesia between patients who received an RLB or ESP block

(4.8 hours. [Range 3.0–24 hours] vs. 8.6 h. [Range 2.7—24 hours], p = 0.8). There

were also no signiﬁcant differences in intraoperative remifentanil requirements (0.09

mcg/kg/min [SD 0.03] vs. 0.1 mcg/kg/min [SD 0.03], p = 0.45) [30].

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422 C. R. Cowart et al.

RLB Summary

The RLB attempts to target the ventral and dorsal rami in addition to the lateral cuta-

neous and small branches of the intercostal nerves. A continuous RLB has demon-

strated effective analgesic effects for rib fractures and breast surgery. It also has been

shown to reduce intraoperative and postoperative opioid requirements, shorten time

to extubation, and lower pain scores in pediatric patients undergoing cardiac surgery

with a medial sternotomy. An RLB may not be as effective as a PVB in reducing pain

scores and opioid requirements for patients undergoing VATS. RLB and ESP blocks

may be comparable in rescue analgesia and intraoperative opioid needs in patients

undergoing breast surgery.

8 Rhomboid Intercostal and Rhomboid Intercostal

Sub-Serratus Blocks (Renamed Rhomboid Intercostal

Plane Block)

Technique

The rhomboid intercostal block (RIB) and combined rhomboid intercostal and sub-

serratus block (RISS) were initially described by Elsharkaway et al. in 2018 and

applied in a case study by Kozanhan et al. in 2019 [31, 32]. These blocks target the

lateral cutaneous branches of the intercostal nerves with potential spread to the ventral

and dorsal rami by performing two injections of local anesthetic into the rhomboid

intercostal and sub-serratus spaces. The block is performed by placing the patient in

the sitting, lateral, or prone position. A linear array ultrasound is typically used in

the parasagittal oblique position and is used to scan in between the spine and scapula

at T5-6 to locate the trapezius and rhomboid muscles, deeper ribs, and pleura. To

perform the RIB, the needle is then advanced in-plane into the fascial plane between

the rhomboid muscle and intercostal muscles. Local anesthetic can then be injected

after conﬁrming spread with saline and conﬁrming negative aspiration for blood.

In patients receiving a RISS, an additional injection is performed in a more caudal

and lateral location between the serratus anterior and external intercostal muscles at

T8-9.

Indications and Recent Research

The RIB and RISS blocks have been previously used for analgesia after lung trans-

plants and rib fractures. Multiple studies have evaluated the efﬁcacy of an RIB block

in isolation, RIB versus RISS, and the role of these blocks compared to PECS II,

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Perioperative Pain Management for Chest Wall Procedures 423

SAP, and ESP blocks. The efﬁcacy of a continuous RISS block for postoperative

analgesia in thoracic surgery has also been evaluated.

A randomized trial comparing the effectiveness of a continuous RIB versus PCA

with IV sufentanil for postoperative analgesia in patients who underwent unilateral

VATS was conducted with 66 patients. Patients who were randomized to the RIB

group had a catheter placed in the fascial plane between the rhomboid and intercostal

muscles at the level of T5 under ultrasound guidance and 0.2% ropivacaine was

administered continuously into the fascial plane. It was found that patients who

received the continuous RIB reported higher global quality recovery scores (QoR-

40) (p < 0.001), lower postoperative NRS scores at rest at 6, 12, and 24 hours (p

< 0.05), and lower postoperative NRS scores while moving at 3, 6, 12, 18, 24, and

36 hours (p < 0.05) compared to patients who received only an opioid PCA [33].

Chen et al. conducted a meta-analysis involving four RCTs, with a total of 216

patients, investigating the analgesia of a RIB in patients undergoing both breast and

thoracoscopic surgery. The study revealed that patients who received the RIB versus

those who received no block reported lower NRS scores at rest at 0–1 and 6–8 hours

after surgery (p < 0.05). There was no signiﬁcant difference in NRS scores at 24 hours

(p = 0.77). Patients in the RIB groups also required less postoperative opioids (MD

−57.52 mcg, 95% CI −106.03 to −9.02, p < 0.05) and had a lower incidence of

PONV (10.30% vs. 34.60%, OR 0.212, 95% CI 0.100 to 0.447) [34].

Studies have also compared the RIB to other fascial plane blocks, including the

PECS II, SAP, and ESP blocks. A prospective RCT compared the analgesic effect of

postoperative RIB versus postoperative PECS II versus a control group in patients

undergoing breast surgery. The study found there was no signiﬁcant difference in

postoperative fentanyl requirements between patients who received a RIB or a PECS

II block, but both block groups required less opioid than the control group (29mcg vs.

20mcg vs. 92.67mcg, p < 0.001). There were also no signiﬁcant differences in VAS

scores in patients who received either block [35]. Another RCT compared ultrasound-

guided RIB, SAP, and ESP blocks for analgesia status post VATS. The study revealed

that patients who had either a RIB or an ESP block required less sufentanil in the

ﬁrst 12 hours after surgery than those who received an SAP block (35.2 ± 2.8 mg vs.

35.4 ± 2.8 mg vs. 43.3 ± 2.7 mg, p < 0.001). Similarly, patients who received either

a RIB or an ESP block consumed less sufentanil in the ﬁrst 12–24 hours after surgery

than those who received an SAP block (p < 0.001), while there were no signiﬁcant

differences between the three groups after 24 hours (p = 0.192). The postoperative

dynamic NRS scores at 6, 12, 18, and 24 hours were also signiﬁcantly lower in both

the RIB and ESP groups compared to the SAP block group (p < 0.05) [36].

While the effectiveness of the RIB has been well documented, additional studies

have evaluated the potential differences in efﬁcacy between RIB and RISS blocks.

Deng et al. conducted an RCT with 90 patients in 2021 comparing the RIB versus

RISS block in patients undergoing VATS. It was found that patients who received a

RISS block required less postoperative sufentanil in the ﬁrst 24 hours compared to

patients who received a RIB alone (51.9 ± 2.2 mcg vs. 58.0 ± 3.4 mcg, p < 0.001).

NRS scores at 12, 18, and 24 hours after surgery were also lower in those who

received the RISS block (p < 0.05). The time to ﬁrst postoperative rescue analgesic

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424 C. R. Cowart et al.

was longer in the RISS group compared to the RIB group (p < 0.001). However,

differences in patient satisfaction scores did not show statistical signiﬁcance between

the two blocks [37].

Since more recent studies have demonstrated that a RISS block is more effec-

tive than a RIB alone, further investigations have focused on evaluating the RISS

block. Kozanhan et al. conducted a randomized trial in 2022 evaluating the analgesic

efﬁcacy of a continuous RISS block placed under direct visualization of a thoracic

surgeon before surgical site closure and compared it to an IV opioid PCA in patients

undergoing VATS. The study demonstrated that NRS scores both at rest and while

coughing were lower in patients who received the continuous RISS compared to

opioid PCA (p < 0.001). Postoperative tramadol consumption in both the ﬁrst 24 and

48 hours was lower in patients who received the RISS block compared to control

(65.0 ± 23.28 mg vs. 174.0 ± 33.78 mg, p < 0.001; 178.0 ± 45.38 mg vs. 309.0

± 67.89 mg. p < 0.001). When lung function in each group was compared to each

patient’s baseline, the RISS group demonstrated higher FEV1 (p = 0.0047) and FVC

(p = 0.04) than those who received an opioid PCA. Patient satisfaction scores were

also higher in the RISS group (p < 0.001) with similar rates of PONV between both

groups [38].

RIB and RISS Summary

The RIB and RISS blocks aim to target both the ventral and dorsal rami of thoracic

intercostal nerves. They have been previously used as regional techniques for lung

transplants and rib fractures. A RIB alone can reduce postoperative pain scores

and opioid requirements in patients undergoing VATS and breast surgery. A RIB

compared to a PECS II has shown similar postoperative opioid requirements and

pain scores in breast surgery. When compared to an ESP, the RIB has demonstrated

similar postoperative opioid requirements and pain s cores, while more effective than

a SAP block. Regarding a RIB or a RISS for VATS, a RISS can result in fewer postop-

erative opioid requirements, rescue analgesics, and lower pain scores. A continuous

RISS block placed under direct visualization of a surgeon for VATS can reduce pain

scores and postoperative opioid requirements while increasing FEV1 and FEVC

when compared to an IV opioid PCA.

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Perioperative Pain Management for Chest Wall Procedures 425

9 Mid-Point Transverse Process to Pleura Block (Renamed

Intertransverse Process Block)

Technique

The mid-point transverse process to pleura (MTP) block was originally described by

Costache in 2017 as an alternative to the PVB [39]. It is performed with the patient

in the sitting, lateral, or prone position. A linear array or curvilinear ultrasound

probe may be used to identify the transverse processes of the vertebrae, using the

same scanning technique as with an ESP block. Local anesthetic is injected midway

between the transverse process of the vertebrae and the pleura after conﬁrming nega-

tive aspiration of blood. By injecting in this exact location, it has been claimed the

local anesthetic will penetrate the superior costotransverse ligament and subsequently

reach the paravertebral space [40].

Indications and Recent Research

The MTP block has been shown to be of beneﬁt to patients in both the surgical

and non-surgical population. The most common indication for an MTP block in a

non-surgical setting is in patients presenting with rib fractures [41]. This approach

is typically taken when there are contraindications to placing a thoracic epidural or

performing a PVB. As such, the MTP block should be considered in patients with

rib fractures on anticoagulation or in whom the aforementioned options have proven

technically difﬁcult to perform or unsuccessful. In the surgical population, MTP

blocks have been proven to provide signiﬁcant levels of post-operative analgesia in

patients undergoing a wide array of chest wall procedures ranging from mastectomies

and lymph node dissections [42] to minimally invasive thoracoscopic procedures

[40]. In addition to ﬁrst describing the MTP block in 2017, Costache and colleagues

were also the ﬁrst to describe using the MTP block for complete surgical anesthesia

[43]. This ability to provide full surgical anesthesia is one of the beneﬁts of the MTP

block that has set it apart from the ESP block in many cases. The ability of the MTP

block to provide more reliable and predictable surgical anesthesia is likely due to a

more consistent amount of paravertebral spread when compared to the ESP block

[43].

Summary

The MTP block has been described as a safe alternative to the PVB in a variety of

patients. The MTP block has shown promising results in patients presenting with a

wide array of chest wall pain ranging from rib fractures [41] to those experiencing

postoperative pain from invasive chest wall surgery [42].

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426 C. R. Cowart et al.

10 Conclusion

Chest wall fascial plane blocks can provide effective analgesia in patients under-

going breast, thoracic, and cardiac surgery. Anesthesiologists have several options,

and depending on the surgery, certain blocks may be more efﬁcacious than others.

Combinations of these blocks have also been shown to be effective in providing

another method for anesthesiologists to plan for patient-speciﬁc analgesia. Fascial

plane blocks have the potential to be included in several enhanced recovery pathways

for surgeries involving the chest wall due to various perioperative beneﬁts.

Key Takeaway Points

1. Fascial plane blocks are a relatively simple, effective means of providing pain

control in several types of chest wall surgery.

2. Surgical anesthesia has been demonstrated with some fascial plane blocks, and

can be used in patients in which general anesthesia is relatively contraindicated.

3. Many fascial plane blocks can be used in combination with one another to improve

their effectiveness and to improve overall block coverage.

4. Fasical plane blocks play a large role in enhanced recovery pathways by

broadening the scope of options related to perioperative analgesia.

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https://t.me/med1917

Perioperative Considerations in Patients

Who Use Cannabis

Ramakrishna Gumidyala, Jacob Loyd, Simrat Kaur, Michael E. Schatman,

and Roland Flores

Abstract Cannabis has become the most commonly used illicit substance under

federal law, with over 40 million people having used it as of 2019 (1)thirty percent

of users potentially having a cannabis use disorder (CUD) (2), and nearly 15%

of patients presenting for non-cardiac surgery having reported cannabis use (6).

Cannabis use appears to be associated with systemic physiologic effects including

the potential for serious cardiopulmonary complications, increased anesthetic and

opioid requirements, and postoperative withdrawal. There may be a role for use of

cannabis products in the perioperative period to help optimize these patients, though

more rigorous studies need to be performed to support its use in this setting. In this

chapter, we summarize recently published papers and society guidelines to inform

readers on the perioperative management of these patients.

Keywords Cannabis

· Marijuana · Perioperative · Pain management

R. Gumidyala (

) · J. Loyd · S. Kaur · R. Flores

Department of Anesthesiology, University of Colorado, Aurora, CO, USA

e-mail: Ramakrishna.Gumidyala@cuanschutz.edu

J. Loyd

e-mail: Jacob.Loyd@cuanschutz.edu

S. Kaur

e-mail: Simrat.Kaur@cuanschutz.edu

R. Flores

e-mail: Roland.Flores@cuanschutz.edu

M. E. Schatman

Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of

Medicine, New York, NY, USA

Department of Population Health—Division of Medical Ethics, NYU Grossman School of

Medicine, New York, NY, USA

M. E. Schatman

e-mail: Michael.Schatman@NYULangone.org

A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,

https://doi.org/10.1007/978-3-031-67648-2_27

429

https://t.me/med1917

430 R. Gumidyala et al.

1 Introduction

With the legalization and decriminalization of cannabis in many states, it has become

the most commonly used illicit substance under federal law, according to the National

Surveyon Drug Use and Health [1]. The Substance Abuse and Mental Health Services

Administration estimates that nearly 43 million people used cannabis at least once

as of 2019 [1]. Around 30 percent of cannabis users have a cannabis use disorder

(CUD) [2], an established diagnosis in the DSM IV and V, with criteria that include:

use for longer periods in larger amounts, inability to cut down use, a strong urge to

use, dependence, and withdrawal reactions on cessation, similar to other substance

use disorders [3, 4]. Concomitant with the rise in the use of cannabis, more patients

are presenting for elective and non-elective surgeries than ever before. It is estimated

that approximately 100 million procedures and surgeries are done each year [5],

and while the true prevalence of cannabis use is difﬁcult to estimate due to under-

reporting for a variety of reasons, it is increasingly likely that healthcare providers

will care for cannabis-using patients during the perioperative period. According to

data from a major healthcare network in the U.S. examining over 200,000 patients

undergoing non-cardiac surgery, the prevalence of patients reporting use increased

from 4.9% in 2008 to 14.3% in 2020 [6]. Perioperative cannabis use has been associ-

ated with higher levels of postoperative healthcare utilization [6] and complications

such as myocardial infarction (MI) [7], stroke [8], thromboembolism, neurologic

and respiratory complications, sepsis, and poorer disposition at the time of discharge

[9]. In addition to these associated complications and a variety of other physiologic

impacts, cannabis products are known to modulate pain by both central [10] and

peripheral mechanisms [11]. Not surprisingly, there is also an increasing body of

literature suggesting that cannabis use may have an impact on pain management

and perioperative opioid use among these patients [12–15]. Recommendations for

the management of patients who use cannabis have been lacking, likely in part due

to its legality, heterogeneity in routes of use, the plurality of types of products,

and varying patient physiology. Only recently [16, 17] have guidelines attempted to

summarize recommendations for the care of these patients. In this chapter, we will

cover the pharmacology of cannabis, the physiologic impacts of cannabis use, and

describe the preoperative, intraoperative, and postoperative considerations for the

management of patients who use cannabis products.

2 Pharmacology

Cannabis is derived from the cannabis sativa plant and is grown worldwide.

The compound consists of two primary cannabinoids, delta-9-tetrahydrocannabinol

(THC) and cannabidiol (CBD). THC and CBD generally make up 70% of the plant

[18], with minor cannabinoids making up the remainder of the product. THC is the

major psychoactive component of cannabis and is the primary constituent driving

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