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Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 111-113

Ultrasound-guided multiple injection costotransverse block in a patient with postradiation therapy recurrent dermatofibrosarcoma protuberans: A technical glitch

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission27-Dec-2021
Date of Decision14-Mar-2022
Date of Acceptance17-Mar-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Raunak Parida
Room No. 5011, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_107_21

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Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive soft-tissue tumor with a high recurrence rate, often requiring multiple surgeries with multiple sessions of radiotherapy that alters the anatomy and makes regional anesthesia challenging in these patients. The multiple injection costotransverse block (MICB) is a type of “paravertebral by proxy” block in which the drug is injected within the thoracic intertransverse tissue complex with spread to the paravertebral space without any epidural spread. Unlike the traditional approach to paravertebral block, which involves piercing the superior costotransverse ligament, the MICB has a shallower needle trajectory making needle visualization easier and the more superficial needle tip location reduces the chances of a pleural puncture and subcostal vessel injury. We present the case of a 51-year-old male with recurrent DFSP in the anterior axillary fold who was posted for tumor debulking. As the sonoanatomy was altered due to multiple previous surgeries and radiotherapy, we chose to perform an ultrasound-guided MICB.

Keywords: Dermatofibrosarcoma protuberans, multiple injection costotransverse block, paravertebral by proxy blocks

How to cite this article:
Bhoi D, Parida R. Ultrasound-guided multiple injection costotransverse block in a patient with postradiation therapy recurrent dermatofibrosarcoma protuberans: A technical glitch. Indian J Pain 2022;36:111-3

How to cite this URL:
Bhoi D, Parida R. Ultrasound-guided multiple injection costotransverse block in a patient with postradiation therapy recurrent dermatofibrosarcoma protuberans: A technical glitch. Indian J Pain [serial online] 2022 [cited 2023 Feb 1];36:111-3. Available from: https://www.indianjpain.org/text.asp?2022/36/2/111/354718

  Introduction Top

The widespread use of thoracic paravertebral block has been limited due to its perceived risk of pleural puncture. Multiple injection costotransverse block (MICB) is a newer “paravertebral by proxy” block that achieves drug spread to the paravertebral space without direct injection into it. MICB has a drug spread comparable to the paravertebral block, but it is away from the pleura and has a shallower needle trajectory making it, in theory, a safer and technically easier alternative for hemithoracic regional anesthesia.[1] This would be of particular value, especially for beginners to ultrasound-guided blocks and for patients with difficult sonoanatomy.

  Case Report Top

A 51-year-old male weighing 60 kg, a known case of dermatofibrosarcoma protuberans (DFSP), presented with recurrence of the swelling in the left anterior axillary fold and was posted for tumor debulking. He had undergone multiple surgeries in the past for the removal of these swellings in the bilateral axilla and chest wall and had also undergone a latissimus dorsi flap reconstruction on the left side. He had received radiotherapy multiple times for the same. He had no other systemic illnesses and had a good effort tolerance. Contrast-enhanced computed tomography of the chest revealed a lobulated mass in the skin and subcutaneous plane of the left anterior chest wall invading the pectoralis major and minor muscles and encasing the axillary vessels completely. We planned an awake MICB followed by general anesthesia. Written informed consent was obtained for the regional block and later for the publication also.

MICB was performed under ultrasound guidance using a high-frequency linear probe (6–13 MHz) in a sitting position at three thoracic (T) levels (T2–T3, T3–4, and T4–T5). Since the patient had received radiotherapy and had undergone a latissimus dorsi flap reconstruction, we did a preblock scout scan for feasibility of the block. Parasagittal probe placement revealed the acoustic shadow created by the transverse process; however, the fibrillar pattern of muscle layers was lacking [Figure 1]a, [Figure 1]b, [Figure 1]c. A 22-gauge echogenic needle was inserted in the plane to the probe in a craniocaudal direction, targeting parallel to the superior costotransverse ligament (SCTL). We found that needle advancement was tough as compared to the previous experience of needling in this area. After reaching the target point of the neck of the rib, 7 ml of 0.375% ropivacaine was deposited at each level [Figure 2]a, [Figure 2]b, [Figure 2]c. After 15 min of the block, general anesthesia was induced using fentanyl (2 mcg/kg), propofol (1.5 mg/kg), and atracurium (0.5 mg/kg), and the airway was secured with a ProSeal laryngeal mask airway size #4. Anesthesia was maintained with isoflurane and nitrous oxide. The surgery was performed in the right lateral position. The surgery was uneventful lasting 150 min. Intraoperatively, the patient received intravenous (IV) paracetamol 1 mg, ketorolac 30 mg, and dexamethasone 8 mg. There was no response to surgical stimulus, and the patient did not require any opioid rescue intraoperatively. The patient was shifted to the recovery room for postoperative monitoring where his reported pain score according to the Numerical Rating Scale (NRS) was 5/10, which was managed with IV morphine 4.5 mg. The NRS was less than 3/10 for the next 24 h and was managed with IV paracetamol 1 g 6th hourly and ketorolac 30 mg 12th hourly. The postoperative course was uneventful, and the patient was discharged from the hospital after 2 days.
Figure 1: (a) The patient had undergone a latissimus dorsi flap reconstruction and had received radiotherapy. (b) Sonoanatomy with parasagittal ultrasound probe placed in thoracic area posteriorly. TP: Transverse process. (c) Sonoanatomy in a normal patient without radiotherapy showing the transverse process and paraspinal muscles distinctly

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Figure 2: (a) Echogenic needle in craniocaudal direction in the plane to the ultrasound probe. (b) Needle path targeting neck of the rib and local anesthetic deposition. TP: Transverse process, *Multiple stars showing local anesthetic spread. SCTL: Superior costotransverse ligament. (c) Infraclavicular incision line at the end of surgery

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  Discussion Top

DFSP is a soft-tissue tumor involving the dermis, subcutaneous fat, and sometimes muscle and fascia presenting as a firm, slow-growing plaque. There is a high chance of local recurrence and a low metastatic potential.[2] Skin changes, dermal atrophy, muscle necrosis, fibrosis, and retraction are all late side effects of radiotherapy. It has been associated with increased Type-III collagen and accumulation of sulfated glycosaminoglycans in the fibrotic muscles, which all lead to disorganized tissue structures and can be picked up as abnormal sonoanatomy.[3] Anticipating these changes and staying away from the pleura as there is a lack of control over fine-needle advancement due to the tough fibrotic tissues, we chose the MICB block. The earlier held notion that the needle-tip placement deep to SCTL is a prerequisite for the successful performance of a paravertebral block may no longer be true as demonstrated by various alternatives such as the erector spinae plane block (ESP), midpoint transverse process to pleura block (MTP), and MICB.[4],[5],[6] These blocks are known as “paravertebral by proxy” blocks as the drug spreads to the paravertebral space without direct injection into the space. Nielsen et al. demonstrated in their cadaveric study that the MICB consistently spread to the paravertebral space (PVS), the ventral rami, communicating rami, and the sympathetic trunk without any epidural spread.[1] We were not sure of the drug spread in the fibrotic tissues, so ESP block was not done. Unlike the MTP block, MICB involves needle insertion parallel to the SCTL, reducing the likely risk of pleural puncture or damage to the subcostal vessels. Needle visualization is better in MICB due to its shallower needle trajectory as compared to MTP block or conventional paravertebral block.[7] MICB, with its superficial needle tip location and lack of epidural spread, is a safer and technically easier alternative to a conventional paravertebral block for such patients with suboptimal ultrasound anatomy and fibrotic tissues.

  Conclusion Top

The MICB offers an alternative to the traditional paravertebral block, especially for novice regional anesthesiologists and for cases with poor sonoanatomy. However, the current evidence is confined to cadaveric studies and case reports such as ours, and high-quality clinical trials are needed to establish their clinical efficacy and provide a comparison with other similar techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nielsen MV, Moriggl B, Hoermann R, Nielsen TD, Bendtsen TF, Børglum J. Are single-injection erector spinae plane block and multiple-injection costotransverse block equivalent to thoracic paravertebral block? Acta Anaesthesiol Scand 2019;63:1231-8.  Back to cited text no. 1
Brooks J, Ramsey ML. Dermatofibrosarcoma Protuberans. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 2
Gillette EL, Mahler PA, Powers BE, Gillette SM, Vujaskovic Z. Late radiation injury to muscle and peripheral nerves. Int J Radiat Oncol Biol Phys 1995;31:1309-18.  Back to cited text no. 3
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: A meta-analysis of randomized controlled trials. Br J Anaesth 2010;105:842-52.  Back to cited text no. 4
Costache I, De Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, et al. The mid-point transverse process to pleura (MTP) block: A new end-point for thoracic paravertebral block. Anaesthesia 2017;72:1230-6.  Back to cited text no. 5
Syal R, Chhabra S, Kumar R, Kamal M. Our experience with the mid-point transverse process to pleura block in two patients undergoing modified radical mastectomy. Indian Journal of Pain 2021;35:68.  Back to cited text no. 6
Luyet C, Eichenberger U, Greif R, Vogt A, Szücs Farkas Z, Moriggl B. Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: An imaging study. Br J Anaesth 2009;102:534-9.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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