Blocking of the anterior cutaneous branch of the intercostal nerve refers to the injection of local anesthetic into the parasternal space to block the anterior cutaneous branch of the intercostal nerve passing through it, so as to obtain thoracic Purpose of anterior wall analgesia. The anterior cutaneous branch of the anterior rami of the intercostal nerve is the terminal branch of the intercostal nerve, and its anterior cutaneous branch can be blocked by blocking the intercostal nerve at any location. When blocking the anterior cutaneous branch of the anterior rami of the intercostal nerve alone, it is often blocked parasternally. Evidence-based medicine evidence recommendation level A1a.
Case introduction and outcome:
patients, Female, 79 years old, hospital number 454868, diagnosed with sternocostal arthritis and osteoporosis
Patients with no obvious incentives in the past 1 year have chest pains Back pain, dull pain, slightly aggravated by rib compression, no chest tightness, wheezing, no cough and expectoration, etc. The symptoms have worsened in the past 1 month. The pain was aggravated, VAS 7-8 points, no skin tingling, no hypersensitivity. The chest CT showed no obvious abnormality, EKG (-), and thoracic X-ray showed no obvious fracture, and the bone mineral density showed T: -4.3. Physical examination: thoracic paravertebral tenderness (-), vertebral percussion pain (-). 4th sternocostal joint tenderness (+). 2019-8-27 Ultrasound-guided right sternocostal joint block + right intercostal nerve anterior cutaneous branch block was performed. Immediately after the operation, the pain of the patient was significantly reduced, the VAS score was 1-2 points, and the activities such as twisting the body were not restricted. Afterwards, intravenous bisphosphonates were given to treat osteoporosis. After 2 weeks, the outpatient follow-up was performed, and the pain did not recur.
1. Anatomy
2-6 intercostal space The nerve travels in the corresponding intercostal space, along with the intercostal blood vessels, and migrates near the sternum to become the anterior cutaneous branch of the intercostal nerve, which penetrates the intercostal and pectoralis major muscles vertically in front of the parasternal internal thoracic artery to the subcutaneous , divided into a thinner medial branch and a thicker lateral branch, which innervate the chest skin on the inner side of the nipple.
2. Ultrasound-guided block of anterior cutaneous branch of intercostal nerve
First, the sternal angle can be identified by the body surface positioning technique. The ultrasound probe can be placed next to the sternal angle to locate the second costal cartilage, and the probe can be moved down to the intercostal space to be blocked.
1) Transverse positioning
Transverse the probe Placed on the lateral side of the sternum with the probe perpendicular to the sternum. Ultrasound can display the sternum, pectoralis major, intercostal muscle, transverse pectoralis muscle, internal thoracic artery and vein, pleura, etc. The space between the pectoralis major and the intercostal muscle is the required block plane.
2) Sagittal positioning
Place the probe on the sternum , the longitudinal axis of the probe is parallel to the long axis of the sternum, the ultrasound image of the sternum can be displayed, move the probe outward until the ultrasound image of the sternum disappears, and the costal cartilage, pectoralis major, intercostal muscle, transverse pectoralis and pleura can be displayed under ultrasound. On the sound image, the space between the pectoralis major and the intercostal muscles is the required block plane.