Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report

Abstract

We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.

Figure 1.

Patient in the left lateral decubitus, with the incision site marked at T6. Marks are placed to identify the spinous processes and 3 cm lateral at the level and on the side of the planned incision.

Figure 2.

Parasagittal ultrasound image of the MTP block at T6-7 level. A, Longitudinal ultrasound scan of the transverse process, the pleura, and the MTP point before injection (X mark). B, Local anesthetic was injected at the midpoint between the posterior border of the transverse process and the pleura, with the arrow showing the needle direction. The area of injection of the local anesthetic is marked with a circle. ESM indicates erector spinae muscle; LA, local anesthetic; MTP, midpoint transverse process to pleura; P, pleura; RM, rhomboid muscle; TM, trapezius muscle; TP, transverse process; X, the injection point of the local anesthetic at the midpoint between the transverse process and the pleura.

Figure 3.

Local anesthetic spread in the paravertebral space after the injection, with flattening of the pleura. The arrows indicate the superior costotransverse ligament. ESM indicates erector spinae muscle; LA, local anesthetic; P, pleura; RM, rhomboid muscle; TM, trapezius muscle; TP, transverse process.