Regional anaesthesia · Truncal
Truncal blocks
Blocks for the back, chest wall and abdominal wall: how to do them, what they cover, and which one to choose for the operation in front of you.
Three pages
Choose a region
Each page covers position, equipment, sonoanatomy, needle approach, volume and concentration, coverage and an exam corner for every block.
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Page 1 · Paraspinal
Back
- Erector spinae plane (ESP)
- Mid-point transverse process to pleura (MTP)
- Thoracic paravertebral: sagittal, transverse and landmark
- Paravertebral space anatomy
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Page 2 · Thorax
Chest wall
- Serratus anterior plane: superficial and deep
- PECS I and PECS II (interpectoral and pectoserratus)
- Parasternal intercostal plane, superficial or deep (deep = transversus thoracis plane), both sides
- Others: clavipectoral
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Page 3 · Abdomen
Abdominal wall
- Transversus abdominis plane (TAP): lateral and subcostal
- Rectus sheath
- Quadratus lumborum (QL)
- Ilioinguinal and iliohypogastric
The quadratus lumborum block is done from the flank or back, but it is used for abdominal surgery, so it sits on the abdominal wall page.
Across all three pages
Which block for which operation
Pick an operation to see the dermatomes to cover, the level for a single-shot injection and the block options.
All operations at a glance
| Operation | Dermatomes to cover | Single-shot level |
|---|
Epidural or plane block?
Points that apply to every operation above.
- An epidural is dense, covers both sides and treats visceral as well as wound pain. Plane blocks treat wound (somatic) pain only, so always add multimodal analgesia.
- The cost of an epidural: hypotension from the sympathetic block, closer monitoring after surgery, and it is ruled out by abnormal clotting or sepsis, which are common in emergencies. A plane block is often still possible.
- Anticoagulants: a paravertebral is a deep block, so follow the same stopping times as for an epidural. Superficial plane blocks at a site you can compress carry less bleeding risk, but still check the drugs and clotting.
- Single shot or catheter: a single shot lasts hours. When the pain lasts days (rib fractures, thoracotomy, open laparotomy, open liver resection), use a catheter.
- Multimodal for everyone unless contraindicated: paracetamol, an NSAID or COX-2 inhibitor, a single dose of dexamethasone where PROSPECT recommends it, and opioids as rescue.
If you choose a thoracic epidural, site it to match the incision. A high thoracic epidural spreads mostly downwards, so site it near the top of the incision; a low thoracic one spreads more upwards, so site it near the middle.
| Insertion level | Use for |
|---|---|
| T2–T4 (upper thoracic) | Thoracic surgery |
| T5–T8 (mid-thoracic) | Upper abdominal surgery |
| T9–T11 (low thoracic) | Lower abdominal surgery |
Thoracic epidurals are not otherwise covered on these pages.
Local anaesthetic systemic toxicity (LAST) has its own page, coming soon. Keep the total dose within the maximum for the patient’s weight, especially with bilateral blocks and catheters.