Purpose of Review. Since the original publication on the quadratus lumborum (QL) block, the technique has evolved significantly during the last decade. This review highlights recent advances in various approaches for administering the QL block and proposes directions for future research. Recent Findings. The QL block findings continue to become clearer. We now understand that the QL block has several approach methods (anterior, lateral, posterior, and intramuscular) and the spread of local anesthetic varies with each approach. In particular, dye injected using the anterior QL block approach spread to the L1, L2, and L3 nerve roots and within psoas major and QL muscles. Summary. The QL block is an effective analgesic tool for abdominal surgery. However, the best approach is yet to be determined. Therefore, the anesthetic spread of the several QL blocks must be made clear.

W e read the recent article by Bashandy and Abbas 1 regarding Pecs I and Pecs II blocks for breast cancer procedures. Many anterior branches of intercostal nerves (Th2-6) dominate the region of the internal mammary area. Intercostal nerves transverse on the space (transversus thoracic muscle plane [TTP]) between the transversus thoracic muscles through the paravertebral space. We will describe a case in which the internal mammary area was blocked by injection of a local anesthetic in the TTP (TTP block).An 86-year-old woman was scheduled to undergo segmental resection at the upper outer region of her left breast. We obtained her consent for publishing her case information. A severe heart dysfunction was present (ejection fraction, 35%; Mod-Simpson method) with inferior wall motion abnormalities and mild aortic, mild mitral, and moderate tricuspid regurgitation. Considering the risks of general anesthesia and the postoperative analgesia, we performed TTP and pectoral nerve II (Pecs II) blocks without general anesthesia. The TTP block injection was administered as follows: 15 mL levobupivacaine (0.15%) was injected between the transversus thoracic muscle and the internal intercostal muscle between the third and fourth left ribs connecting at the sternum (Fig. 1). A Pecs II was performed by administering 10 mL of 0.15% levobupivacaine between the pectoralis major and pectoralis minor at the third left rib and 20 mL of 0.15% levobupivacaine between the pectoralis minor and serratus muscles at the fourth left rib by using a 50Â high-frequency linear probe in the S-Nerve ultrasound system (SonoSite Inc, Bothell, Washington). Ten minutes after applying the blocks, the analgesic range of the intercostal nerve from the left Th2-Th6 could be examined and the breast resection was performed without any intraoperative problems. The patient's postoperative course was uneventful, and she was discharged without the need for analgesics.A combination of TTP block and Pecs II block enabled successful breast resection. A Pecs II block alone cannot be performed for a breast resection because it is not analgesic at the internal mammary area. 1-3 In this case, we discovered that TTP block was able to block the region of internal mammary region, thus a combination of the TTP block and Pecs II block without the general operation may be applicable to precordium surgery. Potential complications of TTP blocks include bleeding, infection, pneumothorax, and local anesthetic intoxication. Therefore, future studies are warranted to review the analgesic effects of the TTP block in the context of complications.The authors declare no conflict of interest. REFERENCES 1. Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial. Reg Anesth Pain Med. 2015;40:68-74.2. Blanco R. The 'pecs block': a novel technique for providing analgesia after breast surgery.

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University Hospital Medical Information Network (UMIN) ID number 000018299.

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Study Design A retrospective study. Purpose The first research on the erector spinae plane (ESP) block was published in 2016. To our knowledge, no cohort studies or randomized controlled trials of the ESP block were performed in 2016 and 2017. Overview of Literature This study retrospectively investigated the efficacy of the ESP block in pain management after lumbar spinal surgery. Methods Patients who underwent lumbar spinal surgery in 2017 were enrolled in the study. Those who underwent secondary surgery with local anesthesia other than the ESP block were excluded. The primary outcome was the Numerical Rating Scale (NRS) pain score at various time points until the morning of postoperative day 2. The secondary outcomes were the amount of intravenous fentanyl administered during the first 24 hours following the surgery and the number of patients with complaints of complications such as nausea and vomiting until the morning of postoperative day 2. Results The data of 41 patients undergoing lumbar spinal surgery were retrospectively analyzed. Of these, 23 received only general anesthesia (G group), whereas the other 18 patients received the ESP block in addition to general anesthesia (E group). The NRS pain scores and the amount of fentanyl administered were lower in the G group than in the E group at all measured time points (all data were less than p <0.05). There was no significant difference in the incidence of complications between the two groups ( p =0.11). Conclusions The ESP block provides effective postoperative analgesic effect for 24 hours in patients undergoing lumbar spinal surgery.