Ultrasound-guided parasternal intercostal nerve block
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KeywordsParasternal intercostal nerve block Transversus thoracic muscle plane block Mastectomy PECS
To the Editor:
Recently, transversus thoracic muscle plane block (TTP block) has been reported to block anterior branches of intercostal nerves . TTP block combined with pectoral nerve II (PECS II) block  provide effective analgesia for the total mastectomy.
However, there are some technically difficult points in the TTP block. Firstly, it is sometimes difficult to detect the transversus thoracic muscle by ultrasound because this muscle is so small. Secondly, we need very good needling techniques to perform the TTP block safely because the pleura and the internal thoracic artery are located in the immediate vicinity of the plane.
We propose a simple and secure technique for blocking multiple anterior branches of intercostal nerves, named the parasternal intercostal nerve block (PSI block). To perform a PSI block, we inject a local anesthetic between the pectoral major muscle and the external intercostal muscle (Supplementary Figure). Because anterior branches of the intercostal nerve penetrate through these two muscles to innervate the internal mammary area, injection of a local anesthetic to this plane could block anterior branches of intercostal nerves.