Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.

com/ on July 19, 2021 at American Society for Regional Anesthesia

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Visceral versus somatic pain: an educational review

of anatomy and clinical implications
Andre P Boezaart ‍ ‍,1,2 Cameron R Smith,1 Svetlana Chembrovich,1 Yury Zasimovich,1
Anna Server,3 Gwen Morgan,4 Andre Theron,4 Karin Booysen,5 Miguel A Reina1,6

1
Anesthesiology, University of ABSTRACT often even serves a protective function. If the pain
Florida, Gainesville, Florida, USA Somatic and visceral nociceptive signals travel via (or its treatment) interferes with normal and accept-
2
Lumina Pain Medicine
Collaborative, Surrey, UK different pathways to reach the spinal cord. Additionally, able bodily functions, the pain management is not
3
Anesthesiology, Vall d’Hebron signals regulating visceral blood flow and gastrointestinal appropriate, and physicians must intervene further.
University Hospital, Barcelona, tract (GIT) motility travel via efferent sympathetic nerves. By beginning with a realistic understanding that
Catalunya, Spain To offer optimal pain relief and increase GIT motility and surgery hurts, pain originates from two different
4
Syncerus Care, George, Western pain-­generating sources—the soma and the viscera,
blood flow, we should interfere with all these pathways.
Cape, South Africa
5
Private Anesthesiology Practice, These include the afferent nerves that travel with the and by understanding an individual patient’s needs
Pretoria, Gauteng, South Africa sympathetic trunks, the somatic fibers that innervate the and by evaluating an individual patient’s coping
6
Department of Anesthesiology, abdominal wall and part of the parietal peritoneum, and skills, plans can begin to be made that best manage,
CEU San Pablo University the sympathetic efferent fibers. All somatic and visceral not eliminate, pain and focus on function—in this
Faculty of Medicine, Alcorcon,
Madrid, Spain afferent neural and sympathetic efferent pathways are case, GIT function and recovery by enhancing GIT
effectively blocked by appropriately placed segmental blood flow. Although optimal pain management is
Correspondence to thoracic epidural blocks (TEBs), whereas well-­placed only possible if physicians understand the physi-
Dr Andre P Boezaart, truncal fascial plane blocks evidently do not consistently ology and pathophysiology of pain, there seems to
Anesthesiology, University of block the afferent visceral neural pathways nor the be a never-­ending debate as to which is the best way

(ASRA). Protected by copyright.

Florida, Gainesville, FL 32610, sympathetic efferent nerves. It is generally accepted that to achieve optimal pain control and function.
USA; ​ABoezaart@​anest.​ufl.​edu
it would be beneficial to counter the effects of the stress Regional anesthesia (RA) techniques in the periop-
Received 1 September 2020 response on the GIT, therefore most enhanced recovery erative and acute pain environments are perfectly situ-
Revised 6 January 2021 after surgery protocols involve TEB. The TEB failure rate, ated for managing pain and function and for enhanced
Accepted 7 January 2021 however, can be high, enticing practitioners to resort to recovery after surgery (ERAS). RA is a fast-­adapting
truncal fascial plane blocks. In this educational article, and expanding dynamic discipline forever in a state of
we discuss the differences between visceral and somatic development regarding philosophical approaches. An
pain, their management and the clinical implications of example of this is the substantial growth in popularity
these differences. of various truncal fascial plane blocks (FPBs) presum-
ably because of their ease of performance, presumed
advantageous safety profile and effectiveness in
managing perioperative pain.1 2
From time to time during the development and
INTRODUCTION philosophical approach of RA, however, we must step
Pain relief has been a continual beacon in surgical back and look at the bigger picture from a patient-­
research. We have tried over the years to quan- centered point of view—one of the aims of this
tify the role that visceral nociceptive pain plays in communication.
surgical pain but we have not reached consensus. RA mainly aims to block the transmission of
We also remain in doubt regarding how such pain afferent nociceptive impulses and the sympathetic
affects gastrointestinal tract (GIT) function and efferent nerves, thereby blocking the effects of the
blood flow in recovery after surgery. What cannot stress response on GIT function (ERAS). The focus
be in doubt, though, is that visceral pain after major therefore of this communication is the blocking of
abdominal surgery is substantial and debilitating; the transmission of these impulses. We will also
and there can be no arguments against alleviating discuss briefly the transduction, modulation and
pain or against the idea of improving GIT function perception of somatic pain, while going into more
and blood flow. While managing pain, the focus detail of that of visceral pain and focus on what
should be on function. Having no pain after trauma distinguishes the two. We will furthermore elabo-
or surgery is not realistic for either the patient or rate on the importance of visceral pain and ERAS
the treating physician. The goal is thus not for protocols in the patient’s experience and recovery,
‘zero’ pain but rather to manage pain such that the and how and when modern FPBs and thoracic
© American Society of Regional
Anesthesia & Pain Medicine pain does not interfere with function. A patient epidural blocks (TEBs) contribute to ERAS path-
2021. No commercial re-­use. should function properly and appropriately for his ways and how they could be improved.
See rights and permissions. or her condition (eg, sleep, eat, drink, communi-
Published by BMJ. cate, ambulate, have satisfactory bowel and bladder
To cite: Boezaart AP, function, and so on) while reasonably comfortable Basic anatomy and physiology of somatic and
Smith CR, Chembrovich S, without the pain or its treatment interfering with visceral pain and how they differ
et al. Reg Anesth Pain Med these functions. The pain the patient is continuing Nociception is the term used to describe the
2021;46:629–636. to experience then is not only appropriate, but it body’s ability to detect tissue injury, or impending
Boezaart AP, et al. Reg Anesth Pain Med 2021;46:629–636. doi:10.1136/rapm-2020-102084    629
 Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on July 19, 2021 at American Society for Regional Anesthesia
Education
tissue injury, and comprises four basic processes: transduction, Perception
transmission, modulation and perception.3 Transduction is the In the amygdala, nociceptive information is processed and
conversion of signals from the external or internal environment combined with, among other things, emotional and contex-
to a format the nervous system can interpret. Transmission is tual information.16–19 Likewise, the hippocampus is involved in
the conveyance of that information to brain regions responsible developing avoidance behaviours in response to pain-­induced
for processing and interpreting those signals. Modulation is a and anxiety-­induced hyperalgesia.20 21 The nucleus accumbens
phenomenon that describes how the signal is modified during in the striatum is also a key player in the central processing of
transmission. Perception is subjective awareness and is the result pain.22 In the cortex, it appears that the secondary somatosen-
of the integration of a multitude of signals. Perception is heavily sory cortex is the dominant area for the summation of all the
influenced by attention, expectation, and interpretation in the various inputs and processing areas for pain. It is likely here
context of psychological factors and past experiences.3 that perception truly occurs. In this area, the noxious stimuli are
recognized as painful and intensity is coded, along with other
discriminatory aspects of painful stimuli.23 Connections between
Somatic pain the secondary somatosensory cortex and the limbic system
Transduction are also vitally important for the emotional, motivational and
The primary sensory apparatus for the transduction of noci- memory aspects of pain.
ceptive signals is a network of free nerve endings capable of
responding to signals, including mechanical (pressure), thermal,
chemical and other stimulation.3 Histologically, the sensory Visceral pain
apparatuses are connected to primary afferent fibers and include Compared with pain signals originating from the skin that can be
muscle spindles connected to heavily myelinated fibers for well localized, pain originating from viscera, muscles, and bone
proprioception, free nerve endings, nerve endings on hair folli- is described as dull and diffuse, often poorly localized, and can
cles, Meissner’s corpuscles, and Vater-­Pacini or Pacinian corpus- be referred away from its origin as pathways of nerves inner-
cles.4 Several biologically relevant chemicals directly activate vating somatic and visceral pain differ markedly. Visceral pain is
these nerve endings or sensitize them, prompting easier activa- also perceived as more unpleasant than somatic pain24 and found
tion by other stimuli when they are present.5–11 to be more fear-­evoking than somatic pain.25
It is also becoming increasingly evident that bone pain26 27

(ASRA). Protected by copyright.

and ischemic pain behave more like visceral pain than somatic
Transmission pain.28 29 A placebo-­controlled study by Kumar et al27 demon-
Nociceptive signals are carried to the central nervous system strated a postoperative tramadol-­ sparing and analgesic effect
(CNS) by two types of primary afferent neurons: large and of preoperative stellate ganglion block in patients undergoing
lightly myelinated Aδ-fibers that rapidly carry information about upper limb orthopedic (bone) surgery under general anesthesia.
sharp, localized pain; so-­called fast fibers—and small unmyelin- They concluded that bone pain behaved more like visceral than
ated C-­fibers that slowly carry information about dull, achy, somatic pain. Furthermore, Walker et al,30 Cometa et al,29 and
throbbing diffuse pain known as slow fibers. Both have their cell later, Kucera and Boezaart,28 among others, demonstrated that
bodies in the dorsal root ganglion (DRG). The short process of solid appropriate peripheral nerve blocks did not mask ischemic
these neurons (that have no dendrites) enters the spinal cord and pain associated with the development of acute compartment
synapses with secondary afferent neurons in the dorsal horn.12 syndrome. It is not yet clear how the pH changes of ischemic
pain are transduced and how these impulses are carried. It is
believed (but not yet confirmed by research) that ischemic
Modulation pain28–30 and bone pain26 27 are transmitted via afferent nerve
The primary afferent somatic fibers synapse with second-­order fibers that, like visceral pain, are anatomically associated with
neurons in the dorsal horn of the spinal cord. Here, a series of sympathetic afferent fibers coursing along blood vessels (see
complex interactions take place between excitatory and inhib- author note).
itory neurons. Modulation decreases the transmission of noci- The transduction, modulation and perception of visceral pain
ceptive signals up the spinal cord to the brain. Also, descending are very similar to that of somatic pain, with some minor excep-
inhibitory impulses from the CNS affect the incoming signals.13 tions. Its transmission, however, differs vastly.31 There are also
The dorsal horn has several laminae (Rexed laminae) connected differences in habituation to repeated acute pain stimuli, with
to each other. Lamina II is where the C-­fibers terminate, whereas pain ratings decreasing for somatic pain but remaining unchanged
laminae I and V are where the Aδ-fibers end.13 for visceral pain.25 Recently, the physiology of visceral pain has
An important discovery in the understanding of pain was been reviewed comprehensively by Gebhart and Bielefeldt.31
the revelation that there are substances in the brain that mimic
the pharmacologic activity of plant-­ derived opioids.14 These
‘endogenous opioids’, known as endorphins, enkephalins and Transduction
dynorphins, are found within neurons throughout the central Because the viscera have not been as easily accessible as skin
and peripheral nervous systems. Particularly important is that and other tissue, knowledge regarding visceral transduction was
they are concentrated in the brainstem regions previously slower to advance than that of somatic pain. Early clinicians
known to be involved in ‘spontaneous analgesia’.15 The endog- were unclear if there was any sensory innervation, including
enous opioid system can be activated by a variety of stressors, nociception, from the viscera, but anatomical studies in 1933
including pain such as surgery, but short-­acting nerve blocks showed specialized nerve endings similar to Pacinian corpuscles
(single-­injection blocks) may theoretically inhibit this, poten- in the mesentery and peritoneal surfaces.32 However, it remained
tially leaving the patient vulnerable to severe pain when the puzzling to surgeons why the cutting of viscera did not result in
block wears off. This latter point, however, has not yet been meaningful physiological signs of painful stimuli. Intubation of
proven by research. the GI structures and applying distention, different temperatures
630 Boezaart AP, et al. Reg Anesth Pain Med 2021;46:629–636. doi:10.1136/rapm-2020-102084
 Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on July 19, 2021 at American Society for Regional Anesthesia
Education
and chemicals suggested sensation even without distorting the organs in the chest, abdomen and pelvis, and has an influence
parietal peritoneum.33 on function (motility and blood flow) rather than nociception.
Thinly myelinated Aδ-­ fibers and unmyelinated C-­ fibers, The cell bodies of the spinal afferent nerves that are anatom-
thought to be unencapsulated free nerve endings in target ically associated with the sympathetic division of the autonomic
organs, comprise the majority of visceral afferent fibers.31 There nervous system are situated in the DRG.31 The spinal nerves asso-
are also a small number of Pacinian corpuscles in the abdominal ciated with the sympathetic nerves are different from somatic
mesentery that are associated with Aδ-fibers.34 nerves in that the visceral afferent nerves traverse the prever-
tebral and paravertebral ganglia en route to the spinal cord
Transmission (figure 1). In the paravertebral ganglia, they give off collateral
Transmission pathways differ between the visceral and somatic branches that synapse with the paravertebral ganglionic neurons.
systems. Because the viscera originate embryologically from They also spread rostrally and caudally in the sympathetic trunk,
midline structures, they have bilateral innervation, which has often sending terminal fibers to several spinal segments. In the
incorrectly been assumed to be sympathetic because afferent spinal cord, the visceral afferents terminate in the superficial
fibers are anatomically associated with the sympathetic division laminae of the dorsal horn (laminae I and II). This is also the
of the autonomic nervous system. Similarly, vagal and pelvic termination site of the somatic nociceptive afferent fibers31
nerve afferents have been called parasympathetic because they (figure 1).
are anatomically associated with the parasympathetic division of For example, nociceptive impulses that are generated in the
the autonomic nervous system. The vagus nerve innervates all pancreas travel (figure 1, light blue lines) to the celiac ganglion

(ASRA). Protected by copyright.

Figure 1 Visceral afferent innervation pathways. Nociceptive impulses generated in the liver, gall bladder, pancreas, stomach, small bowel, and
right-­sided colon travel to the celiac ganglion (6) and superior mesenteric ganglion (7) (light blue lines in main figure). From there, the impulses travel
with the greater (2) and lesser splanchnic nerves (3) to traverse the prevertebral and paravertebral ganglia en route to the spinal cord (splanchnic
preganglionic in inlay). They may branch and send off collaterals that synapse in the paravertebral ganglion. From here, nociceptive impulses travel via
the white rami communicans (white line in inlay) to the dorsal root ganglion (DRG in inlay), where their cell bodies are situated, and from there via
the posterior spinal roots to the spinal cord. Nociceptive impulses that are generated in the right-­sided colon travel to the inferior mesenteric ganglion
(12) and via the least splanchnic nerve (4) to the paravertebral ganglion from where they follow the same route as the nerves from the greater and
lesser splanchnic nerves. Nociceptive impulses generated from the pelvic organs travel to the sacral sympathetic trunk (15), and from there to the
spinal cord via the sympathetic ganglia and DRG. Inlay: Paravertebral ganglion (yellow) shows the preganglionic sympathetic nerves (light blue),
which synapse in the intermedial-­lateral nucleus in the lateral horn of the spinal cord and leave the spine via the anterior spinal root to enter the
paravertebral sympathetic ganglion. It also illustrates the incoming splanchnic nerve fibers (white line) that traverse the paravertebral ganglion en
route to the DRG and spinal cord. These nerve fibers may branch and send off collaterals that synapse with prevertebral ganglionic neurons. Drawing
published with the kind permission of Mary K Bryson, who holds the copyright.
Boezaart AP, et al. Reg Anesth Pain Med 2021;46:629–636. doi:10.1136/rapm-2020-102084 631
 Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on July 19, 2021 at American Society for Regional Anesthesia
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(figure 1, number 6). From there, the impulses travel with the and somatic pain as a risk factor for chronic postsurgical pain,
greater splanchnic nerves to traverse the paravertebral ganglion although ‘visceral surgical procedures’ seem to have a relatively
from where nociceptive impulses travel via the white rami low risk of leading to chronic pain when compared with ortho-
communicans (figure 1, white line in inlay) to the DRG and from pedic or gyneco-­obstetric surgery.42
there via the posterior spinal roots to the spinal cord. They may
also branch and send off collaterals that synapse with preverte-
bral ganglionic neurons. Practical implications
Viscera also possess an intrinsic nervous system, called the There are several locations where the nociceptive signal can be
enteric nervous system,35 which controls the basic patterns that blocked.
regulate secretion, motility and blood flow of the organs. It 1. At its origin (transduction) where the pain is generated—typ-
also includes sensory neurons that modulate GI function. The ically with topical agents, local anesthetics directly injected at
enteric nervous system is, generally speaking, poorly under- the site, anti-­inflammatory agents, or by removal of the pain
stood. However, it is believed unlikely to contribute to visceral generator (amputation or removal of an organ, for example,
sensation or pain.35 cholecystectomy).
Peritoneal innervation has recently been reviewed by Struller 2. At the para-­aortic ganglia—typically the celiac ganglion, with
et al.36 Essentially, these authors showed that the parietal peri- local anesthetic agents and neurodestructive agents for pain
toneum has dual somatic and visceral innervation. It receives generated from the pancreas, for example.
somatic innervation from the lower intercostal branches, the 3. At a point along the transmission pathway of the nociceptive
upper lumbar branches, and a dense network of unmyelinated pathway—RA, nerve ablation by, for example, radiofrequen-
and myelinated nerve fibers all over the parietal peritoneum. cy ablation, or neuromodulation, for example, invasive or
The parietal peritoneum also receives fibers associated with non-­invasive peripheral nerve stimulation.
the vagal and spinal afferent nerves. The parietal peritoneum 4. At the spinal cord level (transmission and modulation), for
is exquisitely sensitive to pain, pressure, touch, friction, cutting example, with a subarachnoid block and intrathecal drug de-
and temperature.36 livery systems with, for example, opioids, ziconotide and so
The visceral peritoneum, on the other hand, is not innervated, on, or by interfering with the modulation, for example, with
but the submesothelial tissue is innervated by nerves anatom- DRG or spinal cord stimulation (neuromodulation).
ically associated with the sympathetic nervous system.31 The 5. At the CNS, for example, with opioids and other centrally

(ASRA). Protected by copyright.

visceral peritoneum has no somatic innervation.31 active analgesic agents and general anesthetic agents.
Vagus nerve generally is not thought to be involved with If opioids were universally successful and did not have major
visceral nociception, but mounting evidence suggests that vagal unwanted side effects, the discipline of pain medicine and espe-
input plays a role in chemonociception and contributes to cially acute pain medicine would not exist. When considering
adverse effects such as bloating, nausea and apnea, and to the quality and experience of recovery, not only the degree of anal-
unpleasantness associated with visceral pain.31 The role of RA gesia or pain, but analgesic-­related side effects also play a major
here has not yet been fully established. role.43–45 Therefore, the very reason for the existence of RA is
that opioids are not always successful and have major unwanted,
well-­known adverse effects. To be successful, RA has to have the
Clinical implications correct indications, block the correct nerve, and use the correct
Clinical importance of visceral pain technique and equipment.46 Furthermore, RA is or should be an
When considering what is known about the impact of visceral integral part of any ERAS program,47–49 and opioids should be
pain on postoperative recovery, one appreciates the large inter- avoided as far as possible because they cause GIT immobility and
individual variation in visceral pain intensity.37 38 It is likely that other well-­known unwanted side effects.
the relative importance of visceral and somatic pain is procedure Local and topical anesthesia are ideal for interrupting the
specific. For example, pain after laparoscopic inguinal hernia nociceptive signal at its origin (transduction) if it is feasible
repair is most intense on the day of surgery, with visceral pain and if the site is accessible. At the transmission site of somatic
dominating significantly over superficial pain.39 Pain after lapa- pain impulses, peripheral nerve blocks—either targeted or via
roscopic cholecystectomy, on the other hand, may initially have fascial planes—are ideally suited for blocking the pathway of the
a greater contribution from somatic pain in the immediate post- somatic pain impulse. Based on readily available basic macro-­
operative period most probably because the viscus (gall bladder) anatomical and micro-­anatomical facts and the basic require-
is removed. However, as initial somatic pain subsides over the ments of optimal RA, we have to block all the appropriate nerves
first few postoperative days, the relative importance of visceral that transmit pain signals. Further, we want to avoid blocking
pain increases—presumably because of parietal peritoneal irrita- associated nerves that do not participate in nociceptive trans-
tion and inflammation.37 38 mission but have other important functions such as the phrenic
A further concern with uncontrolled acute perioperative nerves.
visceral pain is the development of chronic pain states. Prolonged Truncal FPBs fall short of consistently and reliably blocking
noxious stimulation of viscera and peripheral sensitization of nociceptive signals from the abdominal and thoracic viscera and
visceral nociceptors can lead to central sensitization.40 In fact, the parietal peritoneum,50–53 and although not yet supported by
recent work suggests that after laparoscopic cholecystectomy, research, most probably also the parietal pleura. Functioning
it is early postoperative visceral pain, as opposed to somatic TEBs, on the other hand, always block the somatic nerves
pain, that is independently associated with the development of from the truncal wall and from and to the viscera, but they are
chronic, unexplained pain.41 In addition, the intensity of acute segmental and have high failure and complication rates.46 De
pain in the first postoperative month may predict the develop- Lara González et al demonstrated that a deep lumbar erector
ment of chronic pain.39 However, these studies are limited by spinae block (ESPB) at L4 always acts on the posterior branches
their small numbers. Large database studies examining chronic of the spinal nerves but seldom spreads to the paravertebral
pain to date have not differentiated between acute visceral space to block the proximal portion of the spinal nerves.54
632 Boezaart AP, et al. Reg Anesth Pain Med 2021;46:629–636. doi:10.1136/rapm-2020-102084
 Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on July 19, 2021 at American Society for Regional Anesthesia
Education
Yang et al showed in a cadaveric study that retrolaminar and Truncal FPBs, specifically ESPB, have been the focus, since
ESPBs were consistently associated with posterior spread of dye their original description in 2016,60 of at least 100 publications,
and with limited spread to the paravertebral space.55 Evidence by far the majority published in 2019 and later. A vast number
that ESPB consistently provides visceral pain relief is lacking. of these were cadaver studies with dye injection. These studies
Helander et al,50 in a recent review article, stated that there is did not reveal consistent staining of the paravertebral space
growing evidence for this but still question whether truncal FPBs that houses the thoracic portion of the sympathetic trunk nor
can consistently and reliably block visceral pain and sympathetic the anterior portions of the spinal nerves. From the anatomical
efferent fibers. All the studies they cited are anecdotal and based cadaver studies, it can be seen that ESPB cannot be expected to
on small case series where the surgery was laparoscopic, and the reliably and consistently block the visceral nociceptive impulses,
viscera were either removed or only slightly disrupted. These the sympathetic efferent impulses, nor the intercostal nerves that
case series only report on pain; none thus far report on GI func- innervate the anterior parts of the trunk.55 61–65
tion. For example, Chin et al51 reported three cases of bariatric A multitude of case reports and small case series discussed
surgery that responded well when ESPB was performed. Another earlier in this communication, and some randomized controlled
study52 claims to have demonstrated the analgesic efficacy of the trials where one truncal FPB is compared with another,66
ESPB in a case series of three patients scheduled for ambulatory have been published, but we are anxiously awaiting defini-
laparoscopic cholecystectomy, while Tulgar et al53 concluded tive work where truncal FPBs are compared in a randomized
that ESPB has an effect on visceral and somatic pain but provide controlled trial with TEB or paravertebral block. Kendall et al
no objective evidence that this is the case. They demonstrated in 2020 performed a meta-­analysis of randomized controlled
that its use in laparoscopic cholecystectomy and other abdom- trials concerned with the effect of ultrasound-­guided ESPB on
inal surgeries can be advantageous. Two of their patients were postsurgical pain.67 The authors compared ESPB to no-­block
operated on using endoscopic retrograde cholangiopancreatog- interventions in patients undergoing surgical procedures and
raphy and laparoscopic cholecystectomy, and one patient was reported on 13 trials that included 679 patients. They found
operated on using laparoscopic cholecystectomy together with moderate-­quality evidence that ESPB is an effective strategy to
the inguinal hernia operation. In all these anecdotal case reports, improve postsurgical analgesia in terms of opioid consumption
laparoscopic surgery was performed, and the visceral organ and 6-­hour postsurgical pain, but it has no effect 12 hours post-
removed. Local anesthetic injection around the laparoscopic operatively. In an ongoing study that has only been published
in abstract format thus far, 72 patients have been enrolled and

(ASRA). Protected by copyright.

portals would most likely have had similar results, and all the
patients received multimodal analgesics that included opioids interim findings show that subjects receiving intravenous lido-
to address the unavoidable CNS perception of pain. No reports caine had similar postoperative opioid consumption, with nearly
published thus far could be found that discuss GI function. These equivalent reported pain scores, compared with those subjects
truncal FPBs can be performed as single-­injection or continuous who received transversus abdominis plane blocks for postop-
blocks, are relatively easy to perform, reportedly have very few erative pain associated with renal transplant.68 No subjects in
unwanted side effects and rare complications. However, infor- either study arm experienced any symptoms of local anesthetic
mation has yet to be seen proving that these blocks reliably and systemic toxicity. Comparing ESPB, intercostal nerve block and
consistently involve the sympathetic efferent nerves and spinal paravertebral block in thoracoscopic surgery, Chen et al found
afferents anatomically associated with the sympathetic nerves. paravertebral block superior to ESPB and intercostal nerve
TEB, on the other hand, is effective in blocking both the block.69 Thus, much more work has to be done before truncal
somatic and visceral pain associated with abdominal and thoracic FPBs, especially ESPB alone or combined with other FPBs, are
surgery. It also effectively and reliably blocks efferent sympa- or should be accepted in the mainstream of our armamentarium
thetic fibers, enhances GI function and GI blood flow, and thus for the management of pain associated with thoracic or abdom-
helps to optimize postoperative recovery as part of ERAS path- inal surgery; even including ESPB alone for thoracic wall surgery
ways. Unfortunately, however, it has a steep learning curve and such as breast surgery. Recent criticism by Marhofer et al in
often fails.56–59 Also, the ileus associated with the stress response an editorial2 echoed by Lönnqvist et al in a Daring Discourse
to the GIT that causes bowel distension is a powerful nociceptive article70 strongly advises caution when adopting truncal FPBs
stimulus.31 prior to full evaluation and better understanding of their scope
and mechanism of action.
On the other hand, TEB has been well established and tradi-
DISCUSSION tionally accepted as the ‘gold standard’ for many decades.
RA is ideally suited to manage acute perioperative pain, as Regrettably, no randomized controlled trial to date has compared
well as to enhance function and functional recovery. To apply truncal FPBs with TEB. A brief search on ​ClinicalTrials.​gov also
successful and optimal RA, we have to block the somatic and revealed no ongoing registered studies to compare these. TEB,
visceral afferent nerves of the correct thoracic segments and in spite of its well-­known effect on somatic and visceral pain
the sympathetic efferent nerves for surgery involving the pari- and its extensively studied positive effect of blocking the stress
etal peritoneum (and perhaps the parietal pleura) and visceral response to the viscera by improving GIT motility, function
organs that are not being removed by surgery. This idealistic and blood flow, is not without problems. Apart from the very
goal may not be completely possible at the current state of our rare but devastating complication of epidural hematoma, TEB
development. is well known to block the sympathetic nervous system. This
The introduction of ultrasound into RA practice ushered in has a positive effect on the stress response through unopposed
many truncal FPBs, most of which have been enthusiastically parasympathetic (vagal) activity, but also subsequently blocks the
received, reported and practiced, especially the ESPB. This body’s response to lowered blood pressure from whatever cause.
enthusiasm was enhanced by the many problems experienced Furthermore, TEB suffers a significant failure rate of between
with epidural block, which had been the traditional ‘gold stan- 15% and 30%56–59 and it also has, unlike truncal FPBs, a steep
dard’ for abdominal and thoracic surgery, and later, the prob- learning curve to proficiency. It also requires a robust acute pain
lems associated with thoracic paravertebral blocks. service to properly manage it in the perioperative period.
Boezaart AP, et al. Reg Anesth Pain Med 2021;46:629–636. doi:10.1136/rapm-2020-102084 633
 Reg Anesth Pain Med: first published as 10.1136/rapm-2020-102084 on 18 June 2021. Downloaded from http://rapm.bmj.com/ on July 19, 2021 at American Society for Regional Anesthesia
Education
The question being debated vigorously is whether research continuous peripheral nerve, plexus blocks or truncal FPBs.
and teaching focus should be concentrated on perfecting Visceral pain, however, provides totally different challenges. To
the TEB and targeted continuous peripheral nerve block, or block pain originating from viscera (and most likely bone and
replacing them with truncal FPBs and perfecting multimodal ischemic tissue), the afferent nerves associated with the sympa-
analgesia, or on some combination of these approaches. More thetic nerves have to be blocked. Furthermore, to obtund the
work and randomized controlled trials are required for truncal stress response and enhance recovery after surgery by improving
FPBs before they are, as Lönnqvist et al70 suggest, renamed RIP GIT motility and blood flow via unopposed parasympathetic
II blocks (Rest in Peace II blocks) to join the RIP I block, the (vagal) activity, the efferent sympathetic nerves have to be
intrapleural block, in the history books. Further sophistication blocked. TEB (and paravertebral block to some extent) achieves
of multimodal analgesia should also be forthcoming. the blockage of the afferent nerves conducting visceral pain
As for TEB the work done to treat the associated decreased impulses and efferent sympathetic impulses as well as afferent
blood pressure as suggested by Tsui et al71 with IntraLipid nerves that conduct somatic pain impulses, but poses more tech-
should be vigorously pursued. Furthermore, the unacceptable nical and management problems than truncal FPBs. The latter
failure rate of TEB should receive ongoing and urgent atten- blocks are not yet established to consistently achieve the same
tion. Promising work was started in the 1990s mainly by Tsui results on visceral pain and the obtunding of the stress response.
et al concerning the placement of a nerve stimulator on a stimu-
lating TEB catheter and observing appropriate motor responses Contributors All authors contributed to the researching, drafting, and final writing
as the catheter is placed. Many authors advanced this idea and and approval of this manuscript.
reported near-­spectacular results. It is therefore surprising that Funding The authors have not declared a specific grant for this research from any
this very promising work has not advanced significantly in the funding agency in the public, commercial or not-­for-­profit sectors.
almost quarter century since its original introduction. Examples Competing interests None declared.
of these results being published are Tsui et al among others.72–79 Patient consent for publication Not required.
Other efforts to simplify the TEB and render it more Provenance and peer review Commissioned; externally peer reviewed.
successful have been waveform analysis mainly by Tran et al and Author note A paper by Wahal et al92 published after acceptance of this
others.80–82 Fluoroscopy also received some extensive attention manuscript demonstrated that ischemic and visceral pain have a shared anatomic
and was found to decrease the failure rate to almost zero,83 84 conduction pathway – namely Aδ and C fibers associated with the sympathetic

(ASRA). Protected by copyright.

but this method is generally judged to be too cumbersome by nerves. With this in mind, ischemic pain should be viewed as a form of visceral pain.
most low-­volume practitioners, and fluoroscopy equipment is ORCID iD
not readily available at all institutions. However, few procedures Andre P Boezaart http://​orcid.​org/​0000-​0002-​1221-​1214
are as cumbersome as having to replace failed TEBs.
Finally, ultrasound guidance has been promoted, but because
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