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Concept: Transversus abdominis muscle

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A single-centre, prospective randomised clinical trial investigating the analgesic efficacy of the transversus abdominis plane (TAP) block for adult patients undergoing laparoscopic appendicectomy was conducted.

Concepts: Experimental design, Clinical trial, Randomized controlled trial, Effectiveness, ClinicalTrials.gov, Transversus abdominis muscle, Pharmaceutical industry, Clinical research

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Study Design Cross-sectional repeated measures. Background Rehabilitation of diastasis rectus abdominis (DRA) generally aims to reduce the inter-rectus distance (IRD). We tested the hypothesis that activation of the transversus abdominis (TrA) before a curl-up would reduce IRD narrowing, with less linea alba (LA) distortion/deformation, which may allow better force transfer between sides of the abdominal wall. Objectives This study investigated behavior of the LA and IRD during curl-ups performed naturally and with preactivation of the TrA. Methods Curl-ups were performed by 26 women with DRA and 17 healthy control participants using a natural strategy (automatic curl-up) and with TrA preactivation (TrA curl-up). Ultrasound images were recorded at 2 points above the umbilicus (U point and UX point). Ultrasound measures of IRD and a novel measure of LA distortion (distortion index: average deviation of the LA from the shortest path between the recti) were compared between 3 tasks (rest, automatic curl-up, TrA curl-up), between groups, and between measurement points (analysis of variance). Results Automatic curl-up by women with DRA narrowed the IRD from resting values (mean U-point between-task difference, -1.19 cm; 95% confidence interval [CI]: -1.45, -0.93; P<.001 and mean UX-point between-task difference, -0.51 cm; 95% CI: -0.69, -0.34; P<.001), but LA distortion increased (mean U-point between-task difference, 0.018; 95% CI: 0.0003, 0.041; P = .046 and mean UX-point between-task difference, 0.025; 95% CI: 0.004, 0.045; P = .02). Although TrA curl-up induced no narrowing or less IRD narrowing than automatic curl-up (mean U-point difference between TrA curl-up versus rest, -0.56 cm; 95% CI: -0.82, -0.31; P<.001 and mean UX-point between-task difference, 0.02 cm; 95% CI: -0.22, 0.19; P = .86), LA distortion was less (mean U-point between-task difference, -0.025; 95% CI: -0.037, -0.012; P<.001 and mean UX-point between-task difference, -0.021; 95% CI: -0.038, -0.005; P = .01). Inter-rectus distance and the distortion index did not change from rest or differ between tasks for controls (P≥.55). Conclusion Narrowing of the IRD during automatic curl-up in DRA distorts the LA. The distortion index requires further validation, but findings imply that less IRD narrowing with TrA preactivation might improve force transfer between sides of the abdomen. The clinical implication is that reduced IRD narrowing by TrA contraction, which has been discouraged, may positively impact abdominal mechanics. J Orthop Sports Phys Ther 2016;46(7):580-589. doi:10.2519/jospt.2016.6536.

Concepts: Scientific method, Transversus abdominis muscle, Absolute deviation, Standard deviation, Abdomen, Analysis of variance, Rectus abdominis muscle, Linea alba

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STUDY DESIGN: Descriptive laboratory study. OBJECTIVE: To determine if a proposed clinical test (pressure biofeedback) could detect changes in transversus abdominis (TrA) muscle thickness during an abdominal draw-in maneuver (ADIM). BACKGROUND: Pressure biofeedback may be used to assess abdominal muscle function and TrA activation during an ADIM, but has not been validated. METHODS: Forty-nine individuals (18 male, 31 female) with low back pain who met stabilization classification criteria underwent ultrasound imaging to quantify changes in TrA muscle thickness while a pressure transducer was used to measure pelvic and spine position during an ADIM. Paired t-test was used to compare differences in TrA activation ratio between groups (able or unable to maintain pressure 40 ± 5 mmHg). Groups were further dichotomized based on TrA activation ratio (high > 1.5 or low <1.5). Sensitivity, specificity, and likelihood ratios were calculated. RESULTS: There was not a significant difference (P= .57) in TrA activation ratios (able to maintain pressure 1.59±.28, unable to maintain pressure 1.54±.24) between groups. The pressure biofeedback test had low sensitivity of 0.22 (95% CI: 0.10, 0.42), but moderate specificity of 0.77(95% CI: 0.58, 0.89) and a positive likelihood ratio of 0.94 (95% CI: 0.33, 2.68) and a negative likelihood ratio of 1.02 (95% CI: 0.75, 1.38). CONCLUSIONS: Successful completion on pressure biofeedback does not indicate high TrA activation. Unsuccessful completion on pressure biofeedback maybe more indicative of low TrA activation, but the correlation and likelihood coefficients indicate the pressure test is likely of minimal value to detect TrA activation.J Orthop Sports Phys Ther, Epub 16 November 2012. doi:10.2519/jospt.2013.4397.

Concepts: Spinal disc herniation, Low back pain, Back pain, Transversus abdominis muscle, Acupuncture, Sacroiliac joint, Massage, Likelihood-ratio test

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A subcostal transversus abdominis plane (TAP) phenol injection was performed on a patient with refractory cancer pain due a metastatic involvement of the abdominal wall. A diagnostic block with local anesthetic was performed under ultrasound guidance (USG), resulting in a decrease of 80% and 100% in dynamic and static visual analog scale (VAS) for pain, respectively, for 20 hours. A phenol injection was then performed under USG. The patient reported 70% and 100% reduction in the dynamic and static VAS for pain and had a 50% decrease in the opioid requirement that was maintained for 2 months. TAP blocks offer an interesting tool for either diagnosis or therapeutic purpose in chronic pain management. USG provides an optimal approach to soft-tissue lesions where fluoroscopy techniques are not useful.

Concepts: Vitamin D, Anesthesia, Transversus abdominis muscle, Pain, Chronic pain, Ketamine, Local anesthetic, Iliohypogastric nerve

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BACKGROUND: Although enhanced recovery pathways (ERPs) may permit early recovery and discharge after laparoscopic colorectal surgery (LC), most publications report that the mean hospital stay is 4 and 6 days. This study evaluates the addition of a transversus abdominis plane (TAP) block to the standard ERP. METHODS: In this study, 35 consecutive elective patients received a TAP block at the end of LC. The patients were matched by operation, diagnosis, age, gender, and body mass index (BMI) with 35 recent cases and followed in a prospective institutional review board (IRB)-approved database. All the patients were managed with a standardized ERP. The surgeon placed TAP blocks under laparoscopic guidance that infiltrated 15 ml of 0.5 % Marcaine on both sides of the abdomen. RESULTS: The cases included 8 low pelvic anastomoses, 4 proctectomies with or without an ileal pouch anal anastomosis, 5 sigmoid/left colectomies, 13 ileocolic/right colectomies, 1 total colectomy, and 5 others. The mean age was 59 years for the TAP group and 64.1 years for the control group (p = 0.21). The mean hospital stay was 2 days for the TAP patients and 3 days for the control patients (p = 0.000013). Of the 35 TAP patients, 13 went home on postoperative day (POD) 1 (37 %), 12 on POD 2 (34 %), 8 on POD 3 (23 %), and the remainder on POD 4. Of the 35 control patients, 1 went home on POD 1 (3 %), 10 on POD 2 (29 %), 10 on POD 3 (29 %), 11 on POD 4 (31 %), and the remainder on POD 5 to 8. The TAP patients required fewer narcotics postoperatively than the control patients (respective mean morphine equivalents, 31.08 vs. 85.41; p = 0.01). DISCUSSION: A bilateral TAP block significantly improved the results of an established ERP for patients undergoing LC. Surgeon-administered TAP blocks may be an economical and efficient method for improving the results of LC.

Concepts: Hospital, Surgery, Physician, Body mass index, Transversus abdominis muscle, Diverticulitis, Pseudomembranous colitis, Ileo-anal pouch

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The aim of the study was to assess the effectiveness of ultrasound-guided transversalis fascia plane block (TFP) compared to anterior transversus abdominis plane block (TAP-A) for post-operative analgesia in outpatient unilateral inguinal hernia repair.

Concepts: Inguinal hernia, Transversus abdominis muscle, Iliac crest, Transversalis fascia

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After cesarean delivery, analgesia is often incomplete and a multimodal approach to analgesia is necessary. Transverse abdominal plane (TAP) block has been advocated in this setting, yet no systematic description of the ultrasound anatomy in pregnant women exists in the literature. Therefore, we aimed to describe the sonographical features of relevant structures in pregnant women before and after elective cesarean.

Concepts: Childbirth, Obstetrics, Transversus abdominis muscle, Caesarean section, Transversus abdominis

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Abdominal wall blocks rely on the spread of local anesthetic within musculofascial planes to anesthetize multiple small nerves or plexuses, rather than targeting specific nerve structures. Ultrasonography is primarily responsible for the widespread adoption of techniques including transversus abdominis plane and rectus sheath blocks, as well as the introduction of novel techniques such as quadratus lumborum and transversalis fascia blocks. These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen. This review summarizes the anatomical, sonographic, and technical aspects of the abdominal wall blocks in current use, examining the current evidence for the efficacy and safety of each.

Concepts: Anesthesia, Transversus abdominis muscle, Opioid, Pain, Morphine, Ketamine, Iliac crest, Quadratus lumborum muscle

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Previous research describes an inconsistent relation between temporal changes in transversus abdominis or lumbar multifidus and temporal changes in clinical outcomes. Unfortunately, a relevant systematic review is unavailable. As a result, this systematic review was designed to summarize evidence regarding the association between temporal changes in muscle morphometry and activity in response to treatment and temporal changes in clinical outcomes. Candidate publications were identified from six electronic databases. Fifteen articles were included after scrutinization by two reviewers using the predetermined selection criteria. The methodological quality of these articles was appraised using a standard tool. These methods revealed strong evidence that temporal alterations in transversus abdominis thickness change during contraction (as measured by B-mode or M-mode ultrasound) or feedforward activation of transversus abdominis (assessed via electromyography, tissue Doppler imaging or M-mode ultrasound) were unrelated to temporal changes in LBP/LBP-related disability. There was limited evidence that temporal changes in transversus abdominis lateral sliding or lumbar multifidus endurance were unrelated to temporal changes in LBP intensity. Conflicting evidence was found for the relation between temporal changes in lumbar multifidus morphometry and temporal changes in LBP/LBP-related disability. This review highlights that temporal changes in transversus abdominis features tend to be unrelated to the corresponding LBP/LBP-related disability improvements while the relation between multifidus changes and clinical improvements remains uncertain.

Concepts: Spinal disc herniation, Low back pain, Doppler echocardiography, Echocardiography, Medical ultrasound, Transversus abdominis muscle, Transversus abdominis