Journal of Anesthesia

https://doi.org/10.1007/s00540-017-2439-7

SHORT COMMUNICATION

Novel ultrasound‑guided inter‑semispinal plane block: a comparative

pilot study in healthy volunteers
Yuichi Ohgoshi1   · Ryo Nishizakura1 · Yuki Takahashi1 · Keisuke Takeda1 · Hirosuke Nakayama1 ·
Mariko Kawamata1 · Kiyoyasu Kurahashi1,2

Received: 25 August 2017 / Accepted: 15 December 2017

© Japanese Society of Anesthesiologists 2017

Abstract
We previously reported that a novel multifidus cervicis plane (MCP) block could anesthetize the dorsal rami of the cervical
spinal nerves. While MCP sonoanatomy is easily detectable in most patients, it is sometimes difficult to recognize the MCP
injection plane, especially in elderly patients. Thus, we proposed the inter-semispinal plane (ISP) block as an alternative
for the MCP block. The aim of this study was to evaluate the utility of the ISP block by evaluating the area and duration of
anesthesia, compared with that of the MCP block in eight healthy volunteers. Each participant underwent unilateral ultra-
sound-guided MCP block and ISP block. For each block, 20 ml of ropivacaine 0.2% was injected, and the area of anesthesia
was determined using the pinprick test. The anesthetic area ranged from C4 to T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (3/8;
37.5%) in the MCP block, and from C4 to T1 (1/8; 12.5%), T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (1/8; 12.5%) in the ISP
block. The mean (standard deviation) duration of sensory loss following MCP and ISP blocks was 329 (77) min and 349
(70) min, respectively. Thus, the ISP block may be a reliable alternative to the MCP block.

Keywords  Multifidus cervicis plane block · Inter-semispinal plane block · MCP block · ISP block · Analgesia

We have previously reported that the multifidus cervicis
plane (MCP) block is an effective perioperative analgesic
strategy for cervical spine surgery [1]. Since the multifidus
cervicis muscle is the deepest structure of the five-layered
posterior cervical muscles, the MCP sonoanatomy is some-
times difficult to detect, especially in elderly patients, which
may result in ineffective analgesia. To provide successful
perioperative analgesia during cervical spine surgery, some
modifications are warranted in the MCP block. Here, we
proposed the inter-semispinal plane (ISP) block, which is
an anatomy-based modified approach that is performed by
a local anesthetic injection into the fascial plane between
the semispinalis cervicis and semispinalis capitis muscles.
The injection of the ISP block is superficial relative to that
* Yuichi Ohgoshi
ohgoshi22@gmail.com
1
Department of Anesthesiology, International University
of Health and Welfare Mita Hospital, 1‑4‑3 Mita, Minato‑ku,
Tokyo 108‑8329, Japan
2
Department of Anesthesiology and Intensive Care Medicine,
International University of Health and Welfare, School
of Medicine, Narita, Japan
of MCP block, and thus provides a better detection of the
plane even in elderly patients. This modification is based
on a previous anatomical study demonstrating the running
course of the dorsal rami of the cervical spinal nerve [2].
We hypothesized that the injection in both the MCP and ISP
blocks can spread and block the root of the dorsal rami of
the cervical spinal nerves.
In this study, we separately performed unilateral MCP
block and ISP block on each side in eight healthy volun-
teers and compared their analgesic effects. The purpose of
this comparative pilot study was to evaluate the utility of
the ISP block by comparing the area and duration of anes-
thesia compared with the original MCP block. This study
was approved by the institutional ethics committee of the
International University of Health and Welfare (approval
number: 5-16-50), and was registered in the UMIN Clinical
Trial Registry (UMIN 000027180).
We enrolled six men and two women, 20 to 39 years of
age, with an American Society of Anesthesia physical status
I. After receiving a detailed explanation of the procedure
and its potential side effects, the participants provided writ-
ten informed consent for their participation. The eight vol-
unteers showed no significant differences in their baseline

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characteristics, with a mean [standard deviation (SD)] age of
31.8 (4.8) years (range, 20–39 years), the mean (SD) height
of 170.5 (8.4) cm (range, 154–181 cm), and mean (SD)
weight of 61.4 (9.7) kg (range, 43–70 kg) (Table 1). The
volunteers were allocated to two groups using an envelope
method. In group 1 (n = 4), the MCP block was performed
on the right side and the ISP block on the left side. In group
2 (n = 4), the MCP block was performed on left side and
the ISP block on the right side. In addition, the order of the
blocks was randomly assigned in each group. The second
block was carried out on a different day to facilitate a com-
plete recovery from the first block.
After establishment of the peripheral venous line and
standard non-invasive monitoring, each participant was
placed in a prone position, and the five-layered posterior
cervical muscles were identified at the level of C5 with a
6–15-MHz linear probe oriented in the transverse plane
(S-Nerve, Fujifilm Sonosite, Tokyo, Japan) (Fig. 1a). The
fifth cervical spine was counted from the C7 spinous process
with the probe sliding cranially. After aseptic preparation of
the injection area, lidocaine 1% was used to anesthetize the
skin. Under continuous ultrasound guidance, the needle (22-
G, 0.7 mm × 60 mm, Plexufix, B-BRAUN, Tokyo, Japan)
was introduced in-plane through the skin and advanced into
the fascial plane between the multifidus cervicis and semi-
spinalis cervicis muscles for the MCP block (Fig. 1b), or
between the semispinalis cervicis and semispinalis capitis
muscles for the ISP block (Fig. 1c). After negative aspira-
tion for blood, 20 ml of ropivacaine 0.2% was injected for
each block. The area of sensory loss was assessed carefully
20 min after the block using the pinprick test. To assess the
duration of the block, the pinprick test was first repeated at
10-min intervals, and subsequently at 1-min intervals in the
final phase until the effect of the nerve block disappeared.
All injections were performed by one of the two investiga-
tors (Y.O. or R.N.).
None of the volunteers experienced serious complica-
tions, but equilibrium disturbance caused by unilateral anes-
thesia on the posterior cervical region occurred temporarily
in all participants to a greater or lesser extent. The derma-
tomal distribution of the maximum sensory loss obtained
by the pinprick test and the duration of the blocks’ action
indicated numerically (Table 1) or graphically (Fig. 1d, e).
Anesthetic area obtained by the pinprick test was confined
to the region innervated by the dorsal rami of the spinal
nerves. The upper border of the anesthetic area was C4 in
the dermatome in all volunteers, and the third occipital nerve
and the greater occipital nerve were never blocked (Fig. 1d,
e; Table 1). The lower limit of the anesthetic area of the
MCP block was T2 (3/8; 37.5%), T3 (2/8; 25%), or T4 (3/8;
37.5%), while that of the ISP block was T1 (1/8; 12.5%), T2
(3/8; 37.5%), T3 (2/8; 25%), or T4 (1/8; 12.5%). The mean
(SD) duration of sensory loss was 329 (77) min in the MCP
block and 349 (70) min in the ISP block. The region around
the dorsal midline was not colored (Fig. 1d, e) because it
corresponds to the area of the overlapping cutaneous inner-
vation of the bilateral medial branches. Therefore, unilateral
block could not block the area around the dorsal midline;
thus, perioperative analgesia requires bilateral blocks.
In the present study, we found interesting findings related
to the anatomical features. First, both procedures never
blocked the third occipital nerve and the greater occipital
nerve in any of the participants. This finding indicated that
the extension of local anesthetics injected at the C5 level into
the MC- or IS-plane stemmed from a structure at approxi-
mately the C2-3 spinous process level. We hypothesize that
this structure could be a fascia of the semispinalis capitis
muscle or strong fascial connection between the semispinalis
capitis and inlying muscles. The fascia of the semispinalis
capitis muscle may hinder the spread of local anesthetics,
thus disturbing the anesthesia of the third occipital nerve
and the greater occipital nerve existing above the fascia. As

Table 1  Dermatomal distribution of sensory loss obtained by the pin prick test and duration of action of the MCP and ISP blocks
Participants Age (years)/sex Height/weight MCP block ISP block
(cm/kg)
Area (upper–lower) Duration (min) Area (upper–lower) Duration (min)

Group 1
 1 38/M 170/70 C4(C2)-T3 252 C4(C2)-T2 380
 2 34/M 181/67 C4(C3)-T4 364 C4(C3)-T2 351
 3 30/M 175/70 C4(C3)-T2 354 C4(C3)-T1 402
 4 29/F 162/43 C4(C3)-T4 288 C4(C2)-T3 300
Group 2
 5 39/M 170/65 C4(C3)-T4 358 C4(C2)-T4 238
 6 27/M 180/65 C4(C2)-T2 495 C4(C3)-T2 484
 7 27/M 172/64 C4(C3)-T2 245 C4(C3)-T3 327
 8 26/F 154/47 C4(C2)-T3 277 C4(C2)-T4 311

M male, F female

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Fig. 1  a Transducer orientation and needle insertion point of both
blocks. b, c Ultrasonographic transversal view of the MCP block (b)
and ISP block (c) visualized at the level of the fifth cervical vertebra.
The arrowhead indicates the needle. MC multifidus cervicis muscle,
a result, the upper anesthetic area of the MCP or ISP blocks
was confined to the epidermal region above the C2-3 spinous
process (innervated by the medial branch of C4).
Second, both blocks could anesthetize not only the cervi-
cal region but also the thoracic region; the paralyzed area
was extended to the T1–T4 level. This result suggested that
the local anesthetic placed by each block spread along the
semispinalis cervicis muscle into the thoracic region.
SCA semispinalis capitis muscle, SCE semispinalis cervicis muscle,
SP spinous process, SPL splenius capitis muscle, T trapezius muscle.
d, e Area of sensory loss following MCP block (d) and ISP block (e)
in eight volunteers
There are considerable limitations in this study. First, the
age group of the volunteers who were enrolled in the present
study is not representative of the patients’ age group. The
volunteers are young, and as a result the discernibility of
their five-layered posterior cervical muscles in sonography
is easy. In contrast, the patients who undergo cervical spine
surgery are typically older and the visibility of the layers
may be worse, thus limiting the success of the block. In
13

addition, the spread of the local anesthetics may vary with
age due to multiple factors including muscular degeneration
and other anatomical changes. Second, we used 20 ml of
ropivacaine 0.2% for each block in the present study. When
applying MCP or ISP block for perioperative pain relief,
higher concentrations of local anesthetics may be used to
induce positive and long-term effects. These factors may
cause alterations to the area or the duration of MCP and
ISP blocks.
In summary, the fascial plane of the ISP block was more
superficial to that of the MCP block. Furthermore, the ISP
block provided equivalent effects to the MCP block in block-
ing the multiple dorsal rami of the cervical spinal nerves;
therefore, the ISP block may be a reliable alternative to the
MCP block.
Acknowledgements  The authors thank Dr. Yosuke Usui for his con-
tributions to the anatomical understanding of the block. The authors
also thank the staff of the operating room of International University
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Journal of Anesthesia
of Health and Welfare Mita Hospital for their assistance and support
during data collection.
Funding None.
Compliance with ethical standards 
Conflict of interest  All authors declare that they have no competing
interests.
References
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plane block is effective for cervical supine surgery. Can J Anesth.
2017;64:329–30.
2. Zhang J, Tsuzuki N, Hirabayashi S, Saiki K, Fujita K. Surgical
anatomy of the nerves and muscles in the posterior cervical spine:
a guide for avoiding inadvertent nerve injuries during the posterior
approach. Spine (Phila Pa 1976). 2003;28:1379–84.