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array:24 [ "pii" => "S2341192918301471" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.09.002" "estado" => "S300" "fechaPublicacion" => "2018-11-01" "aid" => "957" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2018" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:514-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935618301397" "issn" => "00349356" "doi" => "10.1016/j.redar.2018.07.004" "estado" => "S300" "fechaPublicacion" => "2018-11-01" "aid" => "957" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2018;65:514-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 594 "formatos" => array:2 [ "HTML" => 327 "PDF" => 267 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL BREVE</span>" "titulo" => "Bloqueo del plano del músculo erector espinal: estudio anatómico-cadavérico para determinar su mecanismo de acción" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "514" "paginaFinal" => "519" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Erector spinae plane block: A cadaver study to determine its mechanism of action" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2062 "Ancho" => 1583 "Tamanyo" => 331351 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Torso 3. A) Corte axial en T9 luego de realizar 2 bloqueos ESP en T5 a cada lado del preparado. En ambos lados se observa como el colorante se deposita por debajo de los músculos erectores espinales y por encima de las apófisis transversas. Flecha amarilla: lugar aproximado donde se depositó el colorante. Línea amarilla: dibuja el contorno derecho de la vertebra. Fechas azules sin relleno: colorante depositado entre el músculo erector y la apófisis transversa. B) Imagen ecográfica del bloqueo ESP, previa a la inyección del colorante en el hemitórax derecho: se observa la aguja de bloque sobre el dorso de la apófisis transversa de T5. AT: apófisis transversa; MES: músculo erector espinal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Vidal, H. Giménez, M. Forero, M. Fajardo" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Vidal" ] 1 => array:2 [ "nombre" => "H." "apellidos" => "Giménez" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Forero" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Fajardo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192918301471" "doi" => "10.1016/j.redare.2018.09.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301471?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618301397?idApp=UINPBA00004N" "url" => "/00349356/0000006500000009/v1_201810280608/S0034935618301397/v1_201810280608/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192918301501" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.09.004" "estado" => "S300" "fechaPublicacion" => "2018-11-01" "aid" => "946" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:520-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 10 "formatos" => array:2 [ "HTML" => 6 "PDF" => 4 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Sedations in diagnostic and/or therapeutic procedures: Quality and safety recommendations" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "520" "paginaFinal" => "524" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sedaciones en procedimientos diagnósticos y/o terapéuticos: recomendaciones de calidad y seguridad" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Cabadas Avion, J.M. Rabanal Llevot, M.À. Gil de Bernabé, E. Guasch Arévalo, C. Aldecoa Álvarez-Santullano, M. Echevarría Moreno" "autores" => array:6 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Cabadas Avion" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Rabanal Llevot" ] 2 => array:2 [ "nombre" => "M.À." "apellidos" => "Gil de Bernabé" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Guasch Arévalo" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Aldecoa Álvarez-Santullano" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Echevarría Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935618301130" "doi" => "10.1016/j.redar.2018.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935618301130?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301501?idApp=UINPBA00004N" "url" => "/23411929/0000006500000009/v1_201811070606/S2341192918301501/v1_201811070606/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192918301495" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.09.003" "estado" => "S300" "fechaPublicacion" => "2018-11-01" "aid" => "951" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:504-13" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Prospective analysis of the complications, efficacy, and satisfaction level on the sedation performed by anaesthetists in gastrointestinal endoscopy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "504" "paginaFinal" => "513" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis prospectivo de las complicaciones, eficacia y grado de satisfacción en la sedación realizada por anestesiólogos en endoscopia digestiva" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2340 "Ancho" => 3167 "Tamanyo" => 847663 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Computerised anaesthesia report for GI endoscopy.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Cabadas Avion, M. Ojea Cendón, M.S. Leal Ruiloba, M.A. Baluja González, J. Sobrino Ramallo, J. Álvarez Escudero" "autores" => array:6 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Cabadas Avion" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ojea Cendón" ] 2 => array:2 [ "nombre" => "M.S." "apellidos" => "Leal Ruiloba" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Baluja González" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Sobrino Ramallo" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Álvarez Escudero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493561830118X" "doi" => "10.1016/j.redar.2018.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561830118X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301495?idApp=UINPBA00004N" "url" => "/23411929/0000006500000009/v1_201811070606/S2341192918301495/v1_201811070606/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief Report</span>" "titulo" => "Erector spinae plane block: A cadaver study to determine its mechanism of action" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "514" "paginaFinal" => "519" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Vidal, H. Giménez, M. Forero, M. Fajardo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Vidal" "email" => array:1 [ 0 => "vidalezequiel@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "H." "apellidos" => "Giménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Forero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Fajardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Durand, Ciudad de Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Anestesia, McMaster University, Hamilton, Ontario, Canada" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo del plano del músculo erector espinal: estudio anatómico-cadavérico para determinar su mecanismo de acción" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2062 "Ancho" => 1583 "Tamanyo" => 329485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Torso 3. (A) Axial slice at T9 after performing 2 ESP blocks in T5 in each hemithorax. The dye is deposited under the erector spinae muscles and above the transverse process in both hemithoraces. Yellow arrow: approximate site where the dye was deposited. Yellow line: outline of the right vertebra. Blue arrows: dye deposited between the erector muscle and the transverse process. (B) Ultrasound image of the ESP block, prior to injecting the dye in the right hemithorax: the needle is observed posterior to the transverse process of T5. AT: transverse process; MES: erector spinae muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The erector spinae plane (ESP) block, recently described by Forero et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> has sparked considerable interest among anaesthesiologists due to its ease of execution and high success rate, which is comparable to other more central anaesthetic techniques, such as epidural and/or paravertebral block. It has proven especially useful in thoracic and upper abdominal surgery. Various studies have demonstrated its usefulness and versatility in the treatment of pain in various acute and chronic diseases.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1–10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Clinical observations in patients, imaging studies, and some anatomical investigations all suggest that analgesia is produced by the passage of the local anaesthetic (LA) from the ESP to the anterior paravertebral space (PVS),<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2,8,11,12</span></a> although this hypothesis has not been proven.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Primary objectives</span><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this cadaver study was to demonstrate the mechanism of action of the ESP block by injecting a volume of dye into the anterior paravertebral compartment at the level of the erector spinae muscle and staining the structures where the LA is deposited.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Secondary objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">To describe a channel through which the LA penetrates bone and muscular structures.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Four adult human torsos subjected to cryopreservation were obtained from the Centre for Simulator Training and Surgical Anatomy (CEAQUS). Written consent was obtained to use and publish the images and results for research and educational purposes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">All specimens were prepared by performing different dissections; the anterior rib cage, the sternum and the clavicles were removed, together with all chest and abdominal organs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Following this, the research team performed an incision from the posterior axillary line to expose the remaining thoracic ribs and spinal column in order to maximize anterior vision of the PVS and improve the manipulation of the specimens.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The dye was injected at sites where the parietal pleura was intact, theorizing that this would ensure an effective blockade and distribution of the injectate in the anterior PVS. This ruled out the possibility of performing additional blocks, and compelled the team to inject the dye in the same hemithorax to maximize the results obtained.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The dye used in all cases was a preparation of 50<span class="elsevierStyleHsp" style=""></span>mg of methylene blue diluted in 500<span class="elsevierStyleHsp" style=""></span>ml saline 0.9% (0.01%). For ultrasound-guided blocks, an M-Turbo<span class="elsevierStyleSup">®</span> ultrasound scanner (SonoSite, Bothell, WA, USA) with an L38 linear transducer and 50<span class="elsevierStyleHsp" style=""></span>mm echogenic peripheral block needles (Stimuplex<span class="elsevierStyleSup">®</span> 360, B. Braun, Melsungen, Germany) were used.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the characteristics of one of the specimens (torso 1), a left parasagittal section was performed at the height of the transverse processes (TP) to observe and record the spread of the dye in the PVS. These data were excluded from the study, but contributed to our understanding of the block (Appendix available on the web, Video 1).</p><p id="par0055" class="elsevierStylePara elsevierViewall">To inject the dye, the linear probe was placed on the back of the spine in a parasagittal plane to the midline, visualizing the TP and the spinal erector muscles in the same window. Once both structures were visualized, the echogenic needle was inserted in a caudal to cranial direction until it contacted the upper edge of the TP, deep to the erector muscles. At this point, small boluses of dye were injected to separate the plane between the erector spinae muscles and the TP, while avoiding intramuscular or superficial injection of the dye. Once the desired image was obtained, a single 20<span class="elsevierStyleHsp" style=""></span>ml shot of methylene blue solution was gradually injected. Still images and videos were recorded of the injections to show the spread of the solution to the plane, and to facilitate subsequent analysis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In torso 2, the procedure was videoed from the anterior surface to record the effect of the nerve block and the anterior–posterior spread of the dye to the structures in real time (Appendix available on the web, Video 2).</p><p id="par0065" class="elsevierStylePara elsevierViewall">To sum up, the nerve blocks were performed as follows:</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Torso 1:</span> ESP block at the level of T5 in the left hemithorax.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Torso 2:</span> 3 ESP blocks; 2 in the right hemithorax, at the level of T4 and T10, and 1 in the left, at the level of T4.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Torso 3:</span> 2 ESP blocks; 1 in each hemithorax, at the level of T5.</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Torso 4:</span> 3 ESP blocks; 2 in the right hemithorax, at the level of T4 and T10, and 1 in the left, at the level of T10.</p><p id="par0090" class="elsevierStylePara elsevierViewall">After the performance of each ESP block in each specimen, the stained area was measured and the number of intercostal spaces (ICS) reached were counted (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Then, the parietal pleura was dissected, from medial to lateral, and the number of ICSs reached was counted again, noting the presence of dye in the PSV and any other structure before moving on to the next block (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). This process was always carried out within 10–20<span class="elsevierStyleHsp" style=""></span>min of injecting the dye, before it could become diluted or lost in the surrounding tissue.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 9 ESP injections, methylene blue was present in 100% of the PSV at the level where the ESP block was performed in the dorsal region. The caudal and cephalad spread of the dye to the adjacent PSV varied (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Dye was also observed to have spread medial and lateral to the puncture site, between the ICSs and into the sympathetic paravertebral chain. A large amount of methylene blue adhered to the parietal pleura, and was removed when this structure was dissected, once the stained ICSs had been recorded (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The number of ICSs covered by the block varied, ranging from 7 to 3, with an average of 4.6. In specimens where 2 punctures were made in the same hemithorax, no overlap of the dyed areas was observed (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Prior to extraction of the pleura, less dye was found in the PVS and ICS compared to that found under the paraspinal muscles, in the plane where the dye was injected (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). During deeper dissections, no dye was found in the invertebral foramen or spinal canal, and no “opening, door or canal” that would allow the posterior to anterior passage of the dye through the bone and muscle planes were observed.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Although the presence of dye in the PVS after ESP injection does not clarify the anatomical pathway followed by the dye, it does shed light on the mechanism of action of the ESP block. Interestingly, the block covered more ICSs (4.6 on average) than would be expected from the volume of injectate. This could be due to the greater number of planes that the dye is required to penetrate to reach the anterior PVS, and could explain the technique's analgesic but non-anaesthetic effect in the rib cage, as described in the different clinical studies published.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,5,6,8,13,14</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition, it is logical to assume that the LA acts through “paravertebralization” of the blockade, which thus reaches the anterior and posterior branches of the spinal nerves and the communicating branches of the nerves of the sympathetic chain. To the best of our knowledge, the site of action of the LA on the ventral rami of the spinal nerves, viewed in real time from the anterior chest wall, has not hitherto been reliably demonstrated using real cadaver models. The videos that show how the dye passes from posterior to anterior of the cadaver model clarifies our findings (Appendix available on the web, Videos 1 and 2).</p><p id="par0125" class="elsevierStylePara elsevierViewall">This study has some limitations, including the small sample size, the performance of more than 1 block per hemithorax, and the use of cryopreserved instead of fresh cadavers that were prepared using different dissections. Another point of interest is that the concentration of methylene blue used was about 10 times lower than that used in most published studies.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,11,15–18</span></a> This was done to avoid dyeing the tissues to the extent that we would be unable to establish which structures were involved and where the dye emerged. The use of dye to demonstrate the clinical effect of local anaesthetics is controversial, but has helped explain the physical mechanism of action of the ESP block.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Certain <span class="elsevierStyleItalic">in vivo</span> factors, such as muscle tone, tissue elasticity, positive pressure of the viscera in the abdomen or the negative pressure in the thorax, could increase the dermatomal spread of the LA or the flow of LA to the PVS, as clinical evidence has shown. Other contributing factors could include the technique itself, the puncture site, the placement of catheters in the erector spinae plane, or whether the needle is inserted in a cranio-caudal direction or <span class="elsevierStyleItalic">vice versa</span>.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,7,8,19</span></a> The site of posterior–anterior infiltration of the LA has not yet been clarified. One hypothesis suggests that it traverses these planes through canals left by the dorsal branches of the spinal nerves that penetrate the erector spinae muscle,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,12,13,15,18</span></a> or through areas of dehiscence in the anterior fascia of the erector spinae muscles and paravertebral ligaments,<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,11,18,20</span></a> or a combination of both.</p><p id="par0135" class="elsevierStylePara elsevierViewall">More cadaver studies are needed to validate the hypotheses presented here, and to confirm whether the LA travels to the PVS through “canals”, or whether it infiltrates a permeable area between the erector spinae muscles and the TP due to positive or negative pressure, from where it emerges from the posterior spinal column and travels anterior to the thoracic PVS.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">The ESP block is a simple, low-risk, high-effect ultrasound-guided technique for managing acute and chronic pain. Analgesia is produced by the LA travelling from the muscle planes posterior to the TP, where the erector muscles are inserted, towards the PVS and the ICSs where it is deposited. The ESP block covers a wide area, ranging from 3 to 7 ICSs, and in some cases it can extend as far as the sympathetic paravertebral chain.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The mechanism by which the LA manages to penetrate the muscular and bone planes to reach the paravertebral region has not yet been clarified.</p><p id="par0150" class="elsevierStylePara elsevierViewall">More clinical and cadaver studies are needed to explain the mechanism of action of this promising regional nerve block technique.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1103952" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1044194" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1103953" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1044193" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Primary objectives" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Secondary objectives" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Materials and methods" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-04" "fechaAceptado" => "2018-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1044194" "palabras" => array:3 [ 0 => "Erector spinae plane block" 1 => "Ultrasound guided regional anaesthesia" 2 => "Cadaver study" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1044193" "palabras" => array:3 [ 0 => "Bloqueo del plano del músculo erector espinal" 1 => "Anestesia regional ecoguiada" 2 => "Estudio cadavérico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The erector spinae plane (ESP) block is a novel technique for the treatment of acute and chronic pain. Its mechanism and site of action has not yet been explained properly.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In order to explain the mechanism of action of the ESP block, injections were performed with methylene blue to simulate the local anaesthetics and to determine its distribution from the anterior side of the thorax. To find an aperture or channel through which the local anaesthetic passes from posterior to anterior through the muscular and bone structures.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Four spinal columns of fresh cryopreserved corpses were used. A total of 9 ultrasound-guided ESP blocks were performed in different regions of the specimens using 20<span class="elsevierStyleHsp" style=""></span>ml of 0.01% methylene blue per block. The distribution of the dye was observed from the anterior side of the thorax, measuring the amount of intercostal spaces stained, before and after the removal of the parietal pleura, and the structures in which the stain was found were recorded.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In all blocks of the ESP, dye was found in the paravertebral space, intercostal spaces, and in some cases in the prevertebral chain. The blocks had a mean of 4.6 intercostal spaces stained, with a maximum of 7 and a minimum of 3. The intensity of the dye was greater on the side of the injection, dorsal to the column, than that found in the ventral part below of the pleura. It was not possible to verify a clear channel through which the dye diffuses towards the previous zone.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">From the data collected in this study, it can be deduced that the blockade of the ESP has a mechanism of anaesthetic action similar to paravertebral blocks. The site from which the anaesthetic would cross from the posterior plane of the spine to the anterior region of the thorax was not clear, and should be investigated in future works.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El bloqueo del plano del músculo erector (ESP) es una técnica novedosa para el tratamiento del dolor agudo y crónico. Su lugar y mecanismo de acción todavía no han sido explicados.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Determinar el mecanismo de acción del anestésico local en el bloqueo ESP a través de la inyección del azul de metileno, describiendo su distribución desde la cara anterior del tórax. Hallar o determinar un paso o canal por el cual el anestésico atraviesa las estructuras musculares y óseas de posterior a anterior.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiales y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se utilizaron 4 columnas de cadáveres frescos criopreservados. Se realizaron 9 bloqueos ESP ecoguiados en diferentes regiones de los especímenes con 20<span class="elsevierStyleHsp" style=""></span>ml de azul de metileno al 0,01% por bloqueo. Se observó la distribución del colorante desde la cara anterior de tórax, midiendo la cantidad de espacios intercostales teñidos, antes y después de la extracción de la pleura parietal, y se registraron las estructuras en que se constató tintura.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En todos los bloqueos ESP se encontró colorante en el espacio paravertebral, los espacios intercostales y en algunos casos en la cadena prevertebral. Los bloqueos tuvieron un promedio de 4,6 espacios intercostales teñidos, con un máximo de 7 y un mínimo de 3. La intensidad del colorante fue mayor del lado de la inyección, dorsal a la columna, que el hallado en la parte ventral por debajo de la pleura. No se logró constatar un mecanismo claro por el que el colorante difundiera hacia el la zona anterior.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Por los datos recogidos en este trabajo se puede deducir que el bloqueo ESP tiene un mecanismo de acción anestésico similar a los bloqueos paravertebrales. El sitio por el cual el anestésico atravesaría desde el plano posterior de la columna a la región anterior del tórax no fue aclarado y debería ser investigado en futuros trabajos.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vidal E, Giménez H, Forero M, Fajardo M. Bloqueo del plano del músculo erector espinal: estudio anatómico-cadavérico para determinar su mecanismo de acción. Rev Esp Anestesiol Reanim. 2018;65:514–519.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2062 "Ancho" => 1583 "Tamanyo" => 329485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Torso 3. (A) Axial slice at T9 after performing 2 ESP blocks in T5 in each hemithorax. The dye is deposited under the erector spinae muscles and above the transverse process in both hemithoraces. Yellow arrow: approximate site where the dye was deposited. Yellow line: outline of the right vertebra. Blue arrows: dye deposited between the erector muscle and the transverse process. (B) Ultrasound image of the ESP block, prior to injecting the dye in the right hemithorax: the needle is observed posterior to the transverse process of T5. AT: transverse process; MES: erector spinae muscle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1652 "Ancho" => 1250 "Tamanyo" => 320782 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Torso 2. ESP block in the upper left quadrant at the level of T4, prior to removal of the parietal pleura. Yellow arrows: indicate the extent of dye spread. Green arrow: dye found near the parevertebral chain. Yellow triangle: estimated site of injection in the posterior plane.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1679 "Ancho" => 1255 "Tamanyo" => 308689 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Torso 2. The parietal pleura was removed to observe the path of the dye. Staining is observed on the intercostal nerves and in the paravertebral spaces. Yellow arrows indicate where the dye adhered to the tissues. Yellow asterisks mark the position of the intercostal nerves.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1667 "Ancho" => 1250 "Tamanyo" => 352089 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Torso 2. ESP block in the lower right quadrant of the same model. The parietal pleura has been removed. Yellow arrows: estimated area where dye was observed. Green dye marks the point where the dye contacts the ramus communicans of the parevertebral chain.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1886 "Ancho" => 1417 "Tamanyo" => 402441 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Torso 3. (A) Partial dissection of the parietal pleura of the left hemithorax after ESP block. The yellow arrows mark the areas where the dye was found, before and after dissection: (1) close to the paravertebral chain; (2) around the dorsal puncture site; (3) in an adjacent intercostal space; (4) dye adhered to the pleura. Blue arrow indicates the direction of dissection of the pleura. Yellow dotted line shows the area of dye spread. Blue dotted line shows the area occupied by the parietal pleura. (B) Image of the right hemithorax after ESP block. The erector spinae muscles have been removed to show the spread of the dye. Blue arrows mark the area where methylene blue is observed on the posterior surface of the spinal column.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ICS: intercostal space; PVS: paravertebral space; +: present.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture number \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Torso \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Puncture level \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Side \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dye in PVS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of ICSs covered \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td 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