Ultrasound-guided multiple injection costotransverse block in a patient with postradiation therapy recurrent dermatofibrosarcoma protuberans: A technical glitch

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive soft-tissue tumor with a high recurrence rate, often requiring multiple surgeries with multiple sessions of radiotherapy that alters the anatomy and makes regional anesthesia challenging in these patients. The multiple injection costotransverse block (MICB) is a type of “paravertebral by proxy” block in which the drug is injected within the thoracic intertransverse tissue complex with spread to the paravertebral space without any epidural spread. Unlike the traditional approach to paravertebral block, which involves piercing the superior costotransverse ligament, the MICB has a shallower needle trajectory making needle visualization easier and the more superficial needle tip location reduces the chances of a pleural puncture and subcostal vessel injury. We present the case of a 51-year-old male with recurrent DFSP in the anterior axillary fold who was posted for tumor debulking. As the sonoanatomy was altered due to multiple previous surgeries and radiotherapy, we chose to perform an ultrasound-guided MICB.