Patient Selection

Lumbar somatic block is often used in a pain clinic setting. In addition, some surgical patients, such as those undergoing herniorrhaphy, benefit from appropriate use of the block. Also, although the frequency of flank incision for renal surgical procedures has decreased since the advent of lithotripsy, patients undergoing flank incisions are well managed with a combination of lower intercostal and lumbar somatic block and light general anesthesia.

Pharmacologic Selection

The local anesthetic choice for lumbar somatic block is limited only by the extent of additional blockade and concerns over systemic toxicity. If pinpoint diagnostic accuracy is essential for chronic pain syndromes, local anesthetic volumes as small as 1 to 2 mL are appropriate; if surgical anesthesia is desired, volumes of 5 to 7 mL per lumbar root are appropriate.

Anatomy

It is useful to conceptualize paravertebral lumbar somatic block as an intercostal block in miniature. Using this concept, the short vertebral transverse process (a “rudimentary rib”) becomes the principal focus and landmark for needle position. Lumbar somatic nerves leave the vertebral foramina slightly caudad and ventral to the transverse process of its respective vertebral level (Fig. 35-1).

Figure 35-1. Lumbar somatic block: anatomy.

As Figure 35-2 illustrates, from the intervertebral foramina the lumbar somatic nerves angle caudad and anteriorly and hence pass anterior to the lateral extent of the transverse process of the next-lower vertebral body (see Fig. 35-1

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