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ourhaileydavies · 11 months

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Expect the Unexpected with Erector Spinae Plane Block in Spine Surgery - Plan for the Worst and Hope for the Best: An Anesthesiologist Perspective-Juniper Publishers

Abstract

Spine surgery is associated with multiple postoperative complications, ranging from simple nausea and vomiting to devastating complications leading to postoperative morbidity or mortality. The postoperative neurological impairment, especially in the neurologically intact patient, is a dreadful event that makes it difficult for the surgeon to perform technically challenging or high-risk spine surgeries. Preoperative or intraoperative factors that can influence the postoperative neurological status include nature and the severity of the pathology, comorbid conditions of the patient, preexisting neurological symptoms, multiple levels involved, complex surgery or instrumentation, surgical blood loss, neurological monitoring, hemodynamic parameters, polypharmacy, and total duration of the surgery.

In addition to several known contributing factors (fixation failure, epidural hematoma, spinal cord edema, and ischemia-reperfusion injury), the role of the erector spinae plane block (ESPB) has recently been cited as a potential cause of postoperative transient paralysis after spine surgery. ESPB is considered a simple and safe regional anesthesia technique that may have an advantage in success rate and analgesic efficacy when used as an adjunct to general anesthesia in spine surgeries. Despite varied patterns of the drug spread, ESPB has been showing promising results due to consistent involvement of dorsal rami that supply all pain generators of the spine surgeries.

The potential role of ESPB in causing postoperative transient neurological complications is a diagnosis of exclusion that requires thorough clinical assessment and step-by-step evaluation using imaging modalities. Before administering ESPB in spine surgery, essential knowledge includes anatomical and technical considerations, drug distribution patterns, safe and effective volumes/types of local anesthetics, and possible associated complications. This review article describes the possible roles of all factors that lead to postoperative neurological impairment and suggests some tips and tricks for using ESPB in spine surgeries to prevent or manage such serious complications appropriately.

Keywords: Transient paraplegia; Erector spinae plane block; ESP block complications; ESP block in spine surgery; Paraplegia due to RA

Keywords: RA: Regional anesthesia; GA: General anesthesia; ESPB: Erector spinae plane block; ERAS: Enhanced recovery after surgery; LA: Local anesthetics; CT: Computed tomography; MRI: Magnetic resonance imaging; ESM: Erector spinae muscles; TP: Transverse process; SMPB: Sacral multifidus plane block; RLB: Retrolaminar block

Introduction

The occurrence of perioperative complications may be inevitable, but their prevention and management are always a shared responsibility of all team members involved. Thorough evaluation of such complications will help develop strategies to prevent and manage the same in the future. A systematic and stepwise approach is warranted before categorizing it as a surgical or anesthetic complication. Several interventions have been introduced in the surgical and anesthetic techniques to improve patient safety and satisfaction. Application of regional anesthesia (RA) alone or as an adjunct to general anesthesia (GA) is one such advance that helps reduce many polypharmacy-related side effects or complications. If a particular complication-reduction modality is inherently causing complications, it requires a comprehensive understanding of the situation and its contributing factors.

An erector spinae plane block (ESPB), a safe and simple RA technique, has shown promising results as an adjunct to multimodal analgesia in various orthopedic, general, thoracic, abdominal, obstetrics, and spine surgeries. In addition to its superior postoperative analgesic profile in spine surgeries at various levels, ESPB reduces hospitalization costs and the possible side effects of extensive anesthetic use. Since opioids have been linked to tumor recurrence [1,2], ESPB also reduces the risk of spine tumor recurrences by significantly reducing its consumption. ESPB meets all criteria suitable for enhanced recovery after surgery (ERAS) protocol [3] by facilitating early discharge and mobilization of patients. Being a novel RA technique, not many complications have been reported so far except for some anecdotal reports of bilateral quadriceps weakness, transient apathy or aphasia, minor neurological complications due to inadvertent intravascular injection of local anesthetics (LA) [4].

Recently, it has been described as a potential cause of transient paralysis after spine surgeries [5]. Therefore, it is essential to understand the differential diagnoses of postoperative neurological impairment, follow the step-by-step approach to rule them out one by one, determine the possible role of ESPB in their development, and learn the tricks for safely administering ESPB during spine surgery. This review article elaborates the essential background knowledge required before and after the administration of ESPB in spine surgeries.

Discussion

Postoperative neurological impairment after spine surgery in a neurologically intact patient is always daunting for the operating surgeon and the patient. Several common theories on neurological deterioration after decompressive spine surgeries include vascular compromise, hypotension, ischemia, direct trauma, or stretching of the neural elements. The major contributing factors of acute paralysis following spine surgery include fixation failure, epidural hematoma, spinal cord edema, and ischemia‑reperfusion injury [6].

Contributory factors

Neurons in the spinal cord are susceptible to ischemia and hypoxia. The mechanisms of spinal cord ischemia are multi-factorial and multi-channel. The pathogenesis of spinal cord lesions after spine surgeries is usually mechanical (pressure) damage via extensive hematoma or edema, resulting in pressure on the spinal cord leading to ischemic damage [7]. An altered cerebrospinal fluid flow dynamic may also cause cord compression [8]. In either case, the ultimate pathogenic cause is a secondary cellular injury due to the disruption of ionic homeostasis, development of free radicals, lipid oxidation, and degeneration of the cytoskeleton [7]. White cord syndrome, an imaging feature of spinal cord ischemia [9], is diagnosed as high intramedullary signal changes on sagittal T2 weighted MRI scans and is often seen in surgeries on the cervical spine.

The spinal infarct is one of the leading causes of paraplegia or quadriplegia in patients with preexisting vascular pathologies (thrombosis) or embolic events during surgery [10]. The anterior spinal cord has a higher risk of ischemia due to fewer anterior spinal artery feeding vessels [10] than the highly vascular posterior spinal cord due to anastomotic pial vessels. The sparing of the posterior column leads to unchanged intraoperative somatosensory evoked potentials [11]. The ischemia-reperfusion injury occurs upon restoring the blood flow to previously ischemic tissues and organs. Increased inflammatory cytokines such as TNF α and IL 1β may be considered vital indicators for evaluating decompression-associated spinal cord ischemia-reperfusion injury [12,13]. Its reported incidence is 2-5.7% following cervical and 14.5% following posterior thoracic decompression surgeries [14, 15].

Transient paralysis is one such complication that manifests itself as a temporary (up to 72 hours) loss of sensations, movements, anal reflexes, and sphincter function below the affected spinal segments [16]. It can occur after vertebroplasty, laminectomy, or thoracic decompressive procedures [17,18]. The longer duration of symptoms, multiple compression sites, and the high degree of preoperative stenosis are considered poor prognostic factors [18].

Who is the culprit?

The exact cause of the postsurgical neurological impairment is a diagnosis of exclusion requiring thorough clinical evaluation and imaging guidance to rule out each contributing factor (Table 1) in a step-by-step manner. Postoperative radiographic studies like computed tomography (CT) scan and magnetic resonance imaging (MRI) can help detect changes suggestive of misplaced implants, hematomas, edema, compressive lesions, white cord syndrome, or direct trauma to the spinal cord. Symptoms due to spinal cord edema typically occur at 48-72 hours post-surgery and may be relieved by anti-edema measures like fluid restriction [19].

The occurrence and severity of ischemia-reperfusion injury correlate with tissue ischemia time, the extent of ischemic tissue, and the oxygen requirement of the affected tissue [20]. The presence of deep tendon and superficial reflexes may rule out the possibility of hysterical paraplegia [18]. After excluding all contributing factors that may cause postoperative neurological impairment, the possible role of ESPB and LA can be considered and further evaluated. It requires an understanding of the anatomical and technical aspects, mechanism of drug spread, factors favoring neuraxial spread, and measures to avoid such incidents in the future [21].

Role of ESPB

ESPB involves depositing the local anesthetic solution between the erector spinae muscles (ESM) and the transverse process (TP) under ultrasound guidance. The ESM consists of three muscles: iliocostalis, longissimus, and spinalis. They arise from and insert into various bony components of the vertebral column [22] and form a paraspinal column that extends from the sacrum to the base of the skull. It gradually tapers upwards in the paravertebral groove on either side of the spinous processes. The retinaculum (thoracolumbar fascia in the lumbar region) that envelops this muscular column also facilitates the LA spread to several thoracic and lumbosacral levels [23]. The diverse multilayered fascial arrangement deep to the ESM may cause the inconsistent LA spread, resulting in multisegmented sensory block mainly involving dorsal rami with sometimes ventral rami.

This Para neuraxial block, when given bilaterally in spine surgery, can be advantageous in success rate and analgesic efficacy [24]. The absence of risks such as hypotension, vascular spread, or pneumothorax makes ESPB relatively safer than epidural anesthesia or paravertebral block. Bilateral ESPB offers effective perioperative analgesia without influencing the hemodynamic parameters. It significantly reduces the perioperative opioid requirements in spine surgeries at various levels (cervical, thoracic, and lumbar, and sacral) [25-32]. Its outcome depends on the volume and concentration of LA used, drug spread, and the anesthesiologist’s experience in selecting and locating the correct level of the TP.

The exact mechanism of action of the ESP block and pattern of the drug spread is still unclear. It has been suggested to anesthetize the spinal nerves by passing through the costotransverse foramen of Cruveilhier, accompanying the dorsal ramus and artery to the paravertebral space [33]. The deposited drug can spread in any direction, such as craniocaudal, anterior-posterior, and lateral-medial planes to reach the paravertebral space, neural foramina, epidural space, or sympathetic chain [34-38]. Fluoroscopic, CT, and MR imaging in living subjects have similarly confirmed the injectate tracking to the paravertebral area, intervertebral foramina, and epidural space following lumbar ESPB [39-42]. There is also a possibility of LA diffusion through the microscopic gaps in the mostly acellular architecture of interlinked collagen fibers of the fascia covering the erector spinae muscle [43].

ESPB at various spine levels

The anatomical differences at the various spine levels can cause varied drug spread and ultimately affect the outcomes of ESPB. Cervical ESPB is technically challenging due to the difficulty in identifying the tips of the cervical transverse processes due to their shorter length. It is mainly given at the C6 or C7 vertebral level. The probe needs to be kept anterolaterally rather than posteriorly to see the cervical TPs [44]. It may not be safe due to its proximity to the neuraxis (shorter transverse processes) and the possibility of bilateral phrenic nerve involvement [45-48].

Thoracic ESPB at the upper vertebral levels (T2 orT3) can be preferred in cervical spine surgery by inserting the needle from caudal-to-cranial direction to achieve the desired LA spread and avoid technical difficulties and complications associated with cervical ESPB. Thoracic ESPB can provide multilevel analgesia even with the small volumes of LA due to rigid boundaries of the thoracic paravertebral spaces that facilitate drug spread at several levels involving ventral and dorsal rami. Lower thoracic level ESPB is mainly performed for lumbar spine surgeries by inserting the needle from cranial-to-caudal direction to achieve the desired LA spread and avoid technical difficulties associated with lumbar ESPB [49,50].

The lumbar ESPB can also be technically challenging due to the increased thickness of the ESMs with their tendinous attachment to the TPs [51, 52] and increased corresponding depth of the intermuscular plane in the lumbar region. The psoas muscle is also closely adherent to the vertebral bodies and the anterior surface of the TPs. The anterior drug spread to include ventral rami may be compromised due to the lack of clear boundaries of lumbar paravertebral spaces [53]. There is a communication through the fat-filled plane between the ESM and TP with the fat-filled psoas compartment containing lumbar nerve roots and plexuses. The spread of LA to the epidural space is possible through this communication [54]. The compressed lamina and the ligaments of the lumbar spine favor LA spread more into the epidural space [55, 56]. Thus, the lumbar ESPB may result in either lumbar plexus block or epidural anesthesia. The resultant weakness in the quadriceps or lower extremity muscles depends on the LA concentration and volume used in ESPB.

Sacral ESPB is mainly described for gender reassignment surgery or perineal surgery [57-61]. Its application for lower lumbar or sacral spine surgery is yet to be determined. The sacral multifidus plane block (SMPB), one of the variants of the paraspinal block, involves the deposition of LA in the plane under the multifidus muscle and bony area between the median and intermediate crests of the sacrum. The possible mechanism of action of SMPB includes blocking the dorsal rami and medial cluneal nerves directly by LA deposition and ventral rami by anterior LA spread through dorsal and ventral sacral foramina. The SMPB may also block the pudendal nerve (S2–S4), lumbosacral plexus, and sciatic nerve via the anterior and cranial LA spread [61, 62].

The role of LA

The possible role of the LA used in ESPB in causing postoperative neurological compromise depends on its inadvertent spread into either the epidural or subarachnoid space. It can be determined based on the occurrence and recovery pattern of the neurological symptoms. Distal-to-proximal and motor-before-sensory recovery patterns are the hallmarks of the differential blockade of the LA [23]. Inadvertent spread of LA into the subarachnoid space can lead to severe hypotension and bradycardia, resulting in unstable intraoperative hemodynamics. The consequences of the epidural spread depend on the density of LA around the spinal nerves, which could be compromised in a subsequent surgical dissection affecting the potentiality of the epidural space.

The concentration of LA, which determines the mass of the drug, also affects the efficacy of any block. The deliberate use of LA in low concentrations can result in a preferred motor-sparing analgesic effect of such high-volume blocks [63, 64]. Bupivacaine and ropivacaine are the most commonly used LAs for bilateral ESPB. Both LA agents consistently display preferential blockade of C-fibres (slow pain) > A-delta fibers (fast pain) > A-beta fibers (touch/pressure) in both preclinical and clinical studies [64-66]. With the increasing concentration, these agents may result in loss of proprioception and loss of motor function. Lipid solubility and higher pKa of LA facilitate intraneural diffusion and ion channel blockade. Ropivacaine exhibits a relative motor-sparing effect due to its lower lipid solubility than bupivacaine [67]. Twenty milliliters of 0.375% ropivacaine is recommended for each side of the bilateral ESPB in adults [68, 69].

Technical aspects of ESPB

Unexpected outcomes like a neurological compromise can be correlated with possible technical errors while administrating ESPB. The first technical aspect is identifying the correct landmark under ultrasound depending on the surgical extent and the desired level of the block. It may further depend on the sonoanatomy quality and the experience of the anesthetist. Sometimes misidentifying the lamina as the tip of the TP can lead to the retrolaminar block (RLB), another variant of the paraspinal block. In RLB, the needle insertion is slightly medial, targeting the lamina of the vertebra instead of the tip of the TP. It works via diffusion of LA into the paravertebral space through the soft tissue gaps between adjacent vertebrae [70]. Both RLB and ESPB were consistently associated with the posterior spread of injectate to the back muscles and fascial layers [37].

Fluoroscopic-guided ESPB can lead to RLB due to the inability to see the tip of TP clearly like under ultrasound, resulting in deposition of the LA solution over the lamina. The proximity of the RLB to the neuraxis can lead to a high probability of epidural spread, which carries the risk of motor weakness. The second important aspect is the ergonomics associated with bilateral ESPB. Administering the bilateral ESPB by standing on only one side of the patient may result in deviation from the ideal needle trajectory on one side compared to the other. Therefore, technical considerations should focus on stabilizing the needle by one person, injecting LA by another person, and performing such bilateral blocks while standing on either side.

The third important aspect includes technical modifications such as keeping an ultrasound probe in a transverse view to help differentiate intramuscular drug spread from the effective linear drug spread between ESM and TP [71]. The fourth aspect is finding alternatives that involve dorsal rami consistently without causing drug spread to other unwanted areas. The thoracolumbar interfacial plane block is one such alternative that targets only the dorsal rami of the spinal nerve. Thus, it can provide more focused dermatomal coverage of the back required for thoracic and lumbar spine surgeries [72, 73]. However, its efficacy in spine surgeries is yet to be determined. We have suggested some tips and tricks for using ESPB in spine surgeries (Table 2), keeping all technical aspects in mind.

Conclusion

Postoperative neurological impairment following spine surgery is a serious concern for the operating surgeon and the patient. The role of ESPB in causing such complications is the diagnosis of exclusion made after a thorough evaluation of clinical symptoms and radiological studies. For that, understanding of various mechanisms involved in ESPB leading to neurological impairment is essential. It should encourage the anesthetists to take extreme precautions while administering this novel block, considering the anatomical differences at various spine levels. Surgeons should anticipate and explain the possibility of neurological deterioration while explaining the risks and benefits of the proposed surgical intervention. Intraoperatively, real-time neurophysiological monitoring is recommended as a useful tool to avoid further neurological deterioration, especially in extensive and multilevel surgeries or in high-risk and neurologically compromised patients.

After identifying or diagnosing such complications, intensive care and regular checking of spinal function are of great importance, along with simultaneous radiological workups to rule out various causative factors. Once paralysis occurs, early diagnosis and early intervention are essential in restoring spinal function. Despite the rare possibility of such complications, ESPB is still a promising option for ensuring effective perioperative analgesia in spine surgeries. It helps reduce postoperative morbidity by keeping the hemodynamic parameters stable and significantly reducing intraoperative blood loss. It can also avoid postoperative complications that lead to delay in mobility and discharge by significantly reducing the need for opioids and polypharmacy. However, further studies are needed to determine the safe concentration and volume of the LA solution used in ESPB, the exact surgery-specific vertebral level to cover desired surgical innervations, and the accurate LA deposition site to prevent spread to undesired areas.

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#spine surgery #spinal cord injury #spine #Juniper Publishers #open access journals

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thelastblueheart · 5 years

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I love you like rlb

THIS IS NOT MINE!!! This was originally posted by tolieawake but has since been deleted. I was able to get my hands on it and have shared it since it is a fandom classic. Please credit them as the writer!

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I love you like rlb has become a well-known, accepted and valuable component of American vernacular. The meaning of the letters ‘rlb’ is unknown, but is uniformly considered to be a statement of a great romantic love, commitment and sacrifice.

In which Tony goes insane trying to figure out why that phrase affects the Cap so much, Bucky teases the press, and Steve and Bucky love each other like rlb.

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I love you like rlb The first time he saw it, Steve stopped dead in his tracks and stared. Tony, who was walking and talking and gesticulating wildly all at the same time (the way that Tony does), didn't notice at first. When he did, he frowned, spun on his heel and headed back to where Steve was standing. “You okay, Cap?” he asked, tugging his sunglasses just far enough down his nose that he could peer at Steve over them. “Fine,” Steve mumbled, but he couldn't quite tear his eyes away. He was staring at the large glass window of the shop beside him or, rather, he was staring through the window at the brightly coloured t-shirt hanging on the mannequin. It was a vivid shade of blue, with yellow swirls crossing it, and white text proudly displayed across the chest. I love you like rlb it proclaimed proudly. “What?” Tony asked, “you never seen that saying before?” Steve swallowed, but didn't answer. Behind the mannequin was a rack of t-shirts, in various colours and patterns, all proclaiming the same thing – I love you like rlb. “I -” Steve started, before stopping to clear his throat. “Do you know what it means?” he asked. “Uh, it's just a saying, Cap,” Tony replied. “You know, like LOL or Got Milk? Roses are red. A prominent part of our popular culture that people use without really thinking about it.” He shrugged. “I don't think anyone knows where it comes from, or what the 'rlb' means – but everyone just takes it to mean, you know, like a declaration of love or something. Lots of love. Lots and lots of love.” He frowned. “I gave Pepper an I love you like rlb bracelet once. Real fancy, solid gold, she wears it occasionally.” He paused his rapid-fire rambling long enough to stare at Steve. “You sure you okay, Cap? 'Cos you look like you seen a ghost or something.” Tony paused. “You haven't seen a ghost, have you?” “No, no, it's just...” Steve let his voice trail off, hands tilted out to the side as he shrugged helplessly. How could he possibly explain it. “I don't know if it's related,” he said, “but some of the guys used to say that, during the war.” “Huh,” Tony said. He turned to look in the window at the t-shirts. “I mean, I know the saying's been around for a long time. One of those things that no-one is quite sure where it started or who said it first.” “Dernier,” Steve muttered. “What?” Shaking his head, Steve took a step away from the display, visibly pulling himself together. “Nothing,” he said. Shoving his hands into his pockets (to stop the shaking he wouldn't admit to), he turned and headed back down the street. “Don't we have somewhere to be?” he asked. - “JARVIS,” Steve said, standing in the middle of his floor of Avengers Tower (because Tony was ridiculous like that about giving them all things), “can you do some research for me, please?” “Certainly, Captain Rogers,” JARVIS replied smoothly. “What would you like me to research?” “I... I saw something today,” Steve said, “while I was out with Tony. He said that it was just a common saying, but...” letting his voice trail off he sighed, scrubbing one hand through his hair. “Sorry, I'm not explaining this right.” “Perhaps you could start with the saying?” JARVIS suggested. “Right, yes, of course.” Taking a deep breath, Steve forced the words – words he'd thought he'd never hear again, through his lips. “I love you like rlb,” he said. His voice cracked and he cleared his throat. There was a stinging in the backs of his eyes, but he resolutely ignored it. “That is a common saying,” JARVIS informed him with a thoughtful hum. “What is it that you would like to know about it?” “Does anyone know where it comes from?” Steve asked. “Tony said no, but, well, I thought maybe it's just not well-known? Or, does anyone know when it started? What it means?” “One moment, please,” JARVIS requested, before making another humming sound. Steve knew it was the sound JARVIS made to let him know he was thinking – or rather, running searches and collating information. Stumbling backwards, Steve let himself fall down onto his couch, grabbing the nearest cushion and almost ripping it apart as he held it tightly, hands clenching in the fabric. “While there does not appear to be any documented origin for the saying,” JARVIS said calmly, his smoothly modulated voice helping to calm Steve, “it is generally attributed as a saying which emerged among American troops during World War II. Returning soldiers brought the saying back to American soil with them. This origin in the War leant a certain romantic slant to the saying, which has persisted to this day. “Interestingly, french troops also carried the saying home to France after the war, which suggests that it was well-known enough that it transferred between Allied troops. Or was known to the resistance. It is also used fairly extensively in all Allied countries, but most prominently in America. “In 1951, it made its first appearance on merchandising – as a small engraving on pendants, which were sold by the Goldman Jewelry company. Stark Industries was involved in the design of the pendants.” Steve sucked a sharp breath in. “Since then,” JARVIS continued, “the phrase has appeared on various items of merchandise continually through the years; although the merchandise itself has changed, the phrase has never fallen out of use. It has been accepted as part of the current American and French vernacular, and appears in numerous romantic comedies, romance novels, and cards, as well as on items of clothing, jewelry, plaques and also tattoos. “The meaning of the letters 'rlb' is unknown, but is uniformly considered to be a statement of a great romantic love, commitment and sacrifice.” Pushing his fist against his mouth, Steve bit at his knuckles, trying to choke down the sob rising in his throat. “In the 1980s,” JARVIS continued, “the phrase was picked up by a number of gay rights campaigners and has since been used proudly by the community. However, evidence suggests that even before that time, and certainly since, it has been used as a phrase to express love between partners, without reference to their sexual orientation. “As there has never been a documented point of origin for the phrase, companies have been able to create merchandise freely, and therefore, at this current time, there is a proliferation of merchandising available. “Despite its unknown origins, and the lack of clarity around its exact meaning, I love you like rlb has become a well-known, accepted and valuable component of American vernacular. I am sorry that I am unable to provide you with the exact meaning of the letters rlb or of a more precise origin.” Sucking in a deep breath, Steve leant back against the couch, blinking rapidly. “It's okay,” he said, ignoring the way his voice cracked once more. “Thanks, JARVIS.” “You are welcome, Captain. If I may, you appear to be experiencing some distress. Would you like me to alert Mr Stark? Or perhaps one of the other inhabitants of the Tower? Miss Potts is currently upstairs and has finished work for the day.” “No,” Steve said, shaking his head. “No, I'm fine. I'll be fine. I just -” Getting up, he stumbled towards his bedroom, shaking lightly and half-tripping over his feet. JARVIS made a concerned sound before falling silent. - The next day, Steve pulled out some jeans, a baseball cap, hoodie and sunglasses, and braved the craziness of 21st century shopping in order to buy a few things. The watch with the engraving on the back went on his wrist. The sweatpants and t-shirt were shoved into a bag, to become his sleeping clothes. The fake dog-tags – well, he got them to add one with a simple string of numbers on it (32557) – and then slung them around his neck, letting them fall down beside his own, real, dog-tags. It wasn't much, wasn't nearly enough, but somehow, it made him feel better. - The fight with the Winter Soldier was nothing like anything Steve had encountered so far in this new century. The Soldier fought hard and fast and with an edge to his movements, despite the precision and grace and obvious training, that made Steve think of back alleys in Brooklyn. His team were yelling on the comm, Hawkeye hissing because neither Steve nor the Soldier would stand still long enough for him to safely take a shot. Iron Man was circling overhead, the Hulk standing nearby and looking ready to smash given half a chance. Widow was racing towards their position, ready to enter the fray. Thor cheered them both on as brave warriors. Then the Soldier grabbed at Steve, and somehow, during the fight, his helmet had been knocked off and the top of his uniform torn just enough that the Soldier's fingers closed over the chain around his neck, tugging and twisting. Steve ducked and rolled to prevent strangulation, even as he snapped his arm out, desperate to grab his dog-tags back. The Soldier froze, gaze fixated on the tags dangling from his hand, eyes widening and punching the breath from Steve's lungs even as his brain scrabbled to find a reason for his reaction. “Cap?” Hawkeye called. “I have a shot.” “Wait,” Steve said. He glanced down at the tags, noticing that the Soldier had grabbed his fake ones, and his eyes were fixed on that phrase. The saying. I love you like rlb Slowly, the Soldier raised his eyes to Steve's. “What?” he asked. His voice was muffled beneath his mask, and Steve found himself stepping forward, reaching out to gently remove the mask. His heart was pounding in his chest and he lost his breath as soon as the mask came away. There were tears in his eyes (he ignored them), and his heart was pounding (faster than he ever remembered it being since the serum). “Bucky,” he whispered. Slowly Bucky (because those were Bucky's eyes, even as they struggled against confusion and the blank stare of the Soldier) formed the words. “I love you like rlb,” he said. - “I'm just saying,” Tony said, “it's a little strange. First, Cap freaks out about the saying when he sees it on some t-shirts, and now the Winter Soldier – the Winter Soldier! - uses it to somehow break the insane amounts of brainwashing he was under.” Clint shrugged. “They say it originated in the war somewhere,” he said. “Maybe Cap was there when it first started.” “And the Soldier?” Tony asked. “We were.” The team turned to see Steve step into the room. His hair was still wet from his shower, and his eyes were suspiciously red and bright. There was a cautious hope in his eyes that made them realise just how withdrawn he'd been. Steve nodded towards the observation window they were all arrayed in front of. On the other side, the Winter Soldier sat at a table, staring down at the dog-tags still clutched in his fist. His hair hung over his face, so they couldn't see it clearly, but he'd been suspiciously quiet and compliant since he had been taken into custody. “We?” Bruce asked, eyes darting over Steve, assessing him. Steve gave him a tight smile. “We,” he repeated. He nodded towards the Soldier. “His name is James Buchanan Barnes. He's my best friend. He -” Steve cut himself off, taking a breath and swallowing. Then he shrugged. “We were there the first time Dernier said it – I don't think he meant for us to hear, but we did.” His gaze turned un-focused, looking off somewhere they couldn't see. - “Are you insane?” Dum Dum hissed, staring at Dernier through the rain. He scowled. “You know what you're risking.” Dernier shrugged, glancing over his own shoulder at where Gabe was sitting under the flap of their tent. “I know,” he agreed. “And I wouldn't risk it for just anything, but I love him like rlb.” “Rlb?” Bucky asked, stepping up beside Steve and frowning through the rain. “What are they talking about?” Steve shrugged, shaking his head. “I'm not sure,” he said, brow furrowed. - Shoving his meager supplies into a pack, Steve slung it up onto his shoulder, turning to face his men. “I don't expect you to follow me,” he said, “but I do ask that you don't try to stop me.” “What's going on?” Falsworth asked, stepping into the tent and glancing around at them. “What do you think?” Morita asked, “we got another rlb situation.” Steve blinked. “What?” he asked, before shaking his head. “Never mind. The rendezvous is in two hours, north-east from here. Get to the pick-up point and -” “No offense, Cap,” Falsworth interrupted, “but we're not going to the rendezvous.” “No chance,” Dum Dum agreed. “You're going after Barnes. So are we.” Steve shook his head. “I can't ask you to -” “You're not asking, we're offering,” Gabe said, pushing himself to his feet. Around them, the others nodded. - They trooped into base camp six days later, covered in mud, tired, hungry, but with Barnes by their sides (well, by Steve's side). Phillips took one look at them, before shaking his head. “Rlb?” he asked. “Rlb,” Falsworth agreed with a nod. - “You got a girl back home?” Steve paused, glancing over at the small huddle of soldiers, grouped around a fire and sharing stories. “Yeah,” one of the others replied. He pulled a worn photo out of his pocket, holding it out to show the others. “This here is my gal,” he replied. ��Prettiest gal around.” “Nice sweetheart,” another soldier commented. He shook his head. “Nah, not just a sweetheart,” he said. “This is the gal I'm gonna marry, I love her like rlb.” The others nodded, smiling understandingly. - “Hey Steve,” Bucky murmured, shifting so that his face was smushed against Steve's neck, where they lay in their tent. “Mmm,” Steve agreed. A wicked smile curved Bucky's lips against Steve's skin. “I love you like rlb,” he said. Rolling his eyes – and his body – Steve turned so that he could look at Bucky. “Really, Buck?” he asked. Bucky just grinned back at him. “What?” he asked. “Haven't you figured out what it stands for yet?” “'Course I have,” Steve replied. “They're not as subtle as they think.” Bucky huffed a laugh. “But you coulda just said 'I love you',” Steve continued. “Coulda,” Bucky agreed. “But I like this better. You know, I heard some soldiers use it earlier today, like it's something special, something more than just 'I love you'. I like that.” “You would,” Steve agreed. Reaching out, he traced his hand over Bucky's forehead, his nose, his cheek. Bucky turned his head, pressing a kiss against Steve's palm. “I love you like rlb, Buck,” Steve said. - “And this is the common floor,” Tony proclaimed, spreading his arms wide and spinning around as he indicated the area they had just stepped into. Behind him, Bucky (because he was all Bucky now, no more Winter Soldier), stared around and gave a low whistle. “Would you look at that,” he said, turning to grin at Steve. “You've been hanging with the rich kids.” Smiling (he hadn't stopped smiling since Bucky had first hugged him, pulling Steve close in the tiny cell they had him in, pressing his lips to Steve's neck and mouthing those words against his skin I love you like rlb), Steve gave a small shrug. “Just one rich kid,” he said. “But a very rich one.” “That's right,” Tony agreed. “So, if you need anything, just let me know. If I don't have it already, I'm pretty sure I can get it for you.” “Got any I love you like rlb t-shirts?” Bucky asked, casting a sly grin at Steve. Tony gaped at him. “What?” he asked, before stopping and shaking his head. “No, don't tell me, I don't want to know,” he said (even though he did really want to know). “JARVIS, please order Barnes some t-shirts.” “Certainly, Sir,” JARVIS agreed easily. - Bucky tended to wear his I love you like rlb t-shirts around the Tower – whenever he wasn't in uniform, he could be found lounging around in one of the shirts. Steve would always give him a soft smile when he saw the shirts, and Tony was fairly sure that was at least half the reason they had basically become Barnes' signature wardrobe. So it wasn't that surprising when he wore one to his first press interview. At least, it wasn't surprising to the Avengers (even if it was driving Tony crazy that Barnes refused to tell him just why he liked the shirts so much), even if it did surprise the press. “Sergeant Barnes,” a reporter asked. “I notice you're wearing a t-shirt with the popular phrase I love you like rlb emblazoned across it. I was just wondering, was this a particular choice? Does it have any significant meaning for you?” Bucky blinked, staring back at the reporter, before turning to look at Steve. “They don't know?” he asked, sounding slightly incredulous (but with that underlying hint of humour that suggested he knew exactly what he was doing and that his incredulity was all part of some crazy plan he had – Tony still couldn't quite believe the things that guy could talk Cap into when his voice took on that edge). “Bucky,” Steve sighed, with a roll of his eyes, but he made no move to stop him. Turning back to the reporters, Bucky smiled sweetly at them. “Sure it means something to me,” he said. “I mean, I was surprised that anyone even remembered this crazy saying.” He gave a small shrug. “I think it was Gabe as first used it,” he said. “Dernier,” Steve softly corrected him. “Right,” Bucky agreed with a laugh, “Dernier.” “Are you telling us,” the reporter asked, eyes wide, “that you know of the first instance of this iconic phrase being used?” “Sure,” Bucky said. “At least, I know it was the guys as first started using it. Not sure if I heard the very first time they said it – it wasn't something they used to say in front of Steve or I, at first.” “Why not?” Bucky laughed again. “Because it was about us,” he replied with a grin. “They didn't want us to know they'd caught on.” Another shrug. “Thought they were being so clever, so subtle.” He shook his head with a fond smile. “Dernier said it about Gabe.” “Jacques Dernier and Gabe Jones,” a reporter asked, “who, years after the war, confirmed that they had been in a romantic relationship since the war?” “And during,” Bucky agreed easily. “And yeah, Dernier said he loved Gabe 'like rlb'. They used it all the time – well, not necessarily the whole 'I love you like rlb', but 'rlb'. Like it was some super secret code they'd made up. Steve's about to do something stupid 'cos I got cut off from the guys again, it's an 'rlb situation'. Explaining to Phillips why we were late to a rendezvous, 'sorry General, but rlb, you know?'” Next to them, Tony was gaping – he was a genius, okay, so he'd figured it out. “And the rlb,” the first reporter asked, leaning forward, “what does that stand for?” Bucky laughed. “Rogers loves Barnes, of course,” he said. - There was a violent and prolific reaction to Bucky's statement. Tony claimed they'd broken the Internet (Steve was fairly sure that was impossible, but he let Tony think he'd convinced them of it), and for a while, none of the reporters were interested in anything else. But, when it came down to it, things were no different. Bucky wore his t-shirts around the Tower, and would lie next to Steve at night, mouthing the words into his skin. Somehow, the fact that this, of everything they'd done and said, of all the history that had been written about them, that this was the thing that lasted and thrived the most – it made Bucky grin. “I always said we had a love like one of those epic romances,” he told Steve fondly. Steve snorted. “You did not,” he replied, “you said I was a punk and that you'd better stick by me 'cos otherwise I'd get myself killed.” Bucky shrugged. “That, too,” he agreed easily. Then he grinned, bright and brilliant, the kind of grin that chased away the lingering shadows of his pain and guilt for a moment. “Still, we're like, the definition of romantic love in this century,” he said. “That's gotta count for something.” “I don't know about that,” Steve replied, “but I do know I love you.” “Like rlb?” Bucky asked. “Sure,” Steve agreed with a laugh, “I love you like rlb. Now sit still, Jerk, I'm trying to draw you.”

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starbellbunny · 7 months

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If it's ok to ask!! What do you mean by not everyone's cup of tea? I myself love some asshole uf Sans myself ♥️

This photo makes me giggle

Spoilers, i suppose? Under the cut :-)

Baaasically. Its a fem!fell sans/ a female reader, lesbians!! Im doing this mostly because i love. Women and a lot of my favourite Fem!fell sans/readers got deleted. I understand not everyone likes female sans but. I DO!!

And, also. Diff story, diff Red. Mwuahah, who knows how she’ll act?

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martyrbat · 1 year

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rlb,,, shoutout to my friends who have self respect and any restraint in hesitating to put soft porn on ur dash but i unfortunately cannot relate. i am the scum of earth hitting shiny buttons and making dick jokes as people gather to watch and/or turn away in horror. ill spam rb it if i want to and you gotta be nice to me bc you signed up for this by following someone named ransom idc idc

#very obviously very /lh #but like. ive posted worse than some softcore batman gifs. yall love objectifying old men its fine !

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serenamilesi · 6 years

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Supporting Statement

Hidden Noise A sound-and-light installation that explores the invisible electromagnetic fields of Wi-Fi networks by turning the non-audible sound produced by a router into a light visualisation from which you can actually detect the noise using a light sensitive device. We spend nearly every moment of every day awash in Wi-Fi signals and other electromagnetic waves that we tend to think as something strictly related to our laptops, however there are lot of other creative ways to display them. Light and sound can play an important role in data visualisation by changing the everyday experience and raising the awareness around invisible technology.

Consisting of two parts, the first part of the interactive installation is made up by a pickup coil attached to a router, in order to increase the signal emitted, it’s connected to an audio stereo amplifier board which in turn is attached to an LED series circuit. The second part is the receiver and it’s designed to generate the interaction between the installation and the user, it is a simply photosensitive device connected to the input of a tiny hand held audio amplifier and a pair of headphones. The aim is placing the photodiode near a source of light to spot the LEDs connected to the router in order to hear the noise emitted by the device, to deceive the user and add some aesthetic to the whole project I put other diodes around the metallic wire to keep a technology-pervasive atmosphere.

I chose to place my project close to a router in a corner of the flight of stairs on the second floor of RLB, as it suits perfectly the main idea of my project, something hidden that we deal with every day and assume as normal but that sometimes underestimate its crucial function. When we think about electromagnetic waves and internet in general we can’t deny the fact that we are surrounded by invisible technology, it's all around us, quietly and constantly powering our access to the world's information. For the same reason we can consider this part of the building as a non-place, as explained by the anthropologist Marc Augé, an anthropological space of transience where the human beings remain anonymous and that do not hold enough significance to be regarded as “places”. To investigate and expand this concept I tried to give a visual interpretation of it by placing the metallic wires up the pipes along the wall and in between the bricks which can be seen both as the “veins” of a living part of the building or as camouflage code.

Biography Serena Milesi is a Communication Design student from Politecnico di Milano, Italy, and she is currently taking part in an exchange program at Plymouth University. Her interests span from interactive art, light design, live music and pretty everything design related. As an incredibly curious person, she is always seeking new knowledge by surrounding herself with inspiring people and visiting creative places, as well as trying to combine her passions in what she does exploring pathways emerging from intersections between visual art and emerging technologies. She likes to think beyond a traditional art exhibition to create an experience that brings a social impact while encouraging people to get close with the work.

Contact information: [email protected] https://vimeo.com/user63638656 https://www.behance.net/milesisere93a3

#hiddennoise #dat501 #plymouth university #electromagnetic fields #digital art and technology #art tech

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super-rendell-brewster-blog · 5 years

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RENDELL L. BREWSTER, CPA, FCCA

Rendell Brewster is a member of the AICPA, American Institute of Certified Public Accountants and the FICPA, the Florida Institute of Certified Public Accountants, and is semi-retired consultant of RLB Financial Services Inc., a financial services firm, based in Miami, Florida.

He is also engaged in consulting assignments dealing with finance, fossil- based and renewable energy and related economic development issues mainly in relation to the Caribbean and Latin America. Consulting assignments involve assisting corporate clients with accessing capital for expansion and development needs from the regional and international financial markets. He provides advice to foreign client on domestic US tax and regulatory compliance issues.

#rendellbrewster #RLBFinancialServicesInc #consultant #aicpa

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jobswzayef · 4 years

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Project Manager

RLB KSA Rider Levett Bucknall is an independent construction property and management consultant. We bring a fresh perspective combining technical expertise and technology to deliver service excellence. Rider Levett Bucknall has had a local presence in the Middle East for over 30 years. Commencing practice in Saudi Arabia in 1982. Since 2007 we have grown rapidly and now have offices throughout the MENA Region where we have been involved in delivering some of the most iconic and innovative buildings in the region. Rider Levett Bucknall has also been recognised for the 13th consecutive year as a Top Employer for excellence in employee conditions. We are a global firm and encourage our KSA people to build global networks within the business and enhance their personal and professional development. Department Overview Our dedicated Project Management Team at RLB are responsible for seeing a project through from the initial planning stages to completion. Their main task is to break down projects into stages taking responsibility for monitoring and managing the programme cost quality and risk of each stage of the project. We pride ourselves on the quality of our service to our clients and enjoy long term relationships with them. We are a sector focused business actively operating and investing in Commercial Residential Mixed Use Sports and Retail clients and projects. Our Project Managers work in close contact with clients advising them on financial matters project risks procurement and contract matters using our experience to provide an informed opinion. Overview of Role Due to the continued success of our Saudi Arabia office we are currently recruiting a Project Manger to work on a large scale build program of works in Riyadh. The programme comprises a high end mixed use portfolio of projects on a single master plan located in Riyadh KSA comprising leisure and entertainment residential and infrastructure assets. You will join an existing client facing team and will be able to demonstrate a broad range of project programme experience. A background in a tier 1 PMC is essential. This will be an extremely challenging yet rewarding role – working for a company with excellent growth plans in the Middle East. Key Responsibilities

Input into establishing execution strategy for individual projects

Day to day management of projects

Accountable as part of a team for individual project success reporting up to the Project Management Leads

Implementation of all procedural requirements as defined in the Quality Plan

Manage project risk and implement agreed mitigation measures

Implement essential control measures systems project procedures in line with the PEP.

Attend meetings and follow up on assigned tasks through to completion

Work with planners to develop specific project schedules and provide early warning of risks to the timeline

Lead the development of weekly and monthly reports

Identify issues related to quality cost or time and advise on corrective actions Key Attributes

Degree in Project Management or similar technical discipline is essential

A chartered member of RICS or CIOB will be ideal

Technical delivery experience gained within a consultancy

Well organised diligent proactive assertive well disciplined and commercially astute.

Excellent communication and presentation skills both written and verbal.

Excellent customer service communication and client external interface skills

A track record of working with teams and managing projects by prioritising workloads and delivering to deadlines

A team player with a ‘can do’ attitude outgoing polite patient diplomatic personable and flexible

Western educated candidates preferred RLB is committed to creating a diverse workplace and is proud to be an equal opportunity employer. All job applicants will receive equal treatment without regard to age sex disability sexual orientation “race” includes nationality national ethnic origins colour marriage civil partnership pregnancy maternity gender reassignment religion and belief If you require any reasonable adjustments to support you during any stage of the application or interview process please contact our recruitment team at careersinbox uk.rlb.com. LI KS1 Apply for job * راتب مجزي جداً. * مكافأت و حوافز متنوعة. * توفير سكن مؤثث أو بدل سكن. * أنتقالات أو توفير بدل عنها. * توفير تذاكر السفر لمن يشغل الوظيفة و عائلته. * نسبة من الأرباح الربع سنوية. * أجازات سنوية مدفوعة الراتب بالكامل. * مسار وظيفي واضح للترقيات. * بيئة عمل محفزة و مناسبة لحالة الموظف. * تأمين طبي للموظيف و عائلته. * تأمينات أجتماعية. التقدم و التواصل مباشرة دون و سطاء عند توافر الألتزام و الجدية التامة و المؤهلات المطلوبة علي: [email protected]

#وظيفة #وظائف_شاغرة #وظائف_خالية #وظائف_كوم #وظيفة_كوم #السعودية #الكويت #الأمارات #عمان #ا

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mikemortgage · 5 years

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Small business tax deduction has CPAs scratching their heads

NEW YORK — Millions of small business owners will be in uncharted waters this income tax filing season as they try to determine if they qualify for a deduction that could exempt a-fifth of their income from taxes.

Five months after the IRS issued guidelines to help business owners and tax advisers understand how the complex deduction works, accountants and tax attorneys still have questions. Even those who have attended seminars and workshops about the new law have come away scratching their heads, especially about a section that bars service providers like doctors, lawyers and consultants from claiming the deduction. Some of these company owners have businesses that don’t easily fit into the IRS guidelines or proposed regulations the agency has also issued.

“There’s a lot of conflicting advice out there,” says Jeffrey Berdahl, a CPA with RLB Certified Public Accountants in Allentown, Pennsylvania. “It’s going to be like the Wild West.”

THE BASICS

The deduction is aimed at giving tax breaks to sole proprietors, partners and owners of S corporations; these businesses are known as pass-throughs because company income “passes through” to owners’ 1040 forms, where it is reported to the IRS. Before the law was enacted, many of these owners couldn’t get the more favourable tax treatment enjoyed by traditional corporations, those known as C corporations.

The new law allows many owners to deduct 20 per cent of what’s called qualified business income. They can get the full deduction as long as their taxable income doesn’t exceed $157,500 for an individual and $315,000 for a married couple filing jointly. But taxable income includes owners’ and spouses’ earnings from outside the business — for example, being employed in a different field or industry — and earnings from investments.

If taxable income is above the $157,500 or $315,000 threshold, owners may get a partial deduction. There are two critical factors that can limit the size of the break. The first involves the company’s W-2 wages, or how much it pays employees, and the value of some of its property; complex calculations go into assessing the impact of wages and property on the deduction.

The second factor affects owners who are in what’s called a specified service trade or business — for example, health providers, attorneys, accountants or consultants. They have no deduction if their taxable income is more than $207,500 for an individual or $415,000 for a married couple.

The IRS spells out the conditions for taking the deduction on its website. Visit https://bit.ly/2RbxOtc .

MORE THAN ONE ACTIVITY OR BUSINESS?

Owners whose businesses involve a variety of activities may find that income from some qualify for the deduction while others don’t, says Angela Dotson, a CPA with Aprio in Atlanta. An optometrist who treats patients may not be able to claim the deduction for that work. But the same optometrist who also sells eyeglasses and contact lenses may be able to use the deduction for that income.

Another example: A graphic designer who consults with clients but also creates websites. “You’re consulting, but also selling a product,” Berdahl notes.

There might be some unpleasant surprises when owners in such situations get to their CPA’s offices. The new law requires separate records for the different types of work.

“They might find their books may not be in good shape for tax reform — they may not show the data CPAs will need to know,” Dotson says. In that case, either the owner has to go back and change the books, or pay extra to have their tax advisers do the work.

Owners who have more than one business with employees may be able to aggregate, or combine the qualified business income of the companies, and lower the impact of W-2 wages on the deduction, says Miguel Farra, a CPA and tax attorney with MBAF in Miami. But the businesses must be in a related industry.

“If you are a real estate developer and somebody that owns real estate as investment property, you probably can aggregate,” Farra says. But someone who owns a cleaning service and an auto servicing shop wouldn’t be able to aggregate their income.

QUESTIONS AWAITING ANSWERS

The guidelines the IRS issued in August aren’t set in stone although the agency said taxpayers could rely on them in compiling their 2018 returns. The agency has issued proposed regulations, and tax professionals have already asked the IRS to clarify a number of issues, including which service providers can claim the deduction. For example, the New York State Bar Association, which asked the IRS for multiple clarifications, said many taxpayers, including those who and rent a small number of real estate properties, may be uncertain about whether the deduction applies to them.

Many of Ed Reitmeyer’s clients don’t like to get extensions of the filing deadlines for the returns. But the uncertainty about the new law is a good reason to get an extra six months to complete and submit returns, he says.

“It may be wise to do so with more clarity coming from Congress or Treasury,” says Reitmeyer, a CPA with Marcum in Philadelphia. However, he says, “with the government shutdown, and the political atmosphere surrounding tax policy, it may take well into the summer to gain any clarity at all.”

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Follow Joyce Rosenberg at http://www.twitter.com/JoyceMRosenberg . Her work can be found here: https://apnews.com/search/joyce%20rosenberg

from Financial Post http://bit.ly/2C7D1w2 via IFTTT Blogger Mortgage Tumblr Mortgage Evernote Mortgage Wordpress Mortgage href="https://www.diigo.com/user/gelsi11">Diigo Mortgage

#IFTTT #Financial Post

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