Erector spinae plane block (ESPB) is an interfascial plane block where a local anesthetic is injected below the erector spinae muscle. It is supposed to work at the origin of spinal nerves based on cadaveric and contrast study. It has emerged as an effective and safe analgesic regional technique. We report ten cases of thoracic and abdominal surgeries using this technique. We compared the hemodynamic stability through systolic blood pressure, mean arterial pressure, and heart rate before and after ESPB. Postoperative analgesia was given through patient-controlled analgesia or continuous opioids. The opioid needed and pain scale were assessed 24 h post surgery.
Keywords: Behavioral pain score, erector spinae plane block, numerical rating score, pain
|How to cite this URL:|
Agung Senapathi TG, Subagiartha I M, Wibawa Nada I K, Oka Mahendra IB. Erector spinae plane block for different surgeries: A case series. Bali J Anaesthesiol [Epub ahead of print] [cited 2021 Apr 22]. Available from: https://www.bjoaonline.com/preprintarticle.asp?id=293613
| Introduction|| |
Erector spinae plane block (ESPB) is a novel interfascial technique with potential applications for multiple procedures. ESPB is an interfascial block that can be performed by superficial or deep-needle approach. In superficial needle technique, drug is injected between the rhomboid major and erector spinae muscles, whereas in the deep-needle approach, drug is injected below the erector spinae muscle. In bilateral ESPB contrast study, cranio-caudal spread of injectate from C7 to T8 on the right side and T1 to T8 on the left side was noticed in the paraspinal gutter with lateral spread till the transverse processes at all levels. Cadaveric studies have shown that T5 level block is adequate to have unilateral multidermatomal sensory block ranging from T1 to L3., This block gives the purpose of a paravertebral block without the risk of pleural puncture. We have reported different cases to illustrate the potential uses of either single-shot or continuous ESPB.
| Case Reports|| |
We managed to collect ten patients aged 18–65 years with physical status American Society of Anesthesiologists I–III from different procedures. They underwent endotracheal-tube general anesthesia combined with ultrasound-guided ESPB. We monitored hemodynamic changes during surgery. In terms of postoperative pain, we measured the pain score using numerical rating score (NRS) in conscious patients and behavioral pain score (BPS) in intubated patients at 24 h postoperatively.
A 62-year-old female was planned for video-assisted thoracoscopic surgery (VATS) for biopsy of right lung tumor. Right ESPB was administered at T6 level. The patient was hemodynamically stable. Postoperative BPS was 3 with 0.25 μg/kg/h fentanyl administration.
A 52-year-old female with left staghorn kidney stone was posted for left open nephrectomy. Left-sided ESPB was performed followed by catheter insertion at T9 level. Intraoperatively, hemodynamic condition was stable. Postoperative NRS was 0 without opioid consumption.
A 56-year-old female with right empyema presented for thoracotomy and decortication. ESPB was performed at T5 level. Postoperatively, the patient reported a BPS of 3 with continuous opioid administration.
A 24-year-old male with a mediastinal tumor was admitted for thoracotomy biopsy. Right-sided ESPB was administered at T5 level. Postoperative NRS was 2 with 5-mg morphine demand.
A 36-year-old male with right lung empyema presented for thoracotomy and decortication. ESPB was administered at T5 level. The highest postoperative NRS was 4, with a morphine demand of 10 mg.
A 44-year-old female was admitted for open cholecystectomy because of multiple cholelithiasis. Right-sided ESPB was administered at T8 level followed by the insertion of a catheter. Postoperative NRS was 0 without opioid consumption.
A 47-year-old male presented with severe pericardial effusion and mediastinal tumor and underwent VATS for pericardial window. Left-sided ESPB was administered at T6 level. Postoperative BPS was 3 with continuous fentanyl management.
A 57-year-old female with right kidney tumor was admitted for radical nephrectomy. ESPB was administered at T9 level. Hemodynamic was stable intraoperatively. The highest NRS was 3, with total opioid consumption of 8 mg.
A 47-year-old male with right lung adenocarcinoma was administered for VATS and fistula repair. ESPB was administered at T6 level. Postoperative NRS was 2 with 5-mg morphine demand.
A 45-year-old male was admitted for open cholecystectomy due to cholelithiasis. Right-sided ESPB was administered at T8 level. Postoperative NRS was 2 with 5-mg morphine demand.
| Discussion|| |
ESPB was first described as a successful treatment option for thoracic neuropathic pain. Further research described that ESPB was an effective analgesic method in breast surgery, thoracic surgery, and major abdominal surgery.,,, The local anesthetic (LA) administered during ESPB spreads in the paravertebral space, leading an effective analgesia for somatic and visceral pain. Cadaveric studies had demonstrated that when 20 ml of fluid was administrated at T7 level, the fluid spreads to C7–T2 levels cranially and L2–L3 levels caudally., ESPB can be performed at T4–T5 level for breast and thoracic surgeries and T7–T8 levels for abdominal surgeries.,,
ESPB is a paraspinal fascial plane block that blocks the dorsal and ventral rami of the spinal nerves to help achieve a multidermatomal sensory block of the anterior, posterior, and lateral thoracic and abdominal walls. There is a hypothesis that the multidermatomal sensory block is due to the cranial and caudal spread of the injected LA. This spread is aided by the thoracolumbar fascia, which extends across the posterior thoracic wall and abdomen. The reported mechanism of action is the diffusion of the injected LA through the connective tissues and toward the spinal nerve roots.,,
The ESPB can be used to deliver regional analgesia for a wide variety of surgical procedures in the anterior, posterior, and lateral thoracic and abdominal areas, as well as for the management of acute and chronic pain. Infection at the site of injection in the paraspinal region and patient refusal are absolute contraindications for performing an ESPB. Anticoagulation may be a relative contraindication to ESPB, although there are no specific guidelines., Complications are very rare because the site of injection is far from the pleura, major blood vessels, and the spinal cord. Infection at the needle insertion site, LA toxicity/allergy, vascular puncture, pleural puncture, pneumothorax, and failed block are the primary complications.
The ESPB represents a simpler, possibly safer alternative to epidural or paravertebral thoracic block because the transverse process, which represents the ultrasonic target, is easily visualized and the point of injection is far from the neuroaxis, pleura, and large vascular structures. This location is an advantage in anesthetized patients or those with additional difficulties. Besides, the extensive craniocaudal diffusion of the anesthetic allows wide coverage with a single injection, allowing the approach to occur at points relatively distant from the surgical zone.,
| Conclusion|| |
We conclude that ultrasound-guided ESPB is effective as an alternative regional anesthetic technique for different surgeries. It has wide applications in pain relief ranging from perioperative acute pain in thoracotomies and abdominal surgeries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Tjokorda Gde Agung Senapathi,
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
Source of Support: None, Conflict of Interest: None