The Erector Spinae Plane Block Provides Visceral Abdominal Analgesia in Bariatric Surgery: A Report of 3 Cases. Reg Anesth Pain Med. 2017;42:372-376. [PMID: 28272292 DOI: 10.1097/aap.0000000000000581]

The effect of ultrasound-guided erector spinae plane block on postsurgical pain: a meta-analysis of randomized controlled trials

Background

The effect of erector spinae plane block has been evaluated by clinical trials leading to a diversity of results. The main objective of the current investigation is to compare the analgesic efficacy of erector spinae plane block to no block intervention in patients undergoing surgical procedures.

Methods

We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases from their inception through July 2019. Included trials reported either on opioid consumption or pain scores as postoperative pain outcomes. Methodological quality of included studies was evaluated using Cochrane Collaboration’s tool.

Results

Thirteen randomized controlled trials evaluating 679 patients across different surgical procedures were included. The aggregated effect of erector spinae plane block on postoperative opioid consumption revealed a significant effect, weighted mean difference of − 8.84 (95% CI: − 12.54 to − 5.14), (P < 0.001) IV mg morphine equivalents. The effect of erector spinae plane block on post surgical pain at 6 h compared to control revealed a significant effect weighted mean difference of − 1.31 (95% CI: − 2.40 to − 0.23), P < 0.02. At 12 h, the weighted mean difference was of − 0.46 (95% CI: − 1.01 to 0.09), P = 0.10. No block related complications were reported.

Conclusions

Our results provide moderate quality evidence that erector spinae plane block is an effective strategy to improve postsurgical analgesia.

The erector spinae plane block causes only cutaneous sensory loss on ipsilateral posterior thorax: a prospective observational volunteer study

BACKGROUND

Ultrasound-guided erector spine plane (ESP) block is widely used in perioperative analgesia for back, chest and abdominal surgery. The extent and distribution of this block remain controversial. This study was performed to assess the analgesia range of an ultrasound-guided ESP block.

METHODS

This prospective observational volunteer study consisted of 12 healthy volunteers. All volunteers received an erector spinae plane block at the left T5 transverse process using real-time ultrasound guidance. Measured the cutaneous sensory loss area (CSLA) and cutaneous sensory declination area (CSDA) using cold stimulation at different time points after blockade until its disappearance. The CSLA and CSDA were mapped and then calculated. The block range was described by spinous process level and lateral extension. The effective block duration for each volunteer was determined and recorded.

RESULTS

The cold sensory loss concentrates at T6-T9. The decline concentrates primarily at T4-T11. The lateral diffusion of block to the left side did not cross the posterior axillary line, and reached the posterior median line on the right. The area of cutaneous sensory loss was (172 ± 57) cm², and the area of cutaneous sensory decline was (414 ± 143) cm². The duration of cutaneous sensory decline was (586 ± 28) minutes.

CONCLUSION

Ultrasound-guided erector spine plane block with 20 mL of 0. 5% ropivacaine provided a widespread cutaneous sensory block in the posterior thorax, but did not reach the anterior chest, lateral chest, or abdominal walls. The range of the blockade suggested that the dorsal branch of spinal nerve was blocked.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, CHiCTR1800014438. Registered 13 January 2018.

Ultrasound-guided erector spinae plane block for postoperative analgesia: a meta-analysis of randomized controlled trials

Background

Ultrasound-guided Erector Spinae Plane Block (ESPB) has been increasingly applied in patients for postoperative analgesia. Its effectiveness remain uncertain. This meta-analysis aimed to determine the clinical efficacy of ultrasound-guided ESPB in adults undergoing general anesthesia (GA) surgeries.

Methods

A systematic databases search was conducted in PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) comparing ESPB with control or placebo. Primary outcome was iv. opioid consumption 24 h after surgery. Standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a random-effects model.

Results

A total of 12 RCTs consisting of 590 patients were included. Ultrasound-guided ESPB showed a reduction of intravenous opioid consumption 24 h after surgery (SMD = − 2.18; 95% confidence interval (CI) -2.76 to − 1.61,p < 0.00001). Considerable heterogeneity was observed (87%). It further reduced the number of patients who required postoperative analgesia (RR = 0.41,95% CI 0.25 to 0.66,p = 0,0002) and prolonged time to first rescue analgesia (SMD = 4.56,95% CI 1.89 to 7.22, p = 0.0008).

Conclusions

Ultrasound-guided ESPB provides effective postoperative analgesic in adults undergoing GA surgeries.

Multimodal Anesthesia via Opioid-Free Analgesia and Erector Spinae Plane Block

Multimodal anesthesia, which combines general and epidural anesthesia, is used in surgical cases in which a large or painful incision is anticipated. However, both epidural blocks and opioid-based analgesia have limitations in application. Here, we present a case of supra-infraumbilical laparotomy in a patient whose history of neurostimulator use and marked scoliosis discouraged the placement of an epidural catheter and whose prior adverse response to opioids prohibited their use. The intraoperative and postoperative management of this patient consisted of a combination of analgesia without opioids and erector spinae plane block. Adequate analgesia was achieved, and intraoperative or postoperative opioids were not required. This case illustrates the importance of mastering alternative and multimodal analgesia techniques that can be used in place of classical analgesia techniques when classical analgesia techniques are not appropriate.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant)

INTRODUCTION

Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain.

METHODS

This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat.

DISCUSSION

This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.

TRIAL REGISTRATION NUMBER

NCT03691922; Recruited Date of registration: October 2, 2018.

Erector spinae plane block and transversus abdominis plane block for postoperative analgesia in cesarean section: A prospective randomized comparative study

BACKGROUND AND AIMS

Erector spinae plane (ESP) block is an interfascial plane block given at the paraspinal region and provides effective visceral and somatic analgesia. Transversus abdominis plane (TAP) block is also an interfascial block that provides adequate somatic pain control. We conducted this study to compare the analgesic efficacy of ESP and TAP blocks with ropivacaine for 48 h after the cesarean section.

MATERIAL AND METHODS

Sixty patients scheduled for elective cesarean section under spinal anesthesia, randomly divided into ESP block (n = 30) or TAP block (n = 30) groups. After completion of surgery, ultrasound-guided ESP or TAP block was given using 0.2% ropivacaine (0.2 ml/kg on either side). Postoperatively visual analogue scale (VAS) score and analgesic requirement of each patient was assessed at regular interval for 48 h by a blinded investigator. Statistical analysis was done using SPSS version 21. Student's t-test and Chi-square test were used for demographic and other data.

RESULTS

ESP block provided prolonged analgesia compared to the TAP block, andthe mean time to first rescue analgesia was 43.53 h and 12.07 h, respectively (P < 0.001). The requirement for total analgesic was also significantly less in the ESP group compared to the TAP group (P < 0.001).

CONCLUSION

ESP block provided prolonged analgesia with a significant decrease in analgesic requirement compared to TAP block and can be used as a standard technique for post-cesarean analgesia.

Analgesic Efficacy of Erector Spinae Plane Block Compared with Intrathecal Morphine After Elective Cesarean Section: A Prospective Randomized Controlled Study

BACKGROUND

We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia.

METHODS

In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups.

RESULTS

No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly.

CONCLUSION

ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.

Lumbar Erector Spinae Plane Block as a Main Anesthetic Method for Hip Surgery in High Risk Elderly Patients: Initial Experience with a Magnetic Resonance Imaging

Objective

Since initial description by Forero for thoracic region, ultrasound guided erector spinae plane (ESP) block has experienced several surgeries for postoperative pain management, chronic pain or surgical anesthesia. Although ESP block has been reported to provide effective analgesia in the thoracic region, its effect in lumbar region still unclear. In this study we aimed to showed our successful experience with lumbar ESP block as a main anesthetic technique in fifteen high risk elderly patients undergoing hip surgery with mild propofol sedation.

Materials and Methods

In this observational study high risk elderly fifteen patients received lumbar ESP block as a main anesthetic technique with mild propofol sedation. 40 mL of local anesthetic mixture (20 mL bupivacaine 0.5%, 10 mL lidocaine 2%, and 10 mL normal saline) was administered between the erector spinae muscles and transverse process at the level of the 4th lumbar vertebra. Also we demonstrate magnetic resonance images and discuss the anatomic basis of lumbar ESP block.

Results

All patients' surgeries were completed without requirement for general anesthesia or local anesthesia infiltration of the surgical site. All patients' pain scores were <2/10 in the recovery room. Significant contrast spread was observed between the Th12 and L5 transverse process and erector spinae muscle and between multifidus muscle and iliocostal muscle at the L2-4 levels. Contrast material was observed at the anterior of the transverse process spreading to the paravertebral, foraminal and partially epidural area/spaces and also in the areas where the lumbar nerves enter the psoas muscle.

Conclusion

Lumbar ESP block when combined with mild sedoanalgesia provides adequate and safe anesthesia in high risk elderly patients undergoing hip surgery.

Erector Spinae Plane Blocks in Major Hepatopancreaticobiliary Surgery: A Case Series

Hepatopancreaticobiliary (HPB) surgery is major upper abdominal surgery with considerable risk of pulmonary complications related to postoperative pain. While epidural analgesia remains an effective analgesic technique for upper abdominal surgery, HPB surgery poses challenges to its use due to coagulopathy. Erector spinae plane (ESP) blocks are a promising alternative to epidurals. Injection of local anesthetic deep to the erector spinae muscle plane and placement of a catheter for prolonged effect provide both somatic and visceral analgesia for both thoracic and abdominal surgery. We describe a series of 3 cases that illustrate the efficacy of ESP blocks after major HPB surgery.

Erector spinae plane block and altered hemostasis: is it a safe option? -a case series

BACKGRUOND

We described 5 cases of uneventful administration of the erector spinae plane (ESP) block to patients with altered hemostasis.

CASE

Five patients were admitted to the intensive care unit with altered hemostasis, defined by the activated partial thromboplastin time ratio or internatinal normalized ratio exceeding 1.5 times the normal value; platelet count equal to or below 80000/μl; or use of anticoagulation therapy. A multimodal analgesic regimen was used for all patients, which proved unsatisfactory and limited successful ventilator weaning, until the administration of the ESP block. Effective analgesia was observed in all patients, with at least 70% reduction in numeric pain scale scores and 83% reduction in opioid consumption, which enabled successful ventilator weaning. No neurologic or hemorrhagic complications were recorded during daily surveillance over 5 days.

CONCLUSIONS

The ESP block may be a suitable regional analgesia technique for patients with altered hemostasis. Further studies are needed to support this finding.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Erector spinae plane block for complete surgical anaesthesia and postoperative analgesia for breast surgeries: A prospective feasibility study of 30 cases

Background and Aims:

Several regional anaesthesia techniques have been described for carcinoma of the breast surgeries in the past but all of them failed to provide adequate surgical anaesthesia and are associated with multiple complications, thus limiting their use. This prospective study was designed to assess the efficacy of erector spinae plane (ESP) block to provide complete surgical anaesthesia without general anaesthesia (GA) and postoperative analgesia in patients undergoing modified radical mastectomy (MRM) surgery.

Methods:

Thirty females of the American Society of Anaesthesiologists physical status I, II or III scheduled for MRM were included in the study to receive unilateral ultrasound-guided ESP block preoperatively (25 ml of 0.5% bupivacaine with dexamethasone 8 mg on the operating side). The primary objective of the study was to evaluate the efficacy of ESP block to provide complete surgical anaesthesia in terms of total number of cases converted to GA.

Results:

Our study shows that ultrasound-guided single-shot ESP block provided complete surgical anaesthesia in all the patients within an average of 31.50 minutes and an average long-lasting postoperative analgesia of 41.73 hours following MRM.

Conclusion:

Our study proves that ESP block is a novel, predictable, secure, and safe option for carcinoma of the breast surgery. Thus, ESP block would surely provide a clinical advantage in these population group.

Erector Spinae Plane Block in Laparoscopic Cholecystectomy, Is There a Difference? A Randomized Controlled Trial

Background

The ultrasound (US)-guided erector spinae plane (ESP) block and oblique subcostal transversus abdominis plane (OSTAP) block are used to decrease postoperative pain and subsequently opioids consumption.

Aim

The aim was to test the hypothesis that US-guided ESP blocks can produce more reduction in opioid usage during the first 24 h after laparoscopic cholecystectomy when compared to OSTAP block.

Settings and Design

Seventy adult patients (20-60 years old) who were planned to undergo elective laparoscopic cholecystectomy were allocated in three groups in randomized controlled trial.

Materials and Methods

The three groups received either port site infiltration, US-guided bilateral ESP block (ESP group), or OSTAP (OSTAP group) with bupivacaine hydrochloride 0.25%.

Statistical Analysis

Postoperative 24 h Morphine consumption, visual analogue scale (VAS), the intraoperative fentanyl (μg) and equivalent morphine dose in the recovery unit were recorded and analyzed using one-way analysis of variance.

Results

The mean 24-h morphine consumption was statistically significant between groups (P < 0.001), but it was insignificant between ESP and OSTAP (P = 0.173). Median (range) and interquartile range of intraoperatively consumed fentanyl showed significance between the three groups (P < 0.001). There was insignificance between ESP block Group II and OSTAP block Group III (P = 0.95) by post hoc analysis. The mean values of VAS at both rest and movement of the control group were significantly higher than the ESP block group at 6 and 12 h postoperative.

Conclusion

Bilateral US-guided ESP block was found to be as effective as bilateral US OSTAP block. There was more decrease in intraoperative rescue fentanyl, PACU morphine analgesia, 24-h morphine, and pain assessment score in both groups than the control port-site infiltration group.Clinical trial registration number: NCT03398564.

Early experience with erector spinae plane blocks in children

BACKGROUND

An erector spinae plane block is a relatively new regional anesthetic technique. Apart from case reports and small series, the literature regarding pediatric use is limited.

AIM

Our objective was to determine the efficacy of the erector spinae plane block in children by measuring the heart rate response to incision. Secondary objectives included feasibility, safety, opioid consumption, and pain scores. Furthermore, we reviewed this block in children published since 2016.

STUDY DESIGN

Case Series; Level of evidence, IV.

METHODS

With Institutional Review Board approval, a retrospective chart review was conducted on all patients who received erector spinae plane block for surgery between October 2017 and May 2019 at a single institution. Blocks were performed under anesthesia, using ultrasound guidance prior to surgical incision. Block details and hemodynamic and analgesic data were collected. In addition, a PubMed literature review was conducted to identify all erector spinae plane block related publications in patients ≤18 years of age.

RESULTS

About 164 patients, 2 days-19.4 years, weighing 2.3-94.7 kg, received erector spinae plane blocks. For more than 79% of single injection blocks, placement time was ≤10 minutes. Using a heart rate increase of <10% at skin incision as criterion, 70.1% of patients had a successful block. Only 20% required long-acting opioids intraoperatively. In a subset of infants who underwent gastrostomy surgery using a dose of 0.5 mL/kg, a local anesthetic spread of at least five dermatomes (0.1 mL/kg/dermatome) was achieved. Per the literature review, 33 publications described erector spinae plane block in 128 children. No complications were reported.

CONCLUSION

Erector spinae plane blocks are relatively easy to perform in children with no complications reported to date. The efficacy of the block for a broad spectrum of surgeries, involving incisions from T1 to L4, is encouraging.

Mechanism of action of the erector spinae plane block: distribution of dye in a porcine model

This study aimed to describe the anatomical distribution of dye injected in the erector spinae plane (ESP) in a porcine living model, which could aid to reveal factors potentially relevant to the unexplained clinical effects of the ESP block. Six pigs received 0.6 mL/kg of 0.25% new methylene blue at the level of the sixth thoracic vertebra through either a cranial-to-caudal or a caudal-to-cranial in-plane ultrasound-guided bilateral ESP injection 20 min before euthanasia.

Spread of dye evaluated through transverse cryosections (four injections) extended from T5 to T10 and from T5 to T8 when a cranial-to-caudal direction of injection was used, and from T5 to T9 and from T5 to T8 when the opposite direction of injection was used. A median of 4.5 medial and lateral branches of the dorsal rami was observed stained through anatomical dissection (eight injections), regardless of the direction of injection. No evidence of dye was found in the thoracic paravertebral or epidural spaces, where the dorsal root ganglia, ventral rami and rami communicantes are located. In all the cases, dye solution was found in the prevertebral thoracic lymph nodes.

In this study, ESP injection resulted in a median spread over five spinal segments (12 injections), staining the lateral and medial branches of the dorsal rami of the spinal nerves, regardless of the direction of the needle used.

[Comparison between erector spinal plane block and epidural block techniques for postoperative analgesia in open cholecystectomies: a randomized clinical trial]

INTRODUCTION AND OBJECTIVES

Blockade of the Erector Spinal Muscle (ESP block) is a relatively new block, initially described for chronic thoracic pain analgesia, but it has already been described for anesthesia and analgesia in thoracic surgical procedures and, more recently, for high abdominal surgeries. The aim of the study was to compare two techniques, ESP Block and Epidural block with morphine and local anesthetic for postoperative analgesia of open cholecystectomy surgeries.

METHODS

Controlled single-blind randomized clinical trial with 31 patients (ESP block, n = 15; Epidural, n = 16), of both genders, ages between 27 and 77 years. The ESP block was performed at the T8 level with injection of 20 mL of 0.5% ropivacaine bilaterally. The epidural block was performed at the T8-T9 space with 20 mL of 0.5% ropivacaine and 1 mg of morphine.

RESULTS

The ESP block group presented higher mean Numeric Pain Scale (NPS) values for pain in the up to 2 hour (p = 0.001) and in the 24 hour (p = 0.001) assessments. The ESP block group had a three-fold increased risk (43.7% vs. 13.3%) of rescue opioid use in the 24 postoperative hours when compared to the epidural group (RR = 3.72, 95% CI: 0.91 to 15.31, p = 0.046).

CONCLUSION

ESP block did not prove to be an effective technique for postoperative analgesia of open cholecystectomy, at the doses performed in this study, having required more use of rescue opioid, and without differences in NPS. More comprehensive studies are required to assess the efficacy of ESP block for the visceral and abdominal somatic component, considering the specific blockade level.

Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression

BACKGROUND

Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD.

MATERIALS AND METHODS

We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting.

RESULTS

Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively).

CONCLUSIONS

There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.

Ultrasound-guided erector spinae plane block for postoperative analgesia in pediatric patients undergoing splenectomy: A prospective randomized controlled trial

BACKGROUND

Many analgesic modalities have been investigated in pediatrics. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in pediatric patients undergoing open midline splenectomy.

METHODS

Sixty patients aged 3-10 years were randomly assigned into two groups: Control group received general anesthesia with bilateral sham erector spinae plane block using 0.3 mL/kg normal saline on each side. Erector spinae plane block group received bilateral ultrasound-guided erector spinae plane block using 0.3 mL/kg bupivacaine 0.25% (on each side) with a maximum dose of 2 mg/kg. Children's Hospital Eastern Ontario Pain Scale (CHEOPS), total consumption of intraoperative fentanyl (1 µg/kg IV in case of inadequate analgesia), time to first rescue analgesic administration, and postoperative paracetamol consumption were recorded over the first 24 hours postoperatively.

RESULTS

The median (IQR) postoperative CHEOPS score at 1 hour was lower in erector spinae plane block group (5.0 (4.75 -5.25)) than the control group (7.0 (6.0-10.0)) (P < .001, 95% CI: 1.0; 5.0). The CHEOPS scores for the first eight postoperative hours were lower in the erector spinae plane block group (5.0 (5.0-6.0)) than the control group (6.0 (6.0 -10.0)) (P ˂ .001, 95% CI: 1.0; 2.0). Intraoperative fentanyl administration was higher in the control group 40.0 (21.5-50.0) μg compared to erector spinae plane block group 0.0 (0.0-0.0) μg (P ˂ .001, 95% CI: 23.0; 48.0). The total postoperative paracetamol consumption was higher in the control group (37.5 ± 17.1 mg/kg) compared to erector spinae plane block group (8.5 ± 10.9 mg/kg) (P ˂ .001, 95% CI: 21.57; 36.43). The time to the first postoperative rescue analgesic requirement was longer in the erector spinae plane block group.

CONCLUSION

Ultrasound-guided erector spinae plane block reduced CHEOPS score for the first eight hours postoperatively with the reduction of intraoperative fentanyl and postoperative paracetamol consumptions.

T4 Erector Spinae Plane Block Relieves Postdural Puncture Headache: A Case Report

Postdural puncture headache (PDPH) is a common complication of neuraxial anesthesia. The gold standard treatment for PDPH is an epidural blood patch (EBP). However, the risks of EBP, and patient willingness to undergo another attempted neuraxial procedure, can prevent patients from receiving this treatment. The erector spinae plane (ESP) block has been used in the treatment of acute postoperative and chronic pain secondary to many indications at many vertebral levels, and a prior case series describes two patients in which ESP block relieved tension headache. In our case report, we describe a novel use of the ESP block at the fourth thoracic vertebral level to relieve PDPH in a super morbidly obese patient with two prior inadvertent dural punctures.

T1 Erector Spinae Plane Block Catheter As a Novel Treatment Modality for Pancoast Tumor Pain

Pancoast tumors are non-small cell lung tumors, which can invade the ribs, vertebrae, sympathetic ganglia and brachial plexus. In this study, a patient with right-sided Pancoast tumor presented with intractable chronic pain on the right neck, upper extremity and chest wall. The chronic pain associated with Pancoast tumor, which was difficult to treat with opioids and other medications, was effectively treated with a high-thoracic erector spinae plane block (ESPB). Prolonged analgesia was provided with an ESP catheter to wean the patient from opioids. This case report provides an example where the novel interfacial ESP block can provide pain relief in challenging situations such as lung malignancies involving deeper structures and extensive areas of pain.

Erector spinae plane block: A safe, simple and effective alternative for knee surgery

Neuraxial anaesthesia techniques are routinely used to manage postoperative pain in patients undergoing lower limb orthopaedic surgery. However, neuraxial anaesthesia is contraindicated in patients with a deformed spine or coagulopathy. Researchers recently described the erector spinae plane block—a safe, easy and effective interfascial plane block for managing chronic thoracic pain. Since then, it has been used for providing analgesia in thoracic, abdominal and hip surgery. We report its analgesic use in two patients undergoing knee surgery: one with lumbar scoliosis undergoing above knee amputation, and the other with haemophilia undergoing bilateral knee arthroplasty.

Comparison of dexmedetomidine and dexamethasone as adjuvant for ropivacaine in ultrasound-guided erector spinae plane block for video-assisted thoracoscopic lobectomy surgery: a randomized, double-blind, placebo-controlled trial

Background

Adding an adjuvant, such as dexmedetomidine or dexamethasone, to a nerve block improves its quality and reduces perioperative opioid consumption. We aimed to compare the effect of dexmedetomidine and dexamethasone as an adjuvant for the erector spinae plane block (ESPB) to control postoperative pain after video-assisted thoracoscopic lobectomy surgery (VATLS).

Methods

Ninety patients, aged 20-65 years who were scheduled to undergo VATLS were enrolled in this trial. The visual analogue scale (VAS) score changes at various time points [waking up in post-anesthesia care unit (PACU) and 2, 4, 6, 8, 12, 24, 48, 72 h after surgery], duration of sensory block, first request to use the patient controlled analgesia (PCA) device, total PCA use, postoperative nausea and vomiting (PONV), rate of rescue analgesia use, and post-surgical hospital stay were recorded.

Results

VAS score was lower in the ropivacaine with dexmedetomidine (RM) group at wake up and at postoperative 2, 4, 12, and 24 h. The median duration of sensory blockade was significantly longer in the RM group (P=0.001). First request to use the PCA machine in the RM group was prolonged significantly compared with that in the ropivacaine alone (R) group and ropivacaine with dexamethasone (RS) group (P<0.001). Total PCA use, post-surgical hospital stay, and rate of rescue analgesia use in The RM group were reduced significantly compared with those in the R and RS groups.

Conclusions

Using dexmedetomidine (1 µg/kg), instead of dexamethasone (10 mg), as an adjuvant of ESPB with ropivacaine, prolonged sensory block duration, provided effective acute pain control, and required lesser rescue analgesia and shorter hospital stays.

Efficacy of ultrasound-guided erector spinae plane block for analgesia after laparoscopic cholecystectomy: a randomized controlled trial†

Background and objectives

The primary aim of this study is to assess the effect of ultrasoung-guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores.

Methods

Patients between 18–70 years old, ASA I-II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US-ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US-ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded.

Results

There were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1, 39] = 24.061, p < 0.0005).

Conclusions

Bilateral US-ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.

Analgesic efficacy of erector spinae plane block in percutaneous nephrolithotomy : A randomized controlled trial

BACKGROUND

The postoperative pain in percutaneous nephrolithotomy (PCNL) is due to dilatation of the renal capsule and the parenchymal tract. The aim of the study was to evaluate the analgesic effect of preoperative single-shot ultrasound(US)-guided erector spinae plane block (ESPB) at theT11 vertebral level in patients undergoing PCNL.

MATERIAL AND METHODS

In this prospective randomized controlled study 56 patients were randomized into 2 groups; group B and group C. An erector spinae plane block (ESPB) was performed preoperatively in all patients; patients in group B received 30 ml 0.25% bupivacaine, while patients in group C received 30 ml normal saline as placebo. The following parameters were evaluated: intraoperative fentanyl consumption, time to first use of patient controlled analgesia (PCA), postoperative morphine consumption over 24 h, pain scores at 0, 2, 4, 6, 12 and 24 h, sedation scores at 2, 6, 12 and 24 h, and patient satisfaction.

RESULTS

Patients in group B had lower intraoperative fentanyl consumption (P = 0.01), longer time to first use of PCA (P = 0.01), lower rescue morphine consumption over 24 h (P = 0.002), and higher patient satisfaction scores (P = 0.02). Postoperative numerical rating scale scores were lower in group B at 2 and 12 h (median = 3 and 2, respectively), as opposed to the control group (median = 4 and 3, respectively, P = 0.02). Sedation scores were higher in group C at 2 and 6 h after the procedure (P = 0.02 and 0.03, respectively).

CONCLUSION

The use of US-guided ESPB provides a good postoperative analgesia and decreases opioid consumption over 24 h in patients undergoing PCNL.

Bilateral single-injection erector spinae plane block versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: a randomized non-inferiority trial

BACKGROUND

Intrathecal morphine (ITM) provides effective postoperative analgesia in living donor hepatectomy but has significant adverse effects. Studies support the efficacy of erector spinae plane (ESP) blocks in laparoscopic abdominal surgery; we therefore hypothesized that they would provide non-inferior postoperative analgesia compared with ITM and reduce postoperative nausea/vomiting and pruritus. We conducted a randomized, controlled, non-inferiority trial to compare the analgesic efficacy of ITM and bilateral single-injection ESP blocks in laparoscopic donor hepatectomy.

METHODS

Fifty-four donors were randomized to receive bilateral ESP blocks with 20 mL 0.5% ropivacaine (n=27) or 400 µg ITM (n=27). Primary outcome was resting pain score 24 hours postoperatively measured on an 11-point numeric rating scale. The prespecified non-inferiority limit was 1. Incidences of postoperative nausea/vomiting and pruritus were assessed.

RESULTS

The mean treatment difference (ESP-ITM) in the primary outcome was 1.2 (95% CI 0.7 to 1.8). The 95% CI upper limit exceeded the non-inferiority limit. Opioid consumption and all other pain measurements were similar between groups up to 72 hours postoperatively. The ESP group had significantly lower incidences of postoperative vomiting (p=0.002) and pruritus (p<0.001).

CONCLUSIONS

Bilateral single-injection ESP blocks resulted in higher resting pain scores 24 hours postoperatively compared with ITM and thus did not meet the study definition of non-inferiority. However, the pain intensity with ESP blocks was mild (mean pain scores <3/10) and associated with reduced incidence of postoperative vomiting and pruritus. It warrants further investigation as an analgesic option after laparoscopic living donor hepatectomy.

TRIAL REGISTRATION NUMBER

KCT0003191.

[Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series]

OBJECTIVE AND BACKGROUND

Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients.

METHOD

Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded.

RESULTS

Pain scores ranged from 0 to 4 among the three patients and 48h opioid consumption in oral morphine equivalents of 4, 6 and 18mg. No adverse events were recorded up to patient discharge from the hospital.

CONCLUSIONS

Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series

Objective and background

Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients.

Method

Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded.

Results

Pain scores ranged from 0 to 4 among the three patients and 48 h opioid consumption in oral morphine equivalents of 4, 6 and 18 mg. No adverse events were recorded up to patient discharge from the hospital.

Conclusions

Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Efficacy of bilateral erector spinae plane block in the management of pain: current insights

Erector spinae plane block (ESPB) is a newly described interfascial plane block, and the number of articles on the bilateral application of ESPB is increasing in the literature. In this paper, in addition to analyzing bilateral ESPB cases and studies published so far, we aimed to review the relevant anatomy, describe the mechanism of spread of the injectant, demonstrate varying approaches to ESPB, and summarize case reports and clinical trials, as well as provide current insight on this emerging and popular block. Randomized controlled studies, comparative studies of ESPB versus other methods, and pharmacokinetic studies of bilateral applications must be the next step in clearly understanding bilateral ESPB.

RETRACTED: The influence of phrenic nerve paralysis for a thoracic erector spinae plane block

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief as it contains fabricated/falsified data. The Editor-in-Chief decision was based on the investigation by the Japanese Society of Anesthesiologists which concluded that no research was conducted and all the data including patient backgrounds were fabricated. The society also concluded that the corresponding author, Dr. Ueshima presented the names of the individuals not involved or only partially involved in research as lead authors, presented the names of the individuals not involved in research as co-authors and submitted papers without the agreement of the co-authors. The investigation report can be found here.

Expanding Role of the Erector Spinae Plane Block for Postoperative and Chronic Pain Management

PURPOSE OF REVIEW

The erector spinae plane block (ESPB), first described in 2016, offers the promise of becoming a safe, less invasive, and technically less demanding alternative to conventional thoracic regional anesthetic techniques including thoracic epidurals and traditional paravertebral blocks. Clinical and cadaveric studies suggest that ESPB acts on the ventral rami of spinal nerves in the paravertebral space via penetration of the intertransverse connection tissues and moreover achieves visceral analgesia via the rami communicantes and sympathetic chain.

RECENT FINDINGS

The block has garnered considerable appeal related to an inherently lower risk of neurovascular and pleural injury, low risk of local anesthetic systemic toxicity, and relative technical simplicity in comparison with epidural or paravertebral blockade. It has been utilized in the treatment of acute perioperative pain in a variety of clinical applications including breast, thoracic, and abdominal surgeries and trauma and may even offer some benefit in spine surgery. Given the combination of its efficacy and decreased associated risk when performed for perioperative pain, use of ESPB should be further explored for the management of chronic pain. Current literature at this time is limited to case studies and series performed by select groups. Though it is important to consider ESPB for chronic pain, further studies are needed to evaluate the efficacy and safety of the ESPB in the management of both acute and chronic pain.