Anatomical basis of erector spinae plane block: a dissection and histotopographic pilot study

Erector spinae plane block (ESPB) enhances hemodynamic stability decreasing analgesic requirements in surgical stabilization of rib fractures (SSRFs)

OBJECTIVE

To evaluate the efficacy of erector spinae plane block (ESPB) on intraoperative hemodynamic stability, opioid and inhalation anesthetic requirements and postoperative analgesic effects in patients undergoing surgical stabilization of rib fractures (SSRFs).

METHODS

We retrospectively reviewed 173 patients who underwent surgical stabilization of rib fractures between May 2020 and December 2023. The patients were allocated into the ESPB group or the control group. Demographic data, intraoperative hemodynamic parameters, total intraoperative opioid consumption, the average minimum alveolar concentration (MAC) of inhalational anesthetics, postoperative simple analgesics and opioid consumption and the length of hospital stay were included in the analysis.

RESULTS

Compared with the control group, the ESPB group had a lower heart rate (HR) in the first 90 min after surgical incision and lower systolic blood pressure (SBP) and mean arterial pressure (MAP) at the beginning of surgery. Intraoperatively, a notable reduction in fentanyl consumption was observed in the ESPB group (p = 0.004), whereas no significant difference was observed in the average MAC of inhalational agents (p = 0.073). Postoperatively, the ESPB group required fewer doses of simple analgesics in the first 24 h (p < 0.001) and 48 h (p = 0.029). No statistically significant difference in the length of hospital stay (p = 0.608) was observed between the groups.

CONCLUSION

ESPB was shown to enhance intraoperative hemodynamic stability, reduce opioid consumption and decrease postoperative analgesic consumption in patients who underwent SSRF. These results suggest that ESPB may serve as a valuable component of multimodal analgesia protocols for SSRF. Larger prospective studies are warranted to confirm the results and evaluate long-term outcomes.

The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery.

DESIGN AND SETTING

The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375).

PARTICIPANTS

Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate.

CONCLUSIONS

Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.

Efficacy of Erector Spinae Plane Block on Postoperative Analgesia for Patients Undergoing Metabolic Bariatric Surgery: A Randomized Controlled Trial

BACKGROUND

Metabolic bariatric surgery (MBS) advocates multimodal analgesia, discouraging opioid use to minimize side effects, such as nausea and vomiting, during postoperative pain management for quicker recovery. Combining erector spinae plane block (ESPB) with multimodal analgesia aims to reduce opioid consumption, improving postoperative recovery. This study aimed to compare morphine consumption between patients with severe obesity undergoing laparoscopic MBS with and without ESPB.

METHODS

This study enrolled 91 patients with severe obesity who underwent laparoscopic MBS involving either sleeve gastrectomy or Roux-en-Y gastric bypass. Of these, 63 patients were included in this study. The participants were randomly allocated to either the intervention group, which received an ESPB before the standard anesthesia protocol, or the control group, which did not receive pre-anesthesia block. The primary outcome measured was 24-h morphine consumption via a patient-controlled analgesia machine. Secondary outcomes included patients' satisfaction, postoperative numerical rating score, changes over time, and quality of recovery (QoR) using the Thai QoR-35 score.

RESULTS

We found no statistically significant difference in morphine consumption between the intervention group and the control group. Furthermore, our analysis revealed no significant between-group differences in patient satisfaction, postoperative numeric rating score, or QoR across all five aspects evaluated using the Thai QoR-35 score.

CONCLUSIONS

ESPB did not reduce morphine consumption or QoR following laparoscopic MBS. Further studies are required to confirm and identify the reasons for the ineffectiveness of ESPB.

Bilateral erector spinae plane block by multiple injection for pain control in pseudomyxoma peritonei surgery: a single-blind randomized controlled trial

OBJECTIVE

Currently, the primary surgical treatment for pseudomyxoma peritonei (PMP) is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The perioperative period is frequently accompanied by severe pain. Erector spinae plane block (ESPB) can enhance analgesia for abdominal surgery. The purpose of this study was to compare the analgesic effects of bilateral multiple-injection ESPB in patients with PMP.

METHODS

Fifty patients with PMP were randomly divided into two groups: the ESPB combined with general anesthesia group (Group E) and the general anesthesia alone group (Group C). Prior to the induction, patients in Group E underwent ESPB at the T7 and T11 levels. The primary outcome was the visual analog scale (VAS) scores during rest at 6 h post-extubation. Secondary outcomes included intraoperative and postoperative opioid consumption, time for first rescue analgesia, frequency distribution of rescue analgesia, incidence of nausea and vomiting, adverse events associated with ESPB.

RESULTS

The Visual Analogue Scale (VAS) scores in Group E were significantly lower compared to Group C at immediate post-extubation (1.6 ± 0.9 vs. 2.4 ± 1.2, P = 0.008), and at 2 (1.9 ± 1.2 vs. 3.2 ± 1.1, P < 0.001), 4 (2.4 ± 1.5 vs. 3.7 ± 1.0, P = 0.001), and 6 h (2.7 ± 1.1 vs. 3.8 ± 1.4, P = 0.004) post-extubation during rest. Similarly, the VAS scores in Group E were significantly lower than those in Group C at immediate post-extubation (3.0 ± 1.4 vs. 4.6 ± 1.2, P < 0.001), and at 2 (3.8 ± 1.7 vs. 4.9 ± 1.4, P = 0.019), 4 (3.5 ± 1.3 vs. 5.3 ± 1.5, P < 0.001), and 6 h (3.9 ± 1.8 vs. 4.9 ± 1.3, P = 0.004) post-extubation during movement. In Group E, the intraoperative remifentanil administration (2319.3 ± 1089.5 vs. 2984.6 ± 796.1, P = 0.017) and the amount of rescue analgesia within 2 h post-extubation (0 vs. 4, P = 0.037) were significantly less than in Group C, and the first rescue analgesia time was shorter as well (231.4 ± 147.5 vs. 668.8 ± 416.7, P < 0.001).

CONCLUSION

Compared to general anesthesia alone, bilateral multiple-injection ESPB with 0.2% ropivacaine can enhance analgesia and reduce opioid administration in patients with PMP. However, the duration of analgesia with ESPB is relatively short due to the low concentration of the local anesthetic used.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300069504, 20/03/2023.

The Analgesic Mechanism and Recent Clinical Application of Erector Spinae Plane Block: A Narrative Review

Now, the erector spinae plane block (ESPB) is widely used in various thoracolumbar surgeries. It has unique advantages: simple and convenient operation, low safety risks, and reduced opioid use. The ESPB is used in thoracic surgery, abdominal surgery, and spinal surgery. There are also relevant research reports on postoperative analgesia during general anesthesia surgery. This article searches the PubMed and Web of Science databases to find and screen relevant studies on ESPB since 2019 and retrospectively summarizes the current indications of ESPB. The methodological quality of the included studies was assessed using the Cochrane bias risk tool. The results showed that the current research on ESPB generally provides low-level clinical evidence. The complex anatomy of the erector spinae muscles is both responsible for its unique advantages and restricts its development. Few anatomical studies have clearly and completely demonstrated the diffusion relationship of local anesthetics among the anatomical structures of the erector spinal muscles. The uncontrollability of the diffusion plane prevents ESPB from being applied on a wider scale with a high level of evidence. To further clarify the scope of application of ESPB and achieve the best analgesic effect, in the future, we should focus on the unique anatomical course and distribution of the erector spinal muscles and their fascia and nerves. It is necessary to combine anatomical, imaging, and histological methods to obtain high-quality evidence to guide clinical application.

Effectiveness of the Bilateral and Bilevel Erector Spinae Plane Block (ESPB) in Pediatric Idiopathic Scoliosis Surgery: A Randomized, Double-Blinded, Controlled Trial

BACKGROUND

This study aimed to compare the effect of the ultrasound-guided bilateral and bilevel erector spinae plane block (ESPB) on pain scores, opioid requirement, intraoperative motor-evoked potentials (MEPs), and stress response to surgery expressed by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) versus standard analgesia methods following idiopathic scoliosis surgery.

METHODS

This was a prospective, double-blinded, randomized controlled trial. Sixty patients aged 10 to 18 years and physical status ASA 1 or 2 were randomized into 2 equal groups, each receiving an ESPB or sham block. The primary outcome was the pain scores (Numerical Rating Scale, NRS) within 48 hours after spinal correction and fusion surgery for idiopathic thoracic scoliosis. The secondary outcomes were total opioid consumption, NLR, and PLR levels at 12 and 24 hours postoperatively and intraoperative MEPs.

RESULTS

ESPB patients presented lower NRS scores, signifying less pain, at all time points (30, 60, 90, 120 min; and 6, 12, 24, and 48 h after surgery), all P <0.0001. The total opioid consumption, the incidence of nausea or vomiting, and the need for remifentanil and propofol during surgery were significantly lower in the ESPB group. The surgery-induced stress response expressed by NLR and PLR was considerably lower in the ESPB group. ESPB did not affect the intraoperative MEP's amplitude.

CONCLUSIONS

ESPB is effective for postoperative analgesia, can reduce opioid consumption in patients undergoing scoliosis surgery, and reduces the stress response to surgery. ESPB does not interfere with neuromonitoring.

LEVEL OF EVIDENCE

Level I.

Relationship between injectate volume and disposition in erector spinae plane block: a cadaveric study

INTRODUCTION

Erector spinae plane (ESP) blocks can be used to provide analgesia following thoracoabdominal and lumbar spine surgical procedures. However, the influence of injectate volume and injection location on the spread of anesthetic with ESP blocks remain unclear.

METHODS

Ultrasound-guided ESP injections were performed on two fresh cadavers using a solution of iopamidol radiographic contrast, indocyanine green or methylene blue dye, and saline. The relationship between injectate volume and cephalocaudal spread was assessed using real-time fluoroscopic recordings after incremental ESP injections to the lumbar and thoracic region. Cadavers were then dissected to expose tissue staining and document the precise disposition of the dye within the ES muscle, paravertebral space, dorsal and ventral rami, and other relevant structures.

RESULTS

Larger injection volumes resulted in more extensive cephalocaudal spread in most cases, with fluoroscopic images revealing a small but direct relationship between injectate volume and contrast spread. Dissection reinforced the radiographic findings, with staining ventral to the ES muscle ranging from 4 to 7 paravertebral levels with injections of 30-40 mL vs 12-13 levels following injections of 60-80 mL. No spread of dye to the lamina, transverse processes, paravertebral space, epidural space, or pleura was observed following any injection.

CONCLUSIONS

Increased ESP injection volumes resulted in more extensive cephalocaudal spread, resulting in anesthetic spread to the dorsal rami and ventral ES muscle without involvement of the ventral rami or other anterior structures. Injection volumes of 30 mL may be optimal for ESP blocks requiring analgesia across 4-7 levels.

Erector spinae plane infiltration and anterior rami of spinal nerve: a cadaveric study

BACKGROUND

The erector spinae plane block (ESP block) is frequently employed for thoracic, abdominal, and spinal surgeries, yet its precise mechanism of action remains a subject of debate. While initially postulated to influence both ventral and dorsal rami of the spinal nerve, recent studies indicate a predominant impact on the dorsal rami with limited involvement of the ventral rami. To elucidate this mechanism, we conducted an observational study to assess the distribution of ESP infiltration to the ventral rami.

METHODS

We performed 20 ESP infiltrations bilaterally in 10 unembalmed cadavers, targering the T9 transverse process level. A volume of 20 mL of ropivacaine 0.2% and methylene blue 0.01% was used. Dissection was carried out to assess dye distribution, with a focus on involvement of the ventral and dorsal rami, as well as lateral and longitudinal spread within the spinal muscular plane.

RESULTS

No evidence of dye staining was observed in the ventral rami in any of the cadavers; however, the dorsal rami consistently displayed staining. The dye exhibited extensive longitudinal diffusion across the paravertebral musculature, spanning a median of 10 vertebral spaces (T5-L2). The range extended from 3 to 18 spaces, with an IQR of 11 levels (T4-L2), predominantly affecting the longissimus and iliocostalis muscles.

CONCLUSIONS

The infiltration of injectate into the ESP does not contact the ventral rami of segmental spinal nerves. The inference that an in vivo ESP block is a paravertebral "by-proxy" is, therefore, unlikely.

Intraoperative changes in upper extremity perfusion index after thoracic paravertebral and intertransverse process block in patients undergoing lung resection surgery

Background

Perfusion index (PI) has been used as a surrogate marker of sympathetic blockade. This study evaluated changes in PI of bilateral upper extremity after thoracic paravertebral block (PVB) and intertransverse process block (ITPB).

Methods

This pilot study included three groups of patients undergoing elective unilateral pulmonary resection under general anesthesia with PVB (n=11) or ITPB (n=10), or urologic procedures with general anesthesia (control group, n=10). Blockades were performed using 10 mL aliquots of 0.5% ropivacaine administered at T3-4, T5-6, and T7-8 intercostal levels immediately after general anesthesia induction. The PI value of the operating side (PI-O) was divided by the contralateral side (PI-CL), and the relative change to baseline was assessed (relative PI-O/PI-CL), with a 50% increase considered meaningful.

Results

In all cases within the PVB and ITPB groups, a significant increase in PI was observed following the blockades. The median (1Q, 3Q) intraoperative relative PI-O/PI-CL values were 0.9 (0.8, 1.4), 2.1 (1.4, 2.5), and 1.4 (0.9, 1.9) in the control, PVB, and ITPB groups (P=0.01), respectively. Pairwise comparison revealed a significant difference only between the control and PVB groups (adjusted P=0.01). While the relative PI-O/PI-CL value in the control group generally remained close to 1, occasional fluctuations exceeding 1.5 were noted.

Conclusions

PVB induced a noticeable unilateral increase in upper extremity PI, whereas ITPB tended to result in an inconsistent and lesser degree of increase. Monitoring PI values can serve as an indicator of upper extremity sympathetic blockade, but consideration of potential confounders impacting these observations during surgery is essential. Further research is needed to validate these findings.

Lumbar erector spinae plane block versus infrainguinal fascia iliaca compartment block for pain management after total hip arthroplasty: a randomized clinical trial

OBJECTIVE

We aimed to evaluate the effectiveness of ultrasound-guided facia iliaca compartment (FIC) and erector spinae plane (ESP) blocks in managing postoperative pain after total hip arthroplasty surgery.

METHODS

A total of 60 patients were randomized into 2 groups (n = 30): one that received FIC blocks and one that received ESP blocks. FIC and ESP blocks were performed with 30 mL 0.25% bupivacaine at the end of the surgery. The patients received intravenous tramadol and patient-controlled postoperative analgesia. The pain scores, opioid consumption, and adverse events were recorded.

RESULTS

The dynamic pain scores on movement in the postoperative first hour were significantly lower in the ESP block group than in the FIC block group (3 [2-4] vs 4 [2-5], respectively; P = .035). Data are expressed as median (25th-75th percentiles). Postoperative opioid consumption within the first postoperative 8 hours was significantly higher in the FIC block group than in the ESP block group (80 mg [61-100] vs 100 mg [80-120], respectively; P = .010). The adverse effects of opioids did not differ between the 2 groups.

CONCLUSION

ESP and infrainguinal FIC blocks provided similar postoperative analgesia 24 hours after total hip arthroplasty. The ESP block is more beneficial than the FIC block in terms of pain scores and opioid consumption in the early hours of the postoperative period.

TRIAL REGISTRATION

www.ClinicalTrials.gov (ID: NCT05621161).

Pathways of dye spread after injections in the paraspinal spaces-A cadaveric study

BACKGROUND

The erector spinae plane (ESP) block is the most sought-after block since its inception. However, it is more of dorsal rami block with unpredictable ventral diffusion to the paravertebral area. We injected dye in ESP and other paraspinal spaces to study and compare the dye diffusion pattern along the neuroaxis and paraspinal region in human cadavers.

METHODS

In six soft-embalmed cadavers (12 specimens), 20 mL methylene blue dye (erector spinae plane and paravertebral space) or indocyanine green dye (inter-ligament space) was injected bilaterally using an in-plane ultrasound-guided technique at the level of the costotransverse junction of fourth thoracic vertebrae. Dye spread was evaluated bilaterally in the coronal plane in the paravertebral and intercostal spaces from the 1st and the 12th rib. Axial and sagittal sections were performed at the level of the 4th thoracic vertebrae. After cross sections, the extent of dye spread was investigated in ESP, inter-ligament, and paravertebral spaces. The staining of the ventral and dorsal rami and spread into the intercostal spaces was evaluated.

RESULTS

ESP injection was mainly restricted dorsal to the costotransverse foramen and did not spread anteriorly to the paravertebral space. The paravertebral injection involved the origin of the spinal nerve and spread laterally to the intercostal space. The inter-ligament space injection showed an extensive anterior and posterior dye spread involving the ventral and dorsal rami.

CONCLUSIONS

Following ESP injection, there was no spread of the dye anteriorly to the paravertebral space and it only involved the dorsal rami. Inter-ligamentous space injection appears to be the most promising block as dye spread both anteriorly to paravertebral space and posteriorly toward ESP.

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study

OBJECTIVE

The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients.

DESIGN

A prospective, randomized, double-blind, comparative study.

SETTING

At a single institution tertiary referral cardiac center.

PARTICIPANTS

A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy.

INTERVENTIONS

Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia.

MEASUREMENTS AND MAIN RESULTS

The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups.

CONCLUSION

Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients.

Comparison of the median and intermediate approaches to the ultrasound-guided sacral erector spinae plane block: a cadaveric and radiologic study

BACKGROUND

Erector spinae plane block (ESPB) is a well-established method for managing postoperative and chronic pain. ESPB applications for the sacral area procedures are called sacral ESPBs (SESPBs). This cadaveric study aimed to determine the distribution of local anesthesia using the median and intermediate approaches to the SESPB.

METHODS

Four cadavers were categorized into the median and intermediate approach groups. Ultrasound-guided SESPBs were performed using a mixture of radiopaque agents and dye. Following confirmation of the solution distribution through computed tomography (CT), the cadavers were dissected to observe the solution distribution.

RESULTS

CT images of the median group demonstrated subcutaneous pooling of the radiopaque solution between the S1 and S5 horizontal planes. Radiopaque solution also passed from the sacral foramina to the anterior sacrum via the spinal nerves between S2 and S5. In the intermediate group, the solution distribution was observed along the bilateral erector spinae muscle between the L2 and S3 horizontal planes; no anterior transition was detected. Dissection in the median group revealed blue solution distribution in subcutaneous tissue between horizontal planes S1 and S5, but no distribution in superficial fascia or muscle. In the intermediate group, red solution was detected in the erector spinae muscle between the L2 and S3 intervertebral levels.

CONCLUSIONS

Radiologic and anatomic findings revealed the presence of radiopaque dye in the superficial and erector spinae compartments in both the median and intermediate groups. However, anterior transition of the radiopaque dye was detected only in the median group.

Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery in the Context of an Enhanced Recovery after Surgery Protocol: A Prospective Study Comparing Erector Spinae Plane Block versus Transversus Abdominis Plane Block

Regional anesthesia in postoperative pain management has developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus the ultrasound-guided bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a prospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9 and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with 20 mL ropivacaine 0.375% or 0.25%. The primary outcome was the postoperative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB group on postoperative days 0, 1, 2, and 3 (p < 0.001) and, consequently, the number of patients requiring postoperative supplemental analgesic rescue therapies was significantly lower (p < 0.001). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in the group (p < 0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than the TAPB-group in postoperative days from 2 to 4 (1 vs. 3, p > 0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB group and no block-related complications were observed. Our data indicate that ESPB provides postoperative pain control at least as good as TAPB plus morphine, with less local anesthetic needed.

Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy

Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.

Analgesic Efficacy of Nalbuphine as an Adjuvant to Ropivacaine in Erector Spinae Plane Block for Percutaneous Nephrolithotomy: A Randomized, Double-Blinded, Clinical Trial

Background

Erector spinae plane block (ESPB) is an easy and safe method for postoperative analgesia. However its effect lasts only for several hours. This trial was to investigate the effectiveness of different doses of nalbuphine as an adjuvant to ropivacaine in ESPB for patients undergoing percutaneous nephrolithotomy (PCNL).

Methods

Patients scheduled for PCNL were randomized into three groups and received ultrasound-guided ESPB at T10 level for postoperative analgesia. Each subject received 28 mL of 100 mg ropivacaine solution mixed with 2 mL of normal saline (Group R), 2 mL of 10 mg nalbuphine (Group RNL), or 2 mL of 20 mg nalbuphine (Group RNH). Primary outcome was the time to first opioid demand. Secondary outcomes were morphine consumption, VAS scores within 24 h postoperatively, rescue analgesic requirements, and length of hospital stay.

Results

The median [interquartile range, IQR] time to first opioid demand was significantly longer in group RNH (8.70 [6.90,14.85] h) than that of group R and group RNL (2.90 [2.00,6.30] h and 5.80 [2.95,7.00] h, respectively). VAS scores (either resting or active) within 24 h postoperatively were comparable between the three groups, with the most significant differences especially at 4, 6, 8 h. Morphine consumption at 24 h postoperatively was significant for R group vs RNH group (median difference, 9; 95% confidence interval [CI], 1.57 to 16.43; p = 0.02).

Conclusions

Adding 20mg nalbuphine to ropivacaine in ESPB could significantly improve the effect of analgesia and prolong the duration of nerve blocks for PCNL.

Anatomical insights into injectate spread after thoracic erector spinae plane block: A systematic review

BACKGROUND AND AIMS

The efficacy of the erector spinae plane block (ESPB) has been demonstrated in several meta-analyses and it is increasingly being used in clinical practice. However, its mechanism of action is still not fully elucidated. Although initial anatomical studies have suggested the spread of the injectate into the paravertebral space as the main mechanism of action, more recent studies have not consistently demonstrated this. This systematic review was conducted to determine the overall proportion and extent of injectate spread following a thoracic ESPB.

METHODS

PubMed, Scopus and EMBASE were searched. All studies that examined the injectate spread after a thoracic ESPB either through dissection or imaging were included. Excluded were all reviews, studies performed in paediatric patients and non-thoracic ESPBs. The primary outcome was the proportion of subjects with injectate spread in the erector spinae plane (ESP), paravertebral space (PVS), intercostal space (ICS) and epidural space (ES).

RESULTS

This review included 29 studies involving 113 cadavers and 79 volunteers. The proportion of subjects with injectate spread in the ESP, ICS, ES and PVS was 1 (95% confidence interval, 0.97-1), 0.51 (95% CI, 0.38-0.64), 0.38 (95% CI, 0.28-0.5) and 0.57 (95% CI, 0.49-0.64) respectively. The mean spread of injectate in the ESP, ICS, ES and PVS were 9.1 (95% CI, 8.0-10.3), 5.6 (95% CI, 4.0-7.3), 3.1 (95% CI, 1.0-5.3) and 3.5 (95% CI, 2.4-4.6) spinal levels respectively.

CONCLUSION

Based on this study, the thoracic ESPB consistently led to injectate spread into the ESP compartment but less reliable spread into the PVS, ES and ICS compartments. There is also preliminary evidence that an increased time to assessment may be associated with an increased spread of injectate into the PVS.

The Use of Erector Spinae Plane Block Reduces Opioid Consumption and Pain Score in Postoperative Period After Hip Surgery: A Meta-Analysis

Erector spinae plane block (ESPB) is a relatively new regional anesthesia block that has been used in thoracic and abdominal surgeries with variable success. ESPB can easily be administered using an ultrasound technique with a safer profile. Recently, there have been few randomized controlled trials (RCTs) regarding the role of ESPB in hip surgeries. A current meta-analysis was done to evaluate the role of ESPB block in controlling postoperative pain after hip surgeries. PRISMA guidelines were followed to perform this meta-analysis. We used online databases including Science Direct, PubMed, Google Scholar, and Cochrane Library. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database as ID-CRD42023445516 in July 2023. We included studies that reported opioid use, pain control after surgery, and side effects associated with ESPB for hip surgeries. The ReviewManager software, i.e., RevMan for Mac 5.4 (Cochrane Collaboration, Oxford, UK), was utilized to conduct this meta-analysis. We included five RCTs during this meta-analysis. Our results demonstrated that the use of ESPB in hip surgery caused a significant decrease in 24-hour postoperative opioid consumption (p=0.02). ESPB also resulted in a significant decrease in pain scores up to nine hours postoperatively (p<0.05).

The Analgesic Effects of Preemptive Ultrasound-Guided Pericapsular Nerve Group Block in Comparison with Erector Spinae Plane Block in Elderly Undergoing Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Perioperative pain management strategies in the elderly undergoing hip arthroplasty need special and safe preemptive care.

OBJECTIVES

The primary aim of this study was to compare the analgesic effects of preemptive ultrasound-guided pericapsular nerve group (PENG) block and lumbar erector spinae plane block (L-ESPB) in the elderly undergoing hip arthroplasty. The time to the first postoperative rescue analgesia was measured. The secondary aim was to assess the ease of spinal positioning (EOSP), onset of sensory block, block performance time, and patient satisfaction.

METHODS

Before positioning for spinal anesthesia, 69 elderly patients undergoing hip arthroplasty were randomized into three groups (n = 23 per group). The first intervention group received ultrasound-guided PENG block with 20 mL bupivacaine 0.25%; the second intervention group received ultrasound-guided L-ESPB using the same dose of bupivacaine. In the control group, patients received spinal anesthesia without any block.

RESULTS

The time to first postoperative rescue analgesic (morphine) was significantly prolonged in the PENG group (13.3 ± 3.5 h) compared to the L-ESPB (9.5 ± 2.3 h) and control (2.6 ± 0.4 h) groups. The EOSP score was significantly higher in the PENG group compared to the L-ESPB and control groups (P < 0.001). The block performance time and oneset of the sensory block were significantly shorter in the PENG group compared to the L-ESPB group. The highest patient satisfaction scores were observed in the PENG group.

CONCLUSIONS

Preemptive pericapsular nerve group block postponed the need for postoperative analgesia and eased spinal positioning compared to L-ESPB in the elderly undergoing hip arthroplasty.

Analgesic comparison of erector spinae plane block with intercostal nerve block for thoracoscopic surgery: A meta-analysis of randomized controlled trials

INTRODUCTION

The analgesic efficacy of erector spinae plane block (ESPB) versus intercostal nerve block (ICNB) for thoracoscopic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the impact of ESPB versus ICNB on thoracoscopic surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane library databases through May 2023 for randomized controlled trials (RCTs) assessing the effect of ESPB versus ICNB on thoracoscopic surgery. This meta-analysis was performed using the random-effect model or fixed-effect model based on the heterogeneity.

RESULTS

Four RCTs and 203 patients are included in the meta-analysis. Overall, compared with ICNB for thoracoscopic surgery, ESPB results in significantly reduced pain scores at 48 hours (SMD [standard mean difference] = -3.49; 95% CI [confidence interval] = -6.76 to -0.21; P = .04), but demonstrated no impact on pain scores at 24 hours (SMD = -0.04; 95% CI = -1.24 to 1.16; P = .95), pain scores at 4 to 6 hours (SMD = -0.16; 95% CI = -2.02 to 1.71; P = .87), pain scores at 12 hours (SMD = -0.16; 95% CI = -2.38 to 2.05; P = .88) or analgesic consumption (SMD = 0.27; 95% CI = -0.80 to 1.35; P = .62).

CONCLUSIONS

ESPB may be comparable with ICNB for the postoperative pain control of thoracoscopic surgery.

Erector spinae plane block versus intercostal nerve block for postoperative analgesia in lung cancer surgery

BACKGROUND

A recent trend in postoperative analgesia for lung cancer surgery relies on regional nerve blocks with decreased opioid administration. Our study aims to critically assess the continuous ultrasound-guided erector spinae plane block (ESPB) at our institution and compare it to a standard regional anesthetic technique, the intercostal nerve block (ICNB).

PATIENTS AND METHODS

A prospective randomized-control study was performed to compare outcomes of patients, scheduled for video-assisted thoracoscopic (VATS) lung cancer resection, allocated to the ESPB or ICNB group. Primary outcomes were total opioid consumption and subjective pain scores at rest and cough each hour in 48 h after surgery. The secondary outcome was respiratory muscle strength, measured by maximal inspiratory and expiratory pressures (MIP/MEP) after 24 h and 48 h.

RESULTS

60 patients met the inclusion criteria, half ESPB. Total opioid consumption in the first 48 h was 21. 64 ± 14.22 mg in the ESPB group and 38.34 ± 29.91 mg in the ICNB group (p = 0.035). The patients in the ESPB group had lower numerical rating scores at rest than in the ICNB group (1.19 ± 0.73 vs. 1.77 ± 1.01, p = 0.039). There were no significant differences in MIP/MEP decrease from baseline after 24 h (MIP p = 0.088, MEP p = 0.182) or 48 h (MIP p = 0.110, MEP p = 0.645), time to chest tube removal or hospital discharge between the two groups.

CONCLUSIONS

In the first 48 h after surgery, patients with continuous ESPB required fewer opioids and reported less pain than patients with ICNB. There were no differences regarding respiratory muscle strength, postoperative complications, and time to hospital discharge. In addition, continuous ESPB demanded more surveillance than ICNB.

Effect of Ultrasound-guided Erector Spinae Plane Block on Recovery After Laparoscopic Sleeve Gastrectomy in Patients With Obesity: A Randomized Controlled Trial

PURPOSE

Previous research has not evaluated the potential effect of erector spinae plane block (ESPB) on quality of recovery (QoR) after laparoscopic sleeve gastrectomy. Therefore, we investigated the effect of an ultrasound-guided ESPB performed on patients with obesity who have undergone laparoscopic sleeve gastrectomy, measured using the 15-item QoR (QoR-15) scale.

METHODS

A total of 172 patients were enrolled in the study who were aged 18 to 65 years, had a body mass index ≥30 kg/m², were classified as having American Society of Anaesthesiologists physical status Ⅱ to Ⅲ, and had undergone laparoscopic sleeve gastrectomy. The patients were randomly divided into an ESPB group and a sham group (treated with normal saline). The primary outcome was the QoR-15 score, measured using the questionnaire 24 and 48 hours after surgery. The secondary outcomes were postoperative pain score, postoperative cumulative analgesic drug consumption, number of patient-controlled analgesia (PCA) requests, rate of rescue analgesia required at 48 hours, incidence of respiratory complications, and nerve block-related complications. The time of discharge from the postanesthesia care unit, postoperative activity, and length of stay at the hospital were also recorded.

FINDINGS

There was no significant difference in the global QoR-15 scores 24 and 48 hours after the operation. However, the groups' subdimension scores for the emotional state in QoR-15 at 24 and 48 hours after surgery were statistically different (P < 0.05). Meanwhile, patients in the ESPB group who indicated they were "feeling rested" at 24 and 48 hours after surgery and "having a feeling of general well-being" at 24 hours after surgery were significantly better than those in the sham group (P < 0.05). Compared with the sham group, participants in the ESPB group had lower resting pain scores at 6 and 12 hours after surgery and lower movement pain scores at 6, 12, 24, and 36 hours after surgery (P < 0.05). There was no statistical difference between the groups in postoperative cumulative analgesic drug consumption, number of PCA requests, incidence of respiratory complications, time of discharge from the postanesthesia care unit, or postoperative activity.

IMPLICATIONS

Our results indicate that a single ESPB does not improve the global QoR-15 scores after laparoscopic sleeve gastrectomy. However, the visual analog scale score for postoperative pain is reduced.

Erector spinae plane versus fascia iliaca block after total hip arthroplasty: a randomized clinical trial comparing analgesic effectiveness and motor block

BACKGROUND

Ultrasound-guided supra-inguinal fascia iliaca block (FIB) provides effective analgesia after total hip arthroplasty (THA) but is complicated by high rates of motor block. The erector spinae plane block (ESPB) is a promising motor-sparing technique. In this study, we tested the analgesic superiority of the FIB over ESPB and associated motor impairment.

METHODS

In this randomized, observer-blinded clinical trial, patients scheduled for THA under spinal anesthesia were randomly assigned to preoperatively receive either the ultrasound-guided FIB or ESPB. The primary outcome was morphine consumption 24 h after surgery. The secondary outcomes were pain scores, assessment of sensory and motor block, incidence of postoperative nausea and vomiting and other complications, and development of chronic post-surgical pain.

RESULTS

A total of 60 patients completed the study. No statistically significant differences in morphine consumption at 24 h (P = 0.676) or pain scores were seen at any time point. The FIB produced more reliable sensory block in the femoral nerve (P = 0.001) and lateral femoral cutaneous nerve (P = 0.018) distributions. However, quadriceps motor strength was better preserved in the ESPB group than in the FIB group (P = 0.002). No differences in hip adduction motor strength (P = 0.253), side effects, or incidence of chronic pain were seen between the groups.

CONCLUSIONS

ESPBs may be a promising alternative to FIBs for postoperative analgesia after THA. The ESPB and FIB offer similar opioid-sparing benefits in the first 24 h after surgery; however, ESPBs result in less quadriceps motor impairment.

Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion: a single-centre prospective randomised controlled trial

BACKGROUND

Erector spinae plane block is a locoregional anaesthetic technique widely used in several different surgeries due to its safety and efficacy. The aim of this study is to assess its utility in spinal degenerative and traumatic surgery in western countries and for patients of Caucasian ethnicity.

METHODS

Patients undergoing elective lower-thoracic and lumbar spinal fusion were randomised into two groups: the case group (n = 15) who received erector spinae plane block (ropivacaine 0.4% + dexamethasone 4 mg, 20 mL per side at the level of surgery) plus postoperative opioid analgesia, and the control group (n = 15) who received opioid-based analgesia.

RESULTS

The erector spinae plane block group showed significantly lower morphine consumption at 48 h postoperatively, lower need for intraoperative fentanyl (203.3 ± 121.7 micrograms vs. 322.0 ± 148.2 micrograms, p-value = 0.021), lower NRS score at 2, 6, 12, 24, and 36 h, and higher satisfaction rates of patients (8.4 ± 1.2 vs. 6.0 ± 1.05, p-value < 0.0001). No differences in the duration of the hospitalisation were observed. No erector spinae plane block-related complications were observed.

CONCLUSIONS

Erector spinae plane block is a safe and efficient opioid-sparing technique for postoperative pain control after spinal fusion surgery. This study recommends its implementation in everyday practice and incorporation as a part of multimodal analgesia protocols.

TRIAL REGISTRATION

The study was approved by the local ethical committee of Romagna (CEROM) and registered on ClinicalTrials.gov (NCT04729049). It also adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines.

Reference centers for tissue and body donations: Compulsory requirements in Italy

Recent Italian legislation (Law No. 10/2020) establishes the legal, ethical and technical requirements governing how individuals can donate their bodies or tissues post-mortem for study, training, and scientific research purposes. A ministerial working group has recently approved some of the law's implementing rules relating to technical issues. The rules for implementing the new legislation, retrieved from the legal databases and translated into English, are discussed. For the first time in Italy, the law establishes compulsory requirements and minimum characteristics-in terms of logistics, safety, availability of staff, space, and equipment-for institutions to be recognized as reference centers for the conservation and use of bodies and tissues donated post-mortem for study, training and scientific research purposes. This makes it possible to standardize the features of such reference centers nationwide, and to coordinate their activities and potential future development, while ensuring basic operational efficiency and workplace safety, the provision of adequate facilities, buildings and equipment, and staff training. The law and its implementing rules discussed here are the first to establish criteria and compulsory requirements for centers receiving body and tissue donations in Italy. This is a step forward for the whole anatomy community, providing practical guidelines for body donation programs and related facilities in other countries too.

The effect of erector spinae plane block on arterial grafts in coronary artery bypass grafting

Background

This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries.

Methods

This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries.

Results

The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05).

Conclusion

The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.

Chronic Pain and Regional Anesthesia: A Call to Action!

Chronic pain is an unwanted companion in the lives of millions of people worldwide, and findings show that more than one in fiveadults in America experience chronic pain [...].

Comparison of analgesic efficacy of different local anesthetic volumes for erector spinae plane block in thoracotomy patients; a prospective randomized trial

BACKGROUND

Erector spinae plane block (ESPB) is a thoracic wall block that has been used frequently in recent years. It was aimed to compare the analgesic efficacy of bupivacaine in different volumes for ESPB in patients undergoing thoracotomy.

METHODS

Patients who were in the age range of 18 to 65 years, ASA I-III, had a body mass index (BMI) of 18-30 kg/m² and were undergoing thoracotomy were included in the study. Patients were assigned to ESPB with 30 ml 0.25% bupivacaine (Group-1) or ESPB with 20 ml 0.25% bupivacaine (Group-2) groups according to the analgesia protocol. In the postoperative care unit, intravenous morphine was administered via a patient-controlled analgesia pump for 24 h. A paracetamol dose of 1 g every 8 h and a dexketoprofen dose of 50 mg twice daily were administered iv for multimodal analgesia.

RESULTS

Visual analog scale (VAS) resting scores, the 1^st (p = 0.001), 2^nd (< 0.001), 4^th (< 0.001), 8^th (< 0.001), 16^th (< 0.010), 24^th (< 0.044), and 48^th (< 0.005)-hour VAS resting results were found to be statistically significantly higher in the 20 ml group than the 30 ml group. VAS cough scores were statistically significantly higher in the 20 ml group at the 1^st (< 0.003), 2^nd (< 0.001), 4^th (< 0.001), 8^th (< 0.001), 16^th (< 0.004), 24^th (< 0.031), and 48^th (< 0.009)-hour. Morphine consumption, and additional analgesic use were found to be statistically significantly higher in the 20 ml group than in the 30 ml group (p < 0.001, p = 0.001, respectively). There was no statistically significant difference between the groups in terms of side effects (p > 0.05).

CONCLUSIONS

The results of ESPB applied with 20 ml and 30 ml of local anesthetic before the surgical incision in thoracotomy patients showed that the use of 30 ml of local anesthetic provided more effective analgesia. In addition, similar side-effect rates show that 30 ml of local anesthetic can be used safely.

Comparison of postoperative IL-6 and IL-10 levels following Erector Spinae Plane Block (ESPB) and classical Thoracolumbar Interfascial Plane (TLIP) block in a posterior lumbar decompression and stabilization procedure: a randomized controlled trial

BACKGROUND AND OBJECTIVES

The erector spinae plane block (ESPB) and classical thoracolumbar interfascial plane (TLIP) block can reduce postoperative pain in lumbar surgery. In this study, we compared the efficacy of ESPB and classical TLIP block in providing perioperative analgesia in patients undergoing lumbar posterior decompression and stabilization by comparing postoperative pain, opioid consumption, and IL-6 and IL-10 serum concentrations between ESPB and classical TLIP block.

METHOD

This was a prospective, double-blinded, randomized controlled trial in tertiary referral hospitals. Forty patients were randomized into two equal groups, each receiving either ESPB or classical TLIP block. The primary outcome was the difference in IL-6 and IL-10 serum concentrations at baseline and 6 h after lumbar posterior decompression and stabilization. The secondary outcome was total opioid consumption and pain score 24 h post-operatively.

RESULT

There were no significant differences between the ESPB and classical TLIP block groups in pain score, IL-6 and IL-10 concentration change, and total opioid consumption post-operatively. There was a significant difference in the time until the first dose of morphine was needed between the ESPB and classical TLIP block groups (300 min vs. 547.5 min; p = 0.002).

CONCLUSION

ESPB and classical TLIP block performance during lumbar surgery have comparable pain scores, IL-6 and IL-10 concentration differences pre- and post-operation, and total opioid consumption post-operatively. However, classical TLIP block provides a prolonged duration of analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04951024.

Erector spinae plane block for postoperative analgesia following percutaneous nephrolithotomy under spinal anaesthesia- A randomised controlled study

Background and Aims

Postoperative pain is a multitude of various irksome sensory, emotional and mental experiences aggravated by surgical trauma and associated with autonomic, endocrine, metabolic, physiological and behavioural responses. The aim of this study was to evaluate the effect of erector spinae plane block (ESPB) in postoperative analgesia following percutaneous nephrolithotomy (PCNL) under spinal anaesthesia.

Methods

This prospective randomised study was conducted on sixty American Society of Anesthesiologists physical status I and II patients scheduled for PCNL under spinal anaesthesia. They were randomised into two equal groups of thirty patients. ESPB was given in group A with 20 ml of injection bupivacaine 0.25% and dexamethasone 8 mg and group B received injection tramadol 1.5 mg/kg intravenously immediately after PCNL. The primary outcome was comparison of visual analogue scale (VAS) score in the first 24 h postoperatively, whereas secondary objectives included hemodynamic variables and requirement of rescue analgesia.

Results

VAS score in group A (ESPB) with mean of 3.15 ± 0.68 was comparatively low when compared to group B with mean of 6.61 ± 0.50 at 6 hours. After 4 h postoperatively, VAS scores continued to be higher and significant number of patients required rescue analgesia in group B.

Conclusion

ESPB reduced VAS score, provided adequate postoperative analgesia, with similar haemodynamic changes and adverse effects in comparison to the conventional analgesia with tramadol in PCNL.

Current evidence of ultrasound-guided fascial plane blocks for cardiac surgery: a narrative literature review

Fascial plane blocks are useful for multimodal analgesia after cardiac surgery since they can provide effective analgesia without the serious risks associated with conventional techniques such as neuraxial hematoma and pneumothorax. This narrative review covers blocks performed at the parasternal intercostal, interpectoral, pectoserratus, serratus anterior, erector spinae, and retrolaminar planes, which are targets for fascial plane blocks in cardiac surgery. Brief anatomical considerations, mechanisms, and currently available evidence are reviewed. Additionally, recent evidence on fascial plane blocks for subcutaneous-implantable cardioverter-defibrillator implantation are also reviewed.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Pectus Excavatum Surgery: A Retrospective Propensity-Score Study

OBJECTIVE

Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

All participants were scheduled for surgical repair of PE.

INTERVENTIONS

From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed.

MEASUREMENT AND MAIN RESULTS

A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005).

CONCLUSIONS

Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial

INTRODUCTION

Erector spinae plane block has been proposed to reduce opioid use and improve pain relief with controversial results. This randomized clinical study aimed to assess the efficacy of erector spinae plane block in major spine surgery including multimodal and 'Enhance Recovery After Surgery' programs.

METHOD

After institutional review board approval, adult patients undergoing elective lumbar spine surgery with standardized general anesthesia, rehabilitation and multimodal analgesia protocols were randomly allocated to receive bilateral ultrasound-guided block with saline versus ropivacaine (3.75 mg/mL). Before surgery, a bilateral erector spinae plane block was performed at lumbar level (third vertebrae) with 20 mL of solution for each side. The primary outcome was morphine consumption after 24 hours. Secondary outcomes included pain scores and side effects, from postanesthesia care unit to discharge, and questionnaires at 3 months on pain and quality of life (EQ-5D).

RESULTS

From November 2019 to July 2021, 50 patients were enrolled with similar characteristics and surgery for each group. After the first 24 hours, there was no statistical difference regarding cumulative intravenous morphine consumption between ropivacaine and saline groups: 7.3 mg (3.7-19) vs 12.5 mg (3.5-26) (p=0.51). Over the five postoperative days, opioid sparing, pain scores and side effects were similar between groups. At 3 months, pain relief, incidence of chronic pain and EQ-5D were similar between groups.

DISCUSSION

Erector spinae plane block used in conjunction with 'Enhance Recovery After Surgery' and multimodal analgesia protocols provides limited reduction in opioid consumption and no long-term benefits.

TRIAL REGISTRATION NUMBER

EudraCT 2019-001678-26.

Comparison of the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block versus thoracic erector spinae block for postoperative analgesia in caesarean section parturients under spinal anaesthesia-A randomised study

Background and Aims

Truncal blocks play an important role in multimodal analgesia regimens to manage the postoperative pain after lower segment caesarean section (LSCS). This study was aimed to compare the analgesic efficacy of ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) and thoracic erector spinae plane block (TESPB) in parturients of LSCS done under subarachnoid block (SAB).

Methods

In a randomised and double blind study, 60 parturients scheduled for LSCS under spinal anaesthesia were randomly divided into two equal groups: group E (n = 30) and group Q (n = 30). After surgery, each parturient received either US guided bilateral TQLB (group Q) or TESPB (group E) with 20 ml 0.375% ropivacaine and 4 mg dexamethasone on each side. Assessments were done at 2, 4, 6, 8, 10, 12 and 24 h. The primary objective was to compare the duration of analgesia (first request to rescue analgesia) and the secondary objectives were to compare pain scores [numerical rating score (NRS)], total amount of tramadol consumption, incidence of nausea-vomiting, parturient satisfaction and other adverse effects in 24 hours postoperatively.

Results

The duration of analgesia (mean ± standard deviation) was comparable in group E (11.90 ± 2.49 h) and group Q (12.56 ± 3.38 h), P = 0.19. Pain scores (NRS) at rest and on movement were comparable at all time points of 2, 4, 6, 8, 10, 12, and 24 h (P > 0.05). The amount of tramadol used was comparable in group E and group Q (P = 0.48).

Conclusion

TESPB and TQLB are equally efficacious to provide postoperative analgesia after LSCS done under SAB when used as a part of multimodal analgesia.

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies

OBJECTIVE

To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.

METHOD

A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.

RESULTS

Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I² = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I² = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I² = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I² = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I² = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I² = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I² = 0%]. There have been no reports of complications from ESPB or other blocks.

CONCLUSION

Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.

Regional Anesthetic Approaches for Postoperative Analgesia Following Vertebral Body Tethering: A Case Series

Vertebral body tethering (VBT) is an innovative surgical technique used to treat juvenile and adolescent idiopathic scoliosis. The optimal anesthetic technique, including the preferred management of postoperative pain, is not known. In this case series, we describe 3 patients with adolescent idiopathic scoliosis who received either continuous erector spinae plane block (ESPB) catheters or intercostal liposomal bupivacaine for postoperative pain management after bilateral VBT via minithoracotomy.

Anatomical basis of fascial plane blocks

Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.

Continuous erector spinae plane block versus intercostal nerve block in patients undergoing video-assisted thoracoscopic surgery: a pilot randomized controlled trial

Background

The optimal analgesia method in video-assisted thoracoscopic surgery (VATS) remains controversial. Intercostal nerve blockade (ICNB) is limited by its duration of action. The erector spinae plane (ESP) block has the potential to provide satisfactory analgesia for VATS; however, the effectiveness of continuous ESP versus surgeon-performed ICNB has not been investigated. The objectives of this study were to establish feasibility of patient recruitment and follow-up before undertaking a fully powered randomized controlled trial (RCT); and, secondarily, to compare opioid usage, pain control, and sensory blockade.

Methods

This feasibility RCT was undertaken at St Joseph’s Hospital, Hamilton, Ontario, Canada, and included 24 patients (>18 years) having elective VATS with at least one overnight stay. Exclusion criteria were patient refusal, body mass index >40 kg/m², contraindications to neuraxial analgesia techniques as per the American Society of Regional Anesthesia and Pain guidelines, known allergy to local anesthetics, language or comprehension barriers, procedures with a higher chance of open surgery, and regular opioid use for ≥3 months preoperatively. Patients underwent either continuous ESP (n=12) or surgeon-performed ICNB (n=12). All patients received routine intraoperative anesthesia care and multimodal analgesia. Feasibility criteria were recruitment rate of two patients/week and full follow-up in all patients in-hospital. We compared opioid consumption, postoperative pain scores (0–10 numerical rating scale), adverse events, patient satisfaction, and distribution of sensory blockade as clinical outcomes (secondary).

Results

Feasibility of primary outcomes was successfully demonstrated. Five patients had an epidural in anticipation of open surgery. Mean opioid consumption as equivalent morphine units was less in the ESP group over the first 24 h (mean difference, 1.63 [95% CI –1.20 to 4.45]) and 48 h (mean difference, 2.34 [95% CI –1.93 to 6.61]). There were no differences in adverse effects.

Conclusions

A fully powered RCT is feasible with modifications. Our results also suggest that continuous ESP is safe and can decrease opioid needs. However, it is important to consider procedures to improve compliance to protocol and adherence to assigned interventions.

Trial registration

Clinicaltrials.gov identifier: NCT03176667. Registered June 5, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00801-7.