Erector spinae plane block for post-cesarean delivery analgesia

Erector spinae plane block in Caesarean sections: A scoping review

Background

Pain management for Caesarean section focuses on multimodal analgesia with a growing interest in the use of regional techniques. Currently, there is no gold standard peripheral regional analgesia technique for Caesarean section. The Erector Spinae Plane Block is a relatively new fascial plane block that may be used to provide analgesia for numerous surgical procedures of the trunk. In recent years it is the fascial plane block that has accumulated the most enthusiasm and debate. Its use in Caesarean section has grown over the past three years.

Objective

To determine the scope of literature published on ESPB in Caesarean sections and to identify deficits in the literature to guide future research.

Methodology

This study was conducted using Arksey and O'Malley's framework for scoping reviews. This included a search of four databases searching for articles published between 2016 and 2022. Studies involving patients receiving ESPB as part of an analgesic strategy after a Caesarean section were included.

Findings

Sixteen articles were included for final review. The most common primary outcomes measured were postoperative pain scores and analgesia consumption. Six ESPB studies recorded a statistically significant reduction in pain scores while three studies described a statistically significant reduction in postoperative analgesia consumption.

Conclusion

The use of ESPB for Caesarean section is gaining momentum however insufficient evidence currently exists to support its widespread use. Further research is required to evaluate the potential benefits of ESPB in specific patient cohorts and in terms of its efficacy about multidimensional patient-centric outcomes.

Anterior Quadratus Lumborum Block at the Lateral Supra-Arcuate Ligament versus Transmuscular Quadratus Lumborum Block for Analgesia after Elective Cesarean Section: A Randomized Controlled Trial

Several studies have shown the effectiveness of trans-muscular quadratus lumborum block (TQLB) in analgesia after cesarean delivery. However, the influence of anterior QLB at the lateral supra-arcuate ligament (QLB-LSAL) in this surgery is unclear. This study aimed to compare the analgesic efficacy of bilateral TQLBs with bilateral QLBs-LSAL following cesarean delivery. Ninety-four parturients scheduled for cesarean delivery under spinal anesthesia were enrolled and randomly allocated to undergo either bilateral TQLBs or bilateral QLBs-LSAL with 0.375% of ropivacaine (20 mL each side) following cesarean delivery. Intravenous sufentanil was administered for patient-controlled analgesia (PCA). The primary outcome was postoperative sufentanil consumption during the initial 24 h post-surgery. Secondary endpoints included pain scores, time to the first PCA request, postoperative rescue analgesia, satisfaction scores, and nausea/vomiting events. Sufentanil consumption was significantly reduced in the QLB-LSAL group in the first 24 h compared with the TQLB group after surgery (29.4 ± 5.7 μg vs. 39.4 ± 9.6 μg, p < 0.001). In comparison with TQLB, the time to the first PCA request in the QLB-LSAL group was significantly longer (10.9 ± 4.1 h vs. 6.7 ± 1.8 h, p < 0.001). No differences were observed between two groups regarding pain scores, rescue analgesia after surgery, satisfaction scores, or nausea/vomiting incidence. The significant reduction in opioid consumption in the first 24 h and prolongation in time to first opioid demand in parturients receiving QLB-LSAL compared with TQLB suggest that the QLB-LSAL is a superior choice for multimodal analgesia after cesarean delivery.

Evaluation of ultrasound-guided bilateral low thoracic erector spinae plane block for postoperative analgesia in cesarean delivery patients: a prospective, randomized, controlled clinical trial

BACKGROUND

Erector spinae plane block (ESPB) is a recently described block. In many reports, ESPB has been reported to provide effective postoperative analgesia in patients undergoing cesarean delivery (CD). Herein, we compared the effectiveness of ESPB and control group in postoperative analgesia in patients undergoing CD under spinal anesthesia.

METHODS

This assessor blinded, prospective, randomized, efficiency study was conducted in the postoperative recovery room and ward at a tertiary university hospital. Eighty-six patients (ASA II-III) were recruited. Following exclusion, 80 patients were randomized into two equal groups (block and control group). Standard multimodal analgesia was performed in the control group while ESPB block was performed in the intervention (ESPB) group. Opioid consumption was measured and pain intensity between groups was compared using Numeric Rating Scores (NRS).

RESULTS

NRS was lower in Group ESPB at 3rd and 6th hours. There was no difference between NRS scores at other hours. Opioid consumption was lower in Group ESPB.

CONCLUSION

When added to multimodal analgesia, bilateral ultrasound guided low thoracic ESPB leads to improve the quality of analgesia in the first 24 hours in patients undergoing CD.

Subarachnoid block and ultrasound-guided transversalis fascia plane block for caesarean section: A randomised, double-blind, placebo-controlled trial

BACKGROUND

After caesarean section, maternal postoperative comfort is critical to allow the new mother to care for her baby. Insufficient pain relief during the postoperative period may delay maternal/infant bonding and, in addition, such pain has been linked to subsequent depression and chronic pain. Caesarean section is commonly performed with a Pfannenstiel incision, and a transversalis fascia plane (TFP) block provides postoperative analgesia in the T12 and L1 dermatomes.

OBJECTIVE

The aim of this study was to investigate the effect of the TFP block on postoperative opioid consumption and pain scores in patients undergoing caesarean section under spinal anaesthesia.

DESIGN

A randomised controlled, double-blind study.

SETTINGS

Single-centre, academic hospital.

PARTICIPANTS

Sixty patients undergoing caesarean section.

INTERVENTIONS

The TFP group (n = 30) received an ultrasound-guided bilateral TFP block with 20 ml of 0.25% bupivacaine. The control group (n = 30) received 20 ml of saline bilaterally. Postoperative analgesia was given every 6 h with intravenous paracetamol 1 g and patient-controlled analgesia (PCA) with morphine.

MAIN OUTCOME MEASURES

Postoperative visual analogue pain scores, morphine consumption, rescue analgesia and opioid-related side effects were evaluated.

RESULTS

In the TFP group, the visual analogue pain scores were significantly lower at rest for 2 h after the operation (P = 0.011) and during active movement at 2, 4 and 8 h postoperatively (P = 0.014, <0.001 and 0.032, respectively). Morphine consumption in the first 24 h after surgery was significantly higher in the control group compared with the TFP group (38.5 ± 11.63 and 19.5 ± 8.33 mg, respectively; P < 0.001). The incidence of postoperative nausea and constipation were statistically higher in the control group than in the TFP group (P < 0.05). Patient satisfaction was significantly higher in the TFP group (P = 0.027).

CONCLUSION

A postoperative TFP block can reduce opioid consumption and relieve acute pain after a caesarean section under spinal anaesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04172727.

The analgesic efficacy of quadratus lumborum block in caesarean delivery: a meta-analysis and trial sequential analysis

PURPOSE

Quadratus lumborum block (QLB) has recently gained popularity for postoperative analgesia after cesarean delivery (CD) as it provides both visceral and somato-sensory blockade of the abdomen. Aim of this meta-analysis was to evaluate the analgesic potential of QLB after CD.

METHODS

Electronic database from inception to December 2019 was searched systematically for randomized-controlled trials comparing QLB with injection of inactive solution in women undergoing CD. Primary outcome was consumption of morphine at 24 h. Morphine consumption at 48 h, dynamic and static pain scores at various time intervals were the secondary outcomes studied.

RESULTS

Seven trials met the inclusion criteria. Morphine consumption was reduced significantly with QLB in comparison to sham or no block at 24 h (mean difference [MD] - 9.84 mg; 95% confidence interval [CI] - 18.16, - 0.50; p = 0.04; I² = zero). Adequate "information size" for above outcome was confirmed with trial sequential analysis, ruling out any possibility of a false-positive result. QLB significantly reduced pain scores at rest (MD - 1.13; 95% CI - 1.75, - 0.56; p = 0.00) and on movement (MD - 1.48; 95% CI - 2.5, - 0.46; p = 0.01) at 6 h. However, statistically significant difference in pain scores persisted only for dynamic pain at 24 h (MD - 0.55; 95% CI - 1.04, - 0.06; p = 0.03). QLB does not provide any additional analgesic benefit to the parturient receiving intrathecal morphine.

CONCLUSION

QLB significantly reduces opioid requirements in CD and may have analgesic effects lasting 24 h.

Relief of Secondary Headaches with High Thoracic Erector Spinae Plane Block

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.