Anatomical description of anaesthetic spread after deep erector spinae block at L-4

Surgical vs ultrasound-guided lumbar erector spinae plane block for pain management following lumbar spinal fusion surgery

PURPOSE

Spinal surgery is associated with severe diffuse pain in the postoperative period. Effective pain management plays an essential role in reducing morbidity and mortality. This study is designed to compare the ultrasound-guided erector spinae plane (ESP) block and surgical infiltrative ESP block for postoperative analgesia management after lumbar spinal fusion surgery.

METHODS

The patients who underwent two or three levels of posterior lumbar spinal fusion surgery were randomly allocated into one of three groups with 30 patients each (Group SE = Surgical ESP block; Group UE = ultrasound-guided ESP block; Group C = Controls). The primary aim was to compare postoperative opioid consumption, and the secondary aim was to evaluate postoperative dynamic and static pain scores and the incidence of opioid-related adverse effects.

RESULTS

There was a significant difference in terms of opioid consumption, rescue analgesia on demand, and both static and dynamic pain scores between groups at all time periods (p < 0.05). Group SE and Group UE had lower pain scores and consumed fewer opioids than the controls (p < 0.05). However, the Group UE had lower pain scores and opioid consumption than the Group SE. The sedation level of patients was significantly higher in the control group than in the other two groups. Also, nausea was more common in controls than in the other groups.

CONCLUSION

While both surgical and ultrasound-guided ESP blocks reduced opioid consumption compared to the controls, the patients who received ultrasound-guided ESP blocks experienced better postsurgical pain relief than those in the other groups (surgical ESP and controls).

Ultrasound‑guided erector spinae plane block in posterior lumbar surgery (Review)

The erector spinae plane block (ESPB) is a novel fascial planar block technique, which is used to reduce postoperative pain in several surgical procedures, including breast, thoracic, spine and hip surgery. Due to its recognizable anatomy and low complication rate, the application of ESPB has been significantly increased. However, it is rarely used in clinical practice for postoperative analgesia after posterior lumbar spine surgery, while the choice of adjuvant drugs, block levels and drug doses remain controversial. Based on the current literature review, ropivacaine and dexmedetomidine could be considered as the best available drug combination. The present review aimed to analyze the currently available clinical evidence and summarize the benefits and challenges of ESPB in spinal surgery, thus providing novel insights into the application of ESPB in the postoperative management of posterior lumbar surgery.

Regional Anesthesia Techniques in Modern Neuroanesthesia Practice: A Narrative Review of the Clinical Evidence

Neurosurgical procedures are often associated with significant postoperative pain that is both underrecognized and undertreated. Given the potentially undesirable side effects associated with general anesthesia and with various pharmacological analgesic regimens, regional anesthetic techniques have gained in popularity as alternatives for providing both anesthesia and analgesia for the neurosurgical patient. The aim of this narrative review is to present an overview of the regional techniques that have been incorporated and continue to be incorporated into modern neuroanesthesia practice, presenting in a comprehensive way the evidence, where available, in support of such practice for the neurosurgical patient.

Spread of local anesthetic injected in the paravertebral space, intertransverse processes space, and erector spinae plane: a cadaveric model

INTRODUCTION

Paraspinal fascial plane blocks have become popular and include the erector spinae plane (ESP) and intertransverse process (ITP) blocks. Controversy exists regarding the exact mechanism(s) of these blocks. We aimed to evaluate the spread of local anesthetic (LA) following ESP and ITP blocks as compared with paravertebral (PV) blocks in a cadaveric model.

METHOD

Single-injection ultrasound guided ESP (n=5), ITP (n=5), and PV (n=5) blocks were performed in 15 fresh cadaver hemithoraces. The extent of LA spread within the erector spinae fascial plane, involvement of the dorsal ramus, and distribution within the PV space, were qualitatively described.

RESULTS

The spread of LA following ESP block extended eight vertebral levels in a cranio-caudal direction, involving the dorsal ramus at each level, but without LA spread into the PV space nor to the ventral rami. LA spread following ITP block extended 1-2 vertebral levels within the PV space and 7 vertebral levels within the erector spinae fascial plane. The spread of LA following PV blocks extended 2-4 vertebral levels, involving the ventral and dorsal ramus at each level, but without LA spread into the ESP.

CONCLUSION

Based on the results of this cadaveric experimental model of paraspinal fascial plane blocks, LA spread following ITP blocks extends into both the PV space and the erector spine fascial plane, and thus may offer a more favorable analgesic profile than ESP blocks.

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.

Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study

STUDY DESIGN

Prospective, randomized controlled double-blinded study.

OBJECTIVE

To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia.

METHODS

81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded.

RESULTS

The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief.

CONCLUSION

Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis.

MATERIALS AND METHODS

The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective.

RESULTS

The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6).

CONCLUSIONS

TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

Efficacy of erector spinae plane block for postoperative analgesia lumbar surgery: a systematic review and meta-analysis

OBJECTIVES

The erector spinae plane (ESP) block is a newly defined regional anesthesia technique first described in 2016. The aim of this meta-analysis is to assess the efficacy of ESP block in improving analgesia following lumbar surgery.

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials (RCTs) that compared the analgesic efficacy of the ESP block with non-block care for lumbar surgery from inception 3 August 2021. The primary outcomes were postoperative opioid consumption and pain scores during the first 24 h. Postoperative pain was measured as pain at rest and on movement at postoperative 0, 4, 8, 12, and 24 h expressed on a visual analog scale (VAS), where 0 = no pain and 10 = the most severe pain.

RESULTS

11 studies involving 775 patients were included in our analysis. The use of ESP block significantly decreased 24-h opioid consumption (WMD, -8.70; 95% CI, -10.48 to -6.93; I² = 97.5%; P < 0.001) compared with the non-block. Moreover, ESP block reduced pain scores at postoperative time-points up to 24 h. ESP block also prolonged the time to first analgesic request (WMD = 6.93; 95% CI: 3.44 to 10.43, I² = 99.8%; P < 0.001). There was less PONV with ESP block versus non-block group (RR, 0.354; 95% CI, 0.23 to 0.56; I² = 25.2%; P < 0.001), but no difference in pruritus.

CONCLUSIONS

ESP block provides less opioid consumption and PONV, lower pain scores, and longer time to first analgesic request in patients undergoing lumbar surgery compared to general anesthesia alone.

Contrast Spread After Erector Spinae Plane Block at the Fourth Lumbar Vertebrae: A Cadaveric Study

INTRODUCTION

In recent years, the erector spinae plane block (ESPB) has seen widespread use to treat acute and chronic pain in the regions of the thoracic spine. While limited data suggest its increasing utilization for pain management distal to the thoracic, abdomen and trunk, the anesthetic spread and analgesic mechanism of ESPB at the level of the lumbar spine has not been fully described or understood.

METHODS

This is an observational anatomic cadaveric study to assess the distribution of solution following an ESPB block performed at the fourth lumbar vertebrae (L4) using ultrasound guidance to evaluate the spread of a 20 ml solution consisting of local anesthetic and methylene blue. The study was performed in an anatomy lab in a large academic medical center. Following injection of local anesthetic with contrast dye, cadaveric dissection was performed to better understand the extent of contrast dye and to determine the degree of staining to further predict analgesic potential. We reviewed the findings of other ESPB cadaveric studies currently available for comparison.

RESULTS

Following cadaveric dissection in an anatomy lab, the contrast dye was observed in the ESP space, and staining was found most cranially at L2 and extending caudally underneath the sacrum. Evaluating the depth of its spread, we found it to be confined to the posterior compartment of the spine sparing the nerve roots bilaterally, which is consistent with the only other cadaveric study of ESPB performed at L4.

CONCLUSION

Our results demonstrate the clinical utility of lumbar ESPB where posterior confinement of local anesthesia is preferred. However, further investigation is needed to determine the efficacy of ESPB in lower extremity analgesia which is predicated on ventral nerve root involvement.

Comparison of the feasibility and validity of a one-level and a two-level erector spinae plane block combined with general anesthesia for patients undergoing lumbar surgery

Background

Spinal surgery causes severe postoperative pain. An erector spinae plane (ESP) block can relieve postoperative pain, but the optimal blocking method has not been defined. The aim of this study is to compare the feasibility of a one-level and a two-level lumbar ESP block and their effect on intraoperative and postoperative analgesia in lumbar spinal surgery.

Methods

A total of 83 adult patients who were scheduled for posterior lumbar interbody fusion were randomly divided into two groups. Patients in Group I (n = 42) received an ultrasound-guided bilateral one-level ESP block with 0.3% ropivacaine, while patients in Group II (n = 41) received a bilateral two-level ESP block. Blocking effectiveness was evaluated, including whether a sensory block covered the surgical incision, sensory decrease in anterior thigh, and quadriceps strength decrease. Intraoperative anesthetic dosage, postoperative visual analogue scale scores of pain, opioid consumption, rescue analgesia, and opioid-related side effects were analyzed.

Results

Of the total number, 80 patients completed the clinical trial and were included in the analysis, with 40 in each group. The time to complete the ESP block was significantly longer in Group II than in Group I (16.0 [14.3, 17.0] min vs. 9.0 [8.3, 9.0] min, P = 0.000). The rate of the sensory block covering the surgical incision at 30 min was significantly higher in Group II than in Group I (100% [40/40] vs. 85.0% [34/40], P = 0.026). The rate of the sensory block in the anterior thigh was higher in Group II (43.8% [35/80] vs. 27.5% [22/80], P = 0.032), but the rate of quadriceps strength decrease did not differ significantly between the groups. The mean effect-site remifentanil concentration during intervertebral decompression was lower in Group II than in Group I (2.9 ± 0.3 ng/ml vs. 3.3 ± 0.5 ng/ml, P = 0.007).There were no significant differences between the groups in terms of intraoperative analgesic consumption, postoperative analgesic consumption, and postoperative VAS pain scores at rest and with movement within 24 h. There were no block failures, block-related complications, and postoperative infection.

Conclusions

Among patients undergoing posterior lumbar interbody fusion, the two-level ESP block provided a higher rate of coverage of the surgical incision by the sensory block when compared with the one-level method, without increasing the incidence of procedure-related complications.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2100043596.

Erector spinae block: beyond the torso

PURPOSE OF REVIEW

This article aims to summarize the current literature describing the application of erector spinae plane (ESP) blocks for regional anesthesia of upper and lower limbs and to discuss the advantages and limitations.

RECENT FINDINGS

Investigations are still at an early stage but results are promising. High thoracic ESP blockade can relieve acute and chronic shoulder pain through local anesthetic diffusion to cervical nerve roots, although it may not be as effective as direct local anesthetic injection around the brachial plexus. It does, however, preserve motor and phrenic nerve function to a greater extent. It will also block the T2 innervation of the axilla which can be a source of pain in complex arthroscopic shoulder surgery. Lumbar ESP blocks provide effective analgesia following hip arthroplasty and arthroscopy, and appear comparable to lumbar plexus, quadratus lumborum, and fascia iliaca blocks. Unlike the latter, they are motor-sparing and are associated with improved postoperative ambulation.

SUMMARY

High thoracic and lumbar ESP blocks have the potential to provide adequate analgesia of the upper and lower limbs respectively, without causing significant motor block. They are thus alternative methods of regional anesthesia when other techniques are not feasible or have undesirable adverse effects.

Comparison of Two Ultrasound-guided Plane Blocks for Pain and Postoperative Opioid Requirement in Lumbar Spine Fusion Surgery: A Prospective, Randomized, and Controlled Clinical Trial

INTRODUCTION

The erector spinae plane (ESP) block and thoracolumbar interfascial plane (TLIP) block were two novel plane blocks. The purpose of this study was to investigate TLIP block and ESP block on the effect of analgesic and opioid consumption in lumbar spine fusion surgery in the perioperative period.

METHODS

Three hundred and four patients who suffered lumbar spine fusion were included and randomly divided into three groups: a control group (n = 102), an ESP block group (n = 100), and a TLIP block group (n = 102). We recorded the numerical rating scale (NRS) pain at movement and static during the postoperative 48 h, opioid consumption, additional analgesic requirement, frequency of patient-controlled analgesia (PCA) compressions, Bruggemann Comfort Scale (BCS) score, side effects, duration of hospital stay, and the life quality score (LQS) after operation at 6 months.

RESULTS

The patients in the ESP block group have better analgesia during 12-48 h postoperative time at static state, a lower frequency of PCA compressions at 24-48 h after surgery, and the opioid consumption in the PCA (sufentanil) were less than those in the TLIP block group (P < 0.05). However, the BCS and LQS scores were no different between the two plane block groups after surgery at 6 months. There was no difference in hospital stay and the incidence of side effect among the three groups.

CONCLUSIONS

Our results found that patients who suffered ESP block have better analgesic effects and less pain scores in static states and less frequency of PCA compression and opioid analgesic consumption compared with those that suffered TLIP block.

TRIAL REGISTRATION

ChiCTR1800019639.

Randomized trial comparing the spread of erector spinae block with the combination of erector spinae block and retrolaminar block in soft embalmed Thiel cadavers

BACKGROUND

Erector spinae plane (ESP) and retrolaminar (RL) blocks show unreliable spread. We hypothesize that the combination of ESP and RL blocks provides more extensive and reliable spread of dye than single ESP blocks. Our primary objective was to compare the spread of dye to the paravertebral spaces after the combination block and ESP block in Thiel embalmed cadavers. Spread, the primary end point, was defined as the number of paravertebral spaces colored with dye per injection.

MATERIALS AND METHODS

A single anesthetist performed ultrasound-guided ESP (20 mL) and combination of ESP and RL (10 mL each) blocks at the third thoracic vertebra of eight soft embalmed Thiel cadavers. Tissue displacement was visualized on an adjacent strain elastography image. Cadavers were dissected 24 hours later and anatomical structures were inspected for the presence of dye.

FINDINGS

Dye was visualized in more paravertebral spaces with the combination block (median 3 (IQR 3-5 (range 0-8)) vs 1.5 (IQR 0.25-2.75 (range 0-3) and difference (1.5 (0-4), p=0.04). Six out of seven (86%) combined erector spinae and RL blocks spread to at least three paravertebral spaces compared with two out of eight (25%) ESP blocks (RR 3.4, 95% CI 1.0 to 11.8; p=0.04). Contralateral spread occurred in three combination blocks and in one ESP block (OR 9.0, 95% CI 4.0 to 21.1; p<0.001).

CONCLUSIONS

In conclusion, the combination of ESP and RL blocks was more extensive and reliable than ESP block alone.

Visceral versus somatic pain: an educational review of anatomy and clinical implications

Somatic and visceral nociceptive signals travel via different pathways to reach the spinal cord. Additionally, signals regulating visceral blood flow and gastrointestinal tract (GIT) motility travel via efferent sympathetic nerves. To offer optimal pain relief and increase GIT motility and blood flow, we should interfere with all these pathways. These include the afferent nerves that travel with the sympathetic trunks, the somatic fibers that innervate the abdominal wall and part of the parietal peritoneum, and the sympathetic efferent fibers. All somatic and visceral afferent neural and sympathetic efferent pathways are effectively blocked by appropriately placed segmental thoracic epidural blocks (TEBs), whereas well-placed truncal fascial plane blocks evidently do not consistently block the afferent visceral neural pathways nor the sympathetic efferent nerves. It is generally accepted that it would be beneficial to counter the effects of the stress response on the GIT, therefore most enhanced recovery after surgery protocols involve TEB. The TEB failure rate, however, can be high, enticing practitioners to resort to truncal fascial plane blocks. In this educational article, we discuss the differences between visceral and somatic pain, their management and the clinical implications of these differences.

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing open radical prostatectomy: A randomized, placebo-controlled trial

STUDY OBJECTIVE

The aim of this study was to evaluate the effect of ultrasound-guided erector spinae plane (ESP) block on postoperative pain in radical prostatectomy, which leads to both visceral and somatic pain.

DESIGN

Prospective, randomized, placebo controlled, double-blinded.

SETTING

University hospital.

PATIENTS

A total of ASA I-III, 50 patients aged 18-65 who were scheduled for elective open radical prostatectomy surgery.

INTERVENTIONS

Patients were randomly allocated to receive an ultrasound-guided ESP block, with either local anesthetic (10 mL of 1% lidocaine +10 mL of 0.5% bupivacaine) or placebo bilaterally.

MEASUREMENTS

The primary outcome was morphine consumption in the first 24 h after surgery. The secondary outcomes were NRS pain scores at rest and coughing, intraoperative remifentanil consumption and need for rescue analgesic during the first 24 h after surgery.

MAIN RESULTS

Both NRS scores for post-anesthesia care unit and NRS_rest scores for 1st hours were lower in Group ESPB (p < 0.001 and p = 0.033, respectively). Cumulative morphine consumption at 24 h post-surgery was similar between the groups (p = 0.447). Rescue analgesic requirement was higher in the placebo injection group than in the ESPB group at the 1st postoperative hour (p = 0.002).

CONCLUSIONS

In open radical prostatectomies, except for the first hour, ESP block is ineffective for pain scores and on morphine consumption compared to the placebo injection group in the postoperative period.

Lumbar erector spinae plane block obtunding knee and ankle reflexes

The erector spinae plane block (ESPB) has recently been described as an effective analgesic strategy for various surgeries at ventral and dorsal parts of body. The block has been utilized for postoperative pain relief in hip surgeries. Cadaveric and clinical studies performed at the lumbar level depict a dorsal spread and minimal ventral spread in the lumbar plexus. So far to our knowledge there is one case report which has described reduced quadriceps strength in a parturient after caesarean section. We report two patients who presented with absent knee reflexes (decreased quadriceps strength) and one patient with absent ankle reflex (foot drop) following continuous ESPB at the level of L3. The initial bolus was with 30 ml of 0.1% bupivacaine followed by a continuous infusion of 0.1% ropivacaine at 8ml/hour. The loss of knee reflexes in two patients and diminished reflexes in one patient suggested spread of local anaesthetic (LA) to the lumbosacral plexus. The LA infusion were stopped in all 3 patients. The average duration of motor block was 18 hours. These complications should be considered if early ambulation is mandatory for patients.

Bilateral ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal fusion: A randomized controlled trial

STUDY OBJECTIVE

Spinal fusion surgery is associated with severe postoperative pain. We examined whether bilateral ultrasound-guided erector spinae plane block could alleviate postoperative pain in patients undergoing lumbar spinal fusion.

DESIGN

Blinded, randomized, controlled study.

SETTING

Tertiary university hospital, operating room, postoperative recovery room and ward.

PATIENTS

Sixty patients with American Society of Anesthesiologists grade I or II scheduled for lumbar spinal fusion surgery were randomized into the erector spinae plane block group (ESPB group) and the control group in a 1:1 ratio.

INTERVENTIONS

Pre-operative ultrasound-guided bilateral erector spinae plane block was performed in the ESPB group, while sham subcutaneous infiltration was performed in the control group.

MEASUREMENTS

The primary outcome was pain intensity at rest within 12 h postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included NRS pain scores at rest and on movement, postoperative opioid consumption and proportions of patients requiring opioid during the first 48 h after surgery.

MAIN RESULTS

The ESPB group (n = 30) showed significantly lower pain scores at rest at 4 h after surgery (estimated mean difference - 1.6, 95% confidence interval [CI] -2.4 to -0.8, p < 0.001), at 8 h (-1.3, 95% CI -1.9 to -0.6, p < 0.001), and at 12 h (-0.7, 95% CI -1.3 to -0.1, p = 0.023). The two groups showed similar pain scores at rest at 24 h after surgery (estimated mean difference - 0.2, 95% CI -0.8 to 0.5) and 48 h (-0.3, 95% CI -0.8 to 0.2). The ESPB group also showed significantly lower pain score on movement at 4 h after surgery (-1.5, 95% CI -2.5 to -0.6). The ESPB group showed a significantly smaller proportion of patients requiring sufentanil within 12 h after surgery (p = 0.020), and the group consumed significantly less sufentanil during that period (p = 0.042).

CONCLUSIONS

Bilateral ultrasound-guided erector spinae plane block improves postoperative analgesia in patients undergoing lumbar spinal fusion.

Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks

STUDY OBJECTIVE

This narrative review discusses the anatomy, mechanism of action, techniques, pharmacology, indications, complications and substitutes for erector spinae plane (ESP) blocks.

INTERVENTIONS

The Medline, Embase and Google Scholar databases (inception-last week of April 2020) were searched. For indications and alternative blocks, a systematic analysis of the available evidence was carried out. In order to highlight the best evidence available, only randomized trials with prospective registration, blinded assessment and sample size justification were retained for analysis.

MAIN RESULTS

The collective body of anatomical studies suggests that ESP block may work through a combination of different mechanisms (e.g., local anesthetic spread to the thoracic paravertebral space, epidural space, and dorsal ramus). Compared to control, the available evidence suggests that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal surgical interventions. Erector spinae plane blocks and thoracic paravertebral blocks seem to provide comparable benefits for thoracoscopic and breast cancer surgery when performed with a similar number of injections. Currently, ESP blocks should be favored over intercostal blocks since, at best, the latter provide similar analgesia to ESP blocks despite requiring multiple-level injections.

CONCLUSIONS

In recent years, ESP blocks have become the topic of considerable clinical interest. Future trials are required to investigate their optimal technique, dose of local anesthetic and perineural adjuvants. Moreover, additional investigation should compare ESP blocks with robust multimodal analgesic regimens as well as truncal blocks such as thoracic epidural block, midpoint transverse process to pleura block, PECS block, quadratus lumborum block, and transversus abdominis plane block.

Anesthetic Techniques: Focus on Lumbar Erector Spinae Plane Block

Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in “Pubmed” and “Google Scholar” database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.

Evaluating the extent of lumbar erector spinae plane block: an anatomical study

Background and objectives

The erector spinae plane (ESP) block is a relatively new interfascial block technique. Previous cadaveric studies have shown extensive cephalocaudal spread with a single ESP injection at the thoracic level. However, little data exist for lumbar ESP block. The objective of this study was to examine the anatomical spread of dye following an ultrasound-guided lumbar ESP block in a human cadaveric model.

Methods

An ultrasound-guided ESP block was performed in unembalmed human cadavers using an in-plane approach with a curvilinear transducer oriented longitudinally. 20 mL of 0.166% methylene blue was injected into the plane between the distal end of the L4 transverse process and erector spinae muscle bilaterally in four specimens and unilaterally in one specimen (nine ESP blocks in total). The superficial and deep back muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and medial–lateral directions.

Results

There was cephalocaudal spread from L3 to L5 in all specimens with extension to L2 in four specimens. Medial–lateral spread was documented from the multifidus muscle to the lateral edge of the thoracolumbar fascia. There was extensive dye in and around the erector spinae musculature and spread to the dorsal rami in all specimens. There was no dye spread anteriorly into the dorsal root ganglion, ventral rami, or paravertebral space.

Conclusions

A lumbar ESP injection has limited craniocaudal spread compared with injection in the thoracic region. It has consistent spread to dorsal rami, but no anterior spread to ventral rami or paravertebral space.

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.