The Erector Spinae Plane Block Provides Complete Surgical Anesthesia in Breast Surgery: A Case Report

The Utility of Erector Spinae Plane Blocks in Breast Surgery: A Practical Review

Background

In plastic surgery, breast surgery patients are among the most susceptible to postoperative pain. Amidst the opioid epidemic, healthcare goals seek to optimize nonopioid multimodal pain control by including regional analgesia. The erector spinae plane block (ESPB) is among several regional blocks used in breast surgery. Although the paravertebral block has previously served as the gold standard, new research focused on ESPB may shift standards.

Methods

A comprehensive PubMed review was performed in September 2023 to identify articles related to ESPB use in breast surgery. Non-English and unavailable articles were excluded. Data extracted included publication year, techniques, and outcomes.

Results

Sixty-eight publications were included, of which 31 were randomized control trials (45.6%). Most were published between 2021 and 2023 (n = 40, 58.8%). Most articles that evaluated pain and opioid use suggested that ESPB performed better than nonblocked groups (n = 26, 38.2% of total articles and n = 4, 5.88% of total articles) and performed similarly to other blocks. However, articles that evaluated the pectoral nerve block suggested it outperformed ESPB in these aspects (n = 6 articles, 8.82%). ESPB was shown to be a safe and procedurally short block to perform, effective in the hands of novice providers.

Conclusions

ESPB offers reliable outcomes, improving pain control and decreasing opioid consumption. In turn, this can decrease healthcare costs and patient morbidity.

Assessment of ultrasound guided erector spinae plane block for early post-operative analgesia for modified radical mastectomy: a prospective, randomized, controlled study

Erector spinae plane block is a recently introduced block with a wide range of indications. The aim of the present study was to assess the efficacy and safety of ultrasound-guided erector spinae plane block on early post-operative pain relief in patients undergoing modified radical mastectomy. We conducted a prospective, randomized, controlled study in a tertiary care institute. Sixty-five patients were enrolled. Final analysis was performed on 58 patients randomized into two groups. Ultrasound-guided erector spinae plane block with 25 mL of 0.25% bupivacaine was given using a 18 gauge needle. No block was given in the other group. All patients received general anesthesia. Primary outcome measure was 24-hour analgesic consumption. Secondary outcome measures included intra-operative fentanyl consumption, time to first analgesic request, Visual Analog Scale score, nausea score, sedation score, wound quality and patient satisfaction score. Post-operative additional analgesics and intra-operative fentanyl were significantly reduced in patients receiving erector spinae plane block. Time to rescue analgesia was significantly delayed. Visual Analog Scale score was significantly lower at all time intervals. Post-operative nausea at various time intervals was also less. Patient satisfaction score was also noted on a 5-point scale and there was a statistical significant difference. We concluded that erector spinae plane block is a safe technique and provides good analgesia in breast surgery.

Comparison of fascial plane blocks (ESPB vs. TPVB) for pain relief following modified radical mastectomy

Background and Aims

The erector spinae plane block (ESPB) is a novel regional anesthesia technique compared to the thoracic paravertebral block (TPVB) in providing postoperative pain relief in breast surgeries. Modified radical mastectomy (MRM) is a commonly performed surgery for breast cancer. The objective of the study is to compare the efficacy of ESPB and TPVB in providing postoperative pain relief after MRM.

Material and Methods

This is a prospective randomized study conducted in a tertiary care teaching hospital. Sixty ASA I-III adult patients (age >18 years) scheduled to undergo elective unilateral MRM for breast cancer were enrolled in the study. Ultrasound-guided ESPB or TPVB with 0.25% bupivacaine was performed preoperatively on the patients randomized into two groups, namely, the ESPB and TPVB groups. All patients received patient-controlled analgesia for postoperative pain relief. Morphine consumption and Visual Analog Score (VAS) for pain were recorded at 3, 6, 12, and 24 h postoperatively.

Results

Primarily, the mean postoperative VAS scores between the two groups at 3, 6, 12, and 24 h showed no statistical significance and were comparable when matched at different time points. However, 24-h morphine consumption was significantly more in the ESPB group (P = 0.035). Duration of block performance also showed a significant difference, with ESPB taking less time to perform (P < 0.001). The mean age and body mass index (BMI) of patients and length of hospital stay in both the groups were similar.

Conclusions

Both ESPB and TPVB provided adequate analgesia in patients undergoing MRM; however, TPVB had better efficacy and opioid-sparing effect when compared to ESPB.

Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BACKGROUND

The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.

CASE PRESENTATION

Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.

CONCLUSIONS

Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Ultrasound-guided continuous erector spinae plane block vs continuous thoracic epidural analgesia for the management of acute and chronic postthoracotomy pain: a randomized, controlled,double-blind trial

Introduction

Postthoracotomy pain (PTP) is a severe pain complicating thoracic surgeries and its good management decreases the risk of PTP syndrome (PTPS).

Objectives

This randomized controlled study evaluated the efficacy of ultrasound-guided continuous erector spinae plane block (ESPB) with or without dexmedetomidine compared with thoracic epidural analgesia (TEA) in managing acute postoperative pain and the possible emergence of PTPS.

Methods

Ninety patients with chest malignancies planned for thoracotomy were randomly allocated into 3 equal groups. Group 1: TEA (20 mL of levobupivacaine 0.25% bolus, then 0.1 mL/kg/h of levobupivacaine 0.1%), group 2: ESPB (20 mL of levobupivacaine only 0.1% bolus every 6 hours), and group 3: ESPB (20 mL of levobupivacaine 0.25% and 0.5 μg/kg of dexmedetomidine Hcl bolus every 6 hours).

Results

Resting and dynamic visual analog scales were higher in group 2 compared with groups 1 and 3 at 6, 24, and 36 hours and at 8 and 12 weeks. Postthoracotomy pain syndrome incidence was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. The grading system for neuropathic pain score was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. Itching, pruritis, and urine retention were higher in group 1 than in ESPB groups.

Conclusion

Ultrasound-guided ESPB with dexmedetomidine is as potent as TEA in relieving acute PTP and reducing the possible emergence of chronic PTPS. However, the 2 techniques were superior to ESPB without dexmedetomidine. Erector spinae plane block has fewer side effects compared with TEA.

Ultrasound-guided multiple-injection costotransverse block for mastectomy and primary reconstructive surgery. A study protocol

BACKGROUND

Post-operative pain amelioration following breast cancer surgery is inconsistent. The novel multiple-injection costotransverse block (MICB) mimics the thoracic paravertebral block by possible anaesthetising the ventral rami of the thoracic spinal nerves and the sympathetic trunk. Proof of concept has been determined in a cadaveric study and needs further clinical testing.

METHODS

This double-blinded, randomised and placebo-controlled study investigates the efficacy of the ultrasound-guided MICB versus placebo in 36 patients undergoing unilateral mastectomy and primary subpectoral reconstruction surgery. Oral pre-operative medicine is standardised for all patients. Active group is pre-operatively administered MICB with three injections of each 10 ml of ropivacaine (5 mg/ml). The placebo group is pre-operatively administered three injections of each 10 ml of saline (0.9%). Standard general anaesthesia is induced and 30 min before emergence 0.2 μg/kg total body weight sufentanil IV, 1 g of paracetamol IV and 4 mg of ondansetron IV (post-operative nausea and vomiting, PONV, prophylaxis) will be administered. All patients are provided with a patient-controlled analgesia pump with morphine. The primary aim is total morphine consumption in the first 24 post-operative hours. Secondary aims are pain intensity, duration of the block, patient satisfaction, side effects, time to ambulation, time to discharge, and quality of recovery.

DISCUSSION

Recruitment began in November 2019 and is expected to finish ultimo 2021. Results are expected to be published in an international peer-reviewed medical journal. The results will hopefully provide a substantial contribution to the knowledge of these new 'intertransverse process blocks' providing regional anaesthesia of the thoracic wall.

Use of a Low Concentration, High Volume Erector Spinae Plane Block for Rescue Analgesia After Melanoma Resection and Axillary Sentinel Lymph Node Biopsy

The erector spinae plane block (ESPB), a recent innovation in regional anesthesia, has been used for analgesia of the thorax and chest. The case presented describes the use of an ESPB postoperatively for rescue analgesia on an elderly, opioid-naïve patient, who had severe postoperative pain after outpatient surgery at an axillary sentinel lymph node biopsy site refractory to escalating IV opioid doses. The rescue ESPB was successful in reducing the patient’s pain to 0/10, allowing the patient to be discharged home and preventing a costly hospital admission.

Erector spinae plane block for postoperative pain and recovery in hepatectomy: A randomized controlled trial

BACKGROUND

The randomized controlled study aimed to examine the efficacy of preoperative ultrasound-guided erector spinae plane (ESP) block combined with ropivacaine in patients undergoing hepatectomy.

METHODS

A total of 60 patients were randomized to ESP block group receiving ropivacaine (Group A) and control group (Group B), n = 30 per group. Visual analog scale (VAS) was recorded in both the groups during rest and movement at the various time intervals. Both the groups were also compared for time to initial anal exhaust, analgesic usage, early postoperative complications and side-effects, walk distance after the operation, time to out-of-bed activity, and duration of hospital stay.

RESULTS

No significant differences were observed in the demographic characteristics. For group A, when compared to group B, VAS scores during rest and movement within post-operative 24 hours were decreased, the time of first anus exhaust and ambulation were earlier, analgesic consumption and the incidence of postoperative nausea, vomiting and headache was reduced, the duration of hospital stay were shorter with longer walk distance.

CONCLUSION

ESP block combined with ropivacaine treatment effectively reduced early postoperative pain and improved recovery after hepatectomy.

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.

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

Background and Aims:

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

Methods:

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

Results:

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

Conclusion:

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

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.

Bilateral Erector Spinae Plane Block for Surgery on the Posterior Aspect of the Neck: A Case Report

The erector spinae plane block is an interfascial plane block whereby local anesthetic is injected within the plane deep to the erector spinae muscle and superficial to the transverse process. To date, it has been used to provide analgesia in thoracic, abdominal, and lumbar regions. We present the first reported case of bilateral erector spinae plane block being used to provide surgical anesthesia in the cervical region.

Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report

The number of total hip arthroplasty cases performed each year continues to increase; accordingly, so does the number of revision total hip arthroplasty procedures. While our traditional method of analgesia for these patients has involved multimodal medications and a continuous lumbar plexus block, we report two cases of patients who received continuous lumbar erector spinae plane blocks. Both patients exhibited excellent pain control postoperatively and were able to discharge home on postoperative day one. This case report illustrates the possible utility of continuous erector spinae plane blocks for postoperative analgesia in the more frequently occurring revision total hip arthroplasty surgeries.

The erector spinae plane block: a narrative review

Regional anesthesia and pain management have experienced advances in recent years, especially with the advent of fascial plane blocks. The erector spinae plane block is one of the newest techniques to be described. In the past two years, publications referring to ESP block have increased significantly. The objective of this review is to analyze the articles about ESP block that have been published to date. We performed a search in the main databases and identified 368 articles. After a selection of the relevant articles, 125 studies were found eligible and were included in the review. The ESP block is performed by depositing the local anesthetic in the fascial plane, deeper than the erector spinae muscle at the tip of the transverse process of the vertebra. Many cases of its use have been described with satisfactory results in the treatment of both acute pain and chronic pain. The applicability of the technique covers many clinical scenarios. Of the 98 case reports reviewed, 12 and 87 articles, respectively described the technique as a treatment for chronic pain and acute pain. The single-shot was the most frequently used technique. As described in the articles published to date, the technique is easy to perform and has a low rate of complications. However, despite the effectiveness of the technique, further studies are necessary to obtain more evidence of its actions.

Successful anesthetic management for total mastectomy in a pregnant woman using general anesthesia combined with continuous erector spinae plane block: a case report

Background

Anesthetic considerations for surgery during pregnancy include the safety of both mother and fetus. We successfully administered anesthesia for total mastectomy to a pregnant woman using general anesthesia combined with continuous erector spinae plane block.

Case presentation

A 41-year-old woman was scheduled to undergo total mastectomy at 18 weeks’ gestation. Hence, we decided to administer general anesthesia combined with continuous erector spinae plane block to minimize physiological stress on both mother and fetus. Continuous erector spinae plane block provided sufficient postoperative analgesia for our patient, completely eliminating the need for additional rescue analgesia during the entire postoperative period.

Conclusions

General anesthesia combined with continuous erector spinae plane block provided adequate analgesia without maternal hypotension in a pregnant woman undergoing total mastectomy.

Mid-point transverse process to pleura block for surgical anaesthesia

The use of ultrasound in regional anaesthesia has expanded our understanding of regional anaesthesia techniques and allowed for the development of novel strategies to achieve blockade of the trunk. Several alternatives to paravertebral block have recently been proposed, but none of these new techniques have yet been shown to provide surgical anaesthesia equivalent to a paravertebral block. This case report describes the successful use of the mid-point transverse process to pleura (MTP) block as the sole anaesthetic technique for a patient undergoing breast surgery.

Ultrasound-guided erector spinae plane block for postoperative analgesia in modified radical mastectomy: A randomised control study

Background and Aims

Several locoregional techniques have been described for providing postoperative analgesia after breast surgery. The optimal technique should be easy to perform, reproducible and provide good analgesia. This randomised control study was designed to evaluate the postoperative analgesic effect of ultrasound-guided erector spinae plane (US-guided ESP) block for modified radical mastectomy (MRM) surgery.

Methods

A total of 40 females belonging to American Society of Anesthesiologists^' 1 or 2 posted for MRM were randomly allocated into Group 1 (control group) and group 2 (ESP group). Patients in Group 1 received only general anaesthesia (GA) and were managed for pain postoperatively according to routine protocol, while group 2 (ESP group) patients received unilateral US-guided ESP block preoperatively (20 mL 0.5% bupivacaine to the operating side) followed by GA. The primary objective of study was to record postoperative 24 h cumulative morphine requirement. Differences between the two groups were analyzed using the Mann-Whitney U-test or a two-tailed Student's t-test.

Results

Postoperative morphine consumption was found to be significantly less in patients receiving US-guided ESP block compared to control group (1.95 ± 2.01 mg required in ESP group vs 9.3 ± 2. 36 mg required in control group, P value = 0.01)). All the patients in control group required supplemental morphine postoperatively compared to only two patients requiring that in US-guided ESP block group (P < 0.01).

Conclusion

US-guided ESP block when given prior to MRM surgery provided effective postoperative analgesia. CTRI registration no. - CTRI/2018/03/012712 registered in the clinical trial registry, India.

Erector spinae plane block combined with a novel technique for selective brachial plexus block in breast cancer surgery -a case report

Background

The breast is innervated by the intercostal nerves and the brachial plexus. We propose a technique to perform breast surgery without general anesthesia using the erector spinae plane (ESP) block and selective block of four nerves that arise from the brachial plexus innervate the breast and the axilla (SBP block).

Case

A 77-year-old man with breast cancer was scheduled for radical mastectomy and axillary clearance. He had a previous history of myocardial infarction with dilated cardiomyopathy and severely impaired ejection fraction. The surgery was performed under regional anesthesia with combined ESP and SBP block. The patient did not require opioids or other supplemental analgesics intra- or postoperatively and was discharged uneventfully.

Conclusions

SBP is a novel block that selectively blocks branches of the brachial plexus that innervate the breast.

Erector spinae block for postoperative analgesia following axillary hidradenitis suppurativa resection: a case report

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the terminal hair follicle of the apocrine gland-bearing skin, presenting with inflamed nodules, abscesses, and sinus tracts. Autoimmune, genetic, and infectious factors have been implicated in its pathogenesis. HS can be managed medically using topical and systemic antibiotics and with tumor necrosis factor antibody therapy in severe cases. Surgical treatment can range from local excision, deroofing or excision of sinus tracts, or wide radical excision of severe lesions. Lesions can be severely painful on their own or following surgical resection. Patients may require opioid therapy due to pain from the lesions themselves or following painful surgical resection. Erector spinae block (ESB) is a recently developed plane block used for the management of pain located in the chest wall or the abdominal wall. Ultrasound guidance is used to guide placement of the needle tip between the transverse process at the desired dermatomal level and the erector spinae muscle group. Traditional descriptions of the ESB have been at the level of the fifth transverse process to treat chest wall pain; in this case report, we describe a novel use of ESB at the level of the second transverse process to treat axillary pain after surgical debridement of axillary HS.

The erector spinae plane (ESP) block: A pooled review of 242 cases

STUDY OBJECTIVE

The erector spinae plane block (ESPB) was first described in 2016 as a regional block for thoracic neuropathic pain. Given its short history, there are a paucity of controlled clinical trials, yet an abundance of case reports. The primary aim of this review is to examine pooled clinical data from published literature to gain an understanding of ESPB characteristics.

DESIGN

A PubMed search was conducted to identify all ESPB related publications. Inclusion criteria included reports of ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. Only publications obtained in English were included. Measures included type of publication, year and country of publication, journal of publication, block technique, anatomic location, age, opioid and adjunct pain medication use, sensory and motor changes, side effects and adverse events. Qualitative statistics were used.

MAIN RESULTS

The initial search yielded 201 publications. After application of inclusion and exclusion criteria, 85 publications from 21 journals were included in the pooled review which yielded 242 reported cases between 2016 and 2018. The majority of publications reported single shot techniques (80.2%), followed by intermittent boluses (12.0%) and continuous infusions (7.9%). 90.9% reported use of multimodal analgesia in addition to the ESPB and 34.7% reported sensory changes from ESPB. A reduction in opioid use was reported in 34.7% of cases. One adverse event involving a pneumothorax was reported.

CONCLUSIONS

To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.