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

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial

BACKGROUND

Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cervical region. Our hypothesis is that an intermediate cervical plexus (IC) block can provide adequate postoperative analgesia compared to a cervical erector spinae (ES) block in patients undergoing anterior cervical spine surgery.

METHODS

In this double-blind prospective trial, 58 patients were randomly assigned into two equal groups prior to the administration of general anesthesia. Patients in the IC group (n = 29) underwent ultrasound-guided bilateral intermediate cervical plexus block with 15 ml of bupivacaine 0.25% administered to each side. The ES group (n = 29) underwent ultrasound-guided bilateral cervical erector spinae plane blocks with 15 ml of 0.25% bupivacaine administered to each side at the C6 level. The primary outcome was to record the time to the first call for rescue analgesia (nalbuphine), and the secondary outcomes were to measure the performance time, the onset of the sensory block, the intraoperative fentanyl consumption, postoperative pain intensity using VAS, the postoperative total nalbuphine consumption, and postoperative complications such as nausea, vomiting, hypotension, and bradycardia.

RESULTS

The performance and onset of sensory block times were significantly shorter in the IC group compared to the ES group. The time to first call for nalbuphine was significantly shorter in the IC group (7.31 ± 1.34 h) compared to the ES group (11.10 ± 1.82 h). The mean postoperative VAS scores were comparable between the two groups at the measured time points, except at 8 h, where it was significantly higher in the IC group, and at 12 h, where it was significantly higher in the ES group. The total nalbuphine consumption was significantly higher in the IC group (33.1 ± 10.13 mg) compared to the ES group (22.76 ± 8.62 mg).

CONCLUSIONS

For patients undergoing anterior cervical spine surgery, the intermediate cervical plexus block does not provide better postoperative regional analgesia compared to the cervical erector spinae block. Performance time and onset time were shorter in the IC group, whereas nalbuphine consumption was lower in the ES group.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov. (NCT05577559, and the date of registration: 13-10-2022).

Ultrasound-guided erector spinae plane block for open inguinal hernia repair: a randomized controlled trial

INTRODUCTION AND OBJECTIVES

Inguinal hernia repair is associated with significant postoperative pain. We assessed the analgesia efficacy of unilateral Erector Spinae Plane block (ESP) performed under ultrasound guidance in patients submitted to open unilateral inguinal hernia repair, comparing ESP to spinal anesthesia administered with or without opioid.

METHODS

Forty-five patients with ages ranging from 27 to 83 years were randomly allocated into three groups: control group receiving spinal anesthesia (n = 14), ESP group receiving ESP block combined with spinal anesthesia (n = 16), and spinal morphine group receiving spinal anesthesia with morphine 1 mcg.kg^-1 as adjuvant drug (n = 15). ESP was performed at the T8 level using 0.5% ropivacaine, 20 mL. We assessed the pain intensity in the initial 24 hours after surgery using the Visual Analogue Scale - VAS and rescue opioid requirement.

RESULTS

The ESP group showed four times higher consumption of rescue opioids than the spinal morphine group, or 26.7% vs. 6.2%, respectively (RR = 4.01; 95% CI: 0.82 to 19.42; p = 0.048). The spinal morphine group showed higher incidence of adverse effects than the ESP group, 37.5% vs. 6.7%, respectively (p = 0.039). There were no statistically significant differences among groups for the mean values of VAS score at 24 hours after surgery (p = 0.304).

CONCLUSION

At the doses used in this study, the ESP block was an ineffective technique for providing postoperative analgesia in unilateral open inguinal hernioplasty and was associated with higher consumption of rescue opioids when compared to spinal anesthesia with or without opioid.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

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

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

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

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