Erector spinae plane block provides complete perioperative analgesia for chronic scapulothoracic pain

Evaluation of Pain Relief and Opioid Consumption With the Addition of an Erector Spinae Plane Catheter Block After an Interscalene Nerve Block in Arthroscopic Rotator Cuff Repair

Background

The effects of the erector spinae plane (ESP) block and interscalene nerve block (ISNB) on arthroscopic rotator cuff repair (RCR) have been investigated separately.

Purpose

To evaluate whether additional catheterization for the ESP block can decrease acute postoperative pain and opioid consumption above the ISNB and multimodal oral analgesics in patients after arthroscopic RCR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were patients who underwent primary arthroscopic RCR between January 1 and December 31, 2021, and received either ISNB (ISNB group) or additional ESP block catheterization (ESP block group) as part of their pain management. Patients who underwent concomitant shoulder procedures were excluded. Patient characteristics, surgical details, pre- and postoperative numerical pain rating scale (NPRS) scores, rescue analgesic use, and possible opioid-related side effects were recorded. The primary outcome was the NPRS score immediately after surgery; secondary outcomes included rescue opioid use and opioid-related side effects until patients were discharged the next day. The Mann-Whitney U test or the chi-square test was used for between-group comparisons. Multiple linear regression analysis was conducted to examine predictors for total opioid consumption.

Results

A total of 54 patients were included-21 in the ISNB group and 33 in the ESP block group. The ESP block group exhibited significantly lower postoperative NPRS scores (2 ± 0.3 vs 3 ± 1.6 for ISNB; P = .003), reduced opioid consumption during hospitalization (0.5 ± 1.3 vs 6.1 ± 8.3 morphine milligram equivalent [MME] for ISNB; P < .001), and fewer opioid-related side effects (0 vs 3 for ISNB; P = .022). Multiple linear regression analysis indicated that the analgesic protocol (β = 5.750; P < .001) and the number of anchors used (β = 1.609; P = .022) were independently correlated with higher opioid consumption. Subgroup analysis revealed that additional ESP block significantly reduced opioid consumption during repairs involving ≥2 tendons (7.6 ± 9 vs 0.5 ± 1.4 MME; P < .001).

Conclusion

The study findings indicated that additional catheterization for the ESP block reduced postoperative pain, opioid consumption, and opioid-related side effects during the acute postoperative period of arthroscopic RCR when the ISNB and multimodal oral analgesics had already been administered. Future studies are needed to evaluate this treatment protocol.

The anatomical features of an ultrasound-guided erector spinae fascial plane block in a cadaveric neonatal sample

BACKGROUND

Since its inception, the erector spinae plane block has been used for a variety of truncal surgeries with success in both adults and children. However, the anatomical features, route of spread, and dermatomal coverage are still not fully understood in a pediatric population.

OBJECTIVES

To identify the anatomical features of the erector spinae fascial plane space by replicating an erector spinae plane block in a fresh neonatal cadaveric sample. The primary aim was to determine the spread of the dye within the fascial plane, while the secondary aims were to determine whether the needle direction or entry site affected the spread.

METHODS

The block was replicated bilaterally using 0.1 mL/kg of iodinated contrast dye in nine fresh unembalmed preterm neonatal cadavers. The dye was introduced under ultrasound guidance at vertebral level T5 and T8. Additionally, the needle was oriented cranial-caudal vs caudal-cranial to determine if the needle orientation influenced the spread of dye. The block was also replicated midway between the adjacent transverse processes as opposed to the lateral tip of the transverse process to determine the spread.

RESULTS

From the total sample size, 14 "blocks" were successfully replicated, while 4 "blocks" were either incomplete or failed blocks. Contrast dye was found in the paravertebral, intercostal, and epidural spaces, including posteriorly over the neural foramina. Results revealed that the needle direction or entry site did not influence the spread within the fascial plane.

CONCLUSION

Contrast material was found in the paravertebral, epidural, and intercostal spaces over an average of 5 vertebral levels when using 0.1 mL/kg.

The extent of cranio-caudal spread within the erector spinae fascial plane space using computed tomography scanning in a neonatal cadaver

BACKGROUND

The erector spinae plane block (ESP) is a novel approach for blockade of the spinal nerves in infants, children, and adults. Until recently, the gold standard for truncal procedures includes the paravertebral and epidural blocks. However, the exact mechanism by which this blockade is achieved is subject to debate.

METHODS

2.3 mL (1 mL/kg) of iodinated contrast dye was injected bilaterally into the erector spinae fascial plane of a fresh unembalmed preterm neonatal cadaver (weighing 2.3 kg), to replicate the erector spinae plane block and to track the cranio-caudal spread of the contrast dye using computed tomography. The "block" was performed at vertebral level T8 on the right-hand side and at vertebral level T10 on the left-hand side.

RESULTS

Contrast dye was spread over three dermatomal levels from T6 to T9 on the right-hand side, while on the left-hand side, the spread was seen over four dermatomal levels from T9 to T11/12. Contrast dye also spread over the costotransverse ligament, into the paravertebral space and further lateral from the lateral border of the erector spinae muscle into the intercostal space. However, no spread was seen in the epidural space.

CONCLUSION

The erector spinae plane block is a versatile technique that can be part of the multimodal postoperative analgesic strategy for truncal surgery. In this study, contrast material dye was tracked over four vertebral levels in the paravertebral space (suggesting an approximate volume of 0.5-0.6 mL per dermatome).