Ultrasound-guided Low Thoracic Erector Spinae Plane Block for Effective Postoperative Analgesia after Lumbar Surgery: Report of Five Cases

Comparison of Ultrasound-Guided Thoracic Paravertebral Block Versus Thoracic Paravertebral Block Combined With Serratus Anterior Plane Block or Erector Spinae Block Following Video-Assisted Thoracoscopic Lobectomy

Purpose

Compared the efficacy of ultrasound-guided thoracic paravertebral block (TPVB) and thoracic paravertebral combined with serratus anterior plane block (SAPB) or erector spinae block (ESPB) following video-assisted thoracoscopic lobectomy(VATL).

Patients and Methods

This retrospective study analyzed the medical records of 295 patients who underwent VATL surgery between August 2021 and January 2023. Patients were divided into three groups: TPVB (92 patients), TPVB combined with SAPB (106 patients), and TPVB combined with ESPB (97 patients). The primary outcomes were postoperative pain levels, measured using an 11-point visual analogue scale (VAS) both at rest and during coughing at 2, 6, 12, 24, and 48 hours postoperatively, as well as cumulative oxycodone consumption within 24 and 48 hours postoperatively.

Results

Postoperative cumulative oxycodone consumption within 24 and 48 hours was significantly lower in the TPVB+SAPB and TPVB+ESPB groups compared to the TPVB group (P < 0.001), with no significant difference between the TPVB+SAPB and TPVB+ESPB groups. The TPVB group exhibited higher VAS pain scores both at rest and during coughing at 2 and 6 hours postoperatively compared to the other two groups (P < 0.005). Within 24 hours postoperatively, the Area Under Curve (AUC) for VAS scores at rest was significantly lower in the TPVB+SAPB group than in the other two groups (P < 0.05), while the AUC for coughing pain was significantly lower in the TPVB+ESPB group compared to the TPVB group (P = 0.049). Nausea or vomiting occurred more frequently in the TPVB group compared to the other groups (P = 0.016).

Conclusion

TPVB combined with SAPB or ESPB provides superior analgesic effects compared to TPVB alone after video-assisted thoracoscopic lobectomy, with both techniques showing comparable analgesic efficacy. However, TPVB+SAPB may offer slightly better analgesia at rest, while TPVB+ESPB may have a potential advantage in reducing postoperative nausea and vomiting.

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.

The Shining Star of the Last Decade in Regional Anesthesia Part-I: Interfascial Plane Blocks for Breast, Thoracic, and Orthopedic Surgery

Regional anesthesia has benefits beyond just treating acute postoperative pain. Interfascial plane blocks, which have been very popular with ultrasound in recent years, function primarily by administering a high volume of a local anesthetic to the fascial plane. Contrary to traditional peripheral nerve blocks, the targeted nerve or structure in interfacial plane blocks is not fully defined, and the indications have not been fully revealed yet. Anatomical, cadaveric, and radiological studies show how effective the interfascial plane blocks play a role. This review focuses on the benefits, techniques, indications, and complications of interfascial plane blocks in the context of breast, thoracic, and orthopedic surgery.

Efficacy of erector spinae plane block on postoperative pain in patients undergoing lumbar spine surgery

BACKGROUND

Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect of erector spinae plane block (ESPB) effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score.

MATERIAL AND METHODS

Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated.

RESULTS

Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times.

CONCLUSION

ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia.

Is Opioid-free Anesthesia Possible by Using Erector Spinae Plane Block in Spinal Surgery?

Objective: Erector spinae plane (ESP) block can be a method to be used for postoperative pain control in lumbar herniated disc operations. The aim of this study is to investigate the effect of erector spinae block in lumbar herniated disc operation on intraoperative and postoperative opioid consumption.

Methods: Sixty patients scheduled for lumbar herniated disc surgery were included in the study. Patients were randomized into two groups: ESP block and control. Ultrasound-guided ESP block with 20 ml 0.25% bupivacaine at the bilateral L3 vertebral level was applied preoperatively to all patients in the ESP group. Patients in both groups were provided with intravenous patient-controlled analgesia (PCA) device containing fentanyl for postoperative analgesia. Fentanyl consumption and visual analogue scale (VAS) score were recorded at 15 min, 1, 6, 12, and 24 hours postoperatively.

Results: Fentanyl consumption (group C: 59.3 ± 20.66, group E: 41.3 ± 21.61, p: 0,02) and VAS score (group C: VASm 4 (2-4), group E: 2 (2-4), p: 0.009) decreased with ESP block application at postoperative one hour. No difference was detected between the two groups in terms of fentanyl consumption and VAS score at 6, 12, and 24 hours postoperatively (p>0.05). The intraoperative heart rate of patients in the ESP group was lower than the control group (p<0.05).

Conclusion: ESP block decreases opioid consumption and VAS score at postoperative one hour in patients, and also patients who receive ESP block do not require intraoperative opioid administration.

Postoperative Analgesic Efficacy of Thoracic Paravertebral Block and Erector Spinae Plane Block Combination in Video-Assisted Thoracic Surgery

Background The combination of a thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) has not been investigated. We aimed to evaluate the effects of the combination of TPVB and ESPB particularly on postoperative pain scores in patients undergoing video-assisted thoracic surgery (VATS). Methods From January 1, 2021, to March 1, 2021, 13 patients older than 18 years who underwent combined ESPB and TPVB for analgesic treatment after elective VATS were included in the study. Standard anesthesia induction was performed for all patients, and the block was performed in the lateral decubitis position before surgery. Using the in-plane technique, an ultrasound (US)-compatible 22-gauge, 8-mm nerve block needle was introduced 2-3 cm lateral to the spinous process of the T6 vertebra and advanced in the caudocranial direction. Fifteen (15) ml of 0.25% bupivacaine was administered and pleural depression was observed. The same needle was withdrawn from the paravertebral space and advanced into the interfascial plane above the transverse process and below the erector spinae muscle at the T5 level. Then, 15 ml of 0.25% bupivacaine was injected. Results The combination of TPVB and ESPB was performed in 13 patients. The mean age was 44.3 (21-68) years. The mean body mass index (BMI) was 23.21 (16.9-35.9) kg/m². Postoperative 24 hours morphine consumption was 24.5 (16-42) mg. In three cases, visual analog scale (VAS) scores at rest were ≥4; therefore, tramadol (25 mg, IV) was given as an additional analgesic. Nausea and vomiting were observed in only one case in the early postoperative period. Conclusıons As a new technique, the combination of TPVB and ESPB in this preliminary study provided effective postoperative pain management along with the use of morphine in acceptable quantities. Large-scale, randomized-controlled, and comparative studies are needed to demonstrate the efficacy of the combination of TPVB and ESPB.

Erector spinae block for postoperative pain management in lumbar disc hernia repair

PURPOSE

Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries.

METHODS

Fifty-four ASA I-II patients aged 18-65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery.

RESULTS

A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p < 0.05 for each timepoint). Total morphine consumption at 24 h after surgery decreased by 57% compared to that of the control group (11.3 ± 9.5 mg in the ESP group and 27 ± 16.7 mg in the control group). NRS scores were similar between the two groups.

CONCLUSION

This study showed that ESP block provided effective analgesia in patients who underwent lumbar disc herniation surgery.

CLINICAL TRIALS REGISTRY

NCT03744689.

Erector Spinae Plane Block for Perioperative Pain Control and Short-term Outcomes in Lumbar Laminoplasty: A Randomized Clinical Trial

BACKGROUND

Spine surgery causes severe pain and can be associated with significant opioid utilization; however, the evidence for opioid-sparing analgesic techniques such as erector spinae plane (ESP) block from controlled studies is limited. We aimed to investigate the analgesic effects of ESP block in lumbar laminoplasty.

METHODS

In this prospective, double-blind, controlled single-center trial, 62 consecutive elective lumbar laminoplasty patients were randomized into either a control group (Group G, N=32) or a treatment group (Group E, N=30). Group G received general anesthesia and multimodal analgesia, similar to group E, while Group E received additional bilateral ESP block after induction of general anesthesia. The primary outcome was postoperative pain scores for the first 48 h after surgery, and the secondary outcomes analyzed included intraoperative anesthetic usage, perioperative analgesic consumption, return of bowel function and satisfaction for acute pain management indicated by overall benefit of analgesia score (OBAS).

RESULTS

Significant differences in pain scores over time were found between the two groups (P=0.010), with Group E patients having significantly lower pain scores than Group G during the first six hours (P=0.000). The opioid consumption in Group G was significantly higher than in Group E both intraoperatively (P=0.000) and postoperatively (P=0.0005). Group E patients had lower intraoperative sevoflurane requirement, improved satisfaction with pain management, and earlier return of bowel function than Group G patients.

CONCLUSION

ESP block is effective in reducing postoperative pain scores and lowering opioid utilization (both intraoperatively and postoperatively), resulting in improved patient satisfaction for pain management in lumbar laminoplasty.

Continuous quadratus lumborum block as post-operative strategy for pain control in spinal fusion surgery

Background and Aims

Lumbar spinal fusions have post-operative pain levels that can be difficult to treat. The objective of this study was to determine if using bilateral quadratus lumborum (QL) nerve block catheters for lumbar fusions changes the patient's post-operative recovery experience by reducing opioid consumption, thereby limiting potential risks and side effects and reducing recovery time.

Methods

There were a total of 52 surgical lumbar fusion patients in this single-center, retrospective cohort review. In control Group A, there were 26 patients who received opioid regimens. In control Group B, there were 26 patients who received bilateral QL block catheters with breakthrough opioid regimens. Forty-eight hour post-operative opioid use in oral morphine milligram equivalents (MME) and length of stay (LOS) from the post-anaesthesia care unit to hospital discharge were examined.

Results

Group A had a mean MME of 307.62 ± 305.37 mg. Group B had a statistically significant lower mean total MME of 133.78 ± 152.66 mg (P = 0.012, α = 0.05). On an average, Group A required 2.3 times the MMEs than Group B. Group A had a mean LOS of 2.34 ± 1.87 days, whereas Group B had a lower mean LOS of 1.98 ± 0.51 days. This difference of 0.36 days was not statistically significant (P = 0.522, α = 0.05).

Conclusion

Surgical lumbar fusion patients who received the QL block catheter had a lower opioid requirement compared to standard opioid regimens. The study was underpowered to detect a difference in LOS.

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.

Erector Spinae Plane Block for Lumbar Spinal Surgery: A Systematic Review

Background

Erector spinae plane block (ESPB) as a new trunk fascia block technique was proposed in 2016. ESPB has aroused the interest of many nerve block experts. However, there are few clinical studies on ESPB for lumbar surgery, and its effectiveness and safety are controversial. The goal of this review is to summarize the use of ESPB for lumbar spine surgery in order to better understand this technique.

Methods

PubMed, EMBASE, Cochrane library and ClinicalTrial.gov databases were searched up to July 30, 2019. According to the inclusion and exclusion criteria established in advance, "lumbar spine surgery" and "ESPB" related MesH terms and free-text words were used. Data on pain scores, analgesic consumptions and adverse effects were reported. All processes follow PRISMA statement guidelines.

Results

A total of 171 participants from 11 publications were identified, including two randomized controlled trials (RCTs), one retrospective cohort study, four case reports and four cases series. Block operation planes from T8 to L4. The main anesthetics used in the block are bupivacaine, ropivacaine and lidocaine. There was evidence for reducing postoperative pain scores and analgesic consumptions.

Conclusion

The effectiveness and safety of ESPB for lumbar spine surgery are still controversial. The current evidence is insufficient to support the widespread use of ESPB for lumbar spine surgery. High-quality RCTs are urgently needed.

Sacral Erector Spinae Plane Block for Gender Reassignment Surgery

The erector spinae plane block (ESPB) is an interfascial plane block that has been used to provide perioperative analgesia for a variety of indications. This case report describes the novel use of the sacral ESPB on a transgender patient undergoing male-to-female gender reassignment surgery for perioperative pain control. The sacral ESPB technique was described and post-operative pain score and opioid requirements were reported. The sacral ESPB was successfully used as an alternative to neuraxial, caudal, or peripheral nerve blocks for gender reassignment surgery.

Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery

Background

With the increase in life expectancy seen throughout the world, the prevalence of degenerative spinal pathology and surgery to treat it has increased. Spinal surgery under general anesthesia leads to various problems and complications, especially in patients with numerous medical comorbidities or elderly patients. For this reason, there is a need for safer anesthetic methods applicable to unhealthy, elderly patients undergoing spinal surgery.

Purpose

To report our experience with utilizing fluoroscopy-guided epidural anesthesia in conjunction with conscious sedation in spinal surgery.

Patients and Methods

We performed a retrospective review of 111 patients at our institution that received fluoroscopy-guided epidural anesthesia for lumbar surgery from February to September 2018. Patients’ records were evaluated to evaluate patient demographics, American Society of Anesthesiology Physical Classification System (ASA) class, and pain numerical rating scores (NRS) preoperatively and throughout their recovery postoperatively. Intraoperative data including volume of epidural anesthetic used, extent of epidural spread, and inadvertent subdural injection was collected. Postoperative recovery time was also collected.

Results

The mean age of our patients was 60 years old with a range between 31 and 83 years old. All patients experienced decreases in postoperative pain with no significant differences based on age or ASA class. There was no association between ASA class and time to recovery postoperatively. Older patients (age 70 years or greater) had a significantly longer recovery time when compared to younger patients. Recovery also was longer for patients who received higher volumes of epidural anesthesia. For every 1 mL increase of epidural anesthetic given, there was an increase in the extent of spread of 1.8 spinal levels.

Conclusion

We demonstrate the safety and feasibility of utilizing conscious sedation in conjunction with fluoroscopy-guided epidural anesthesia in the lumbar spinal surgery.

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.