Ultrasound-guided Erector Spinae Plane Block: Indications, Complications, and Effects on Acute and Chronic Pain Based on a Single-center Experience

Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Patients with Extrahepatic Portal Venous Obstruction Undergoing Splenectomy: A Randomized Controlled Trial

BACKGROUND

Postoperative pain is quite prevalent in patients undergoing splenectomy and shunt surgery for extrahepatic portal venous obstruction (EHPVO) via midline laparotomy incision. Most of these patients present with thrombocytopenia in the preoperative period. The presence of thrombocytopenia excludes the placement of epidural catheter for postoperative analgesia, which is considered the gold standard for laparotomies. Systemic opioids remain the cornerstone of pain management in such cases, but they have their side effects. Better alternatives need to be explored to improve postoperative pain management and recovery. The erector spinae plane block (ESPB) has an excellent risk-benefit ratio and has been used for a wide range of cases, from acute postoperative pain to chronic pain conditions.

METHODOLOGY

This was a randomized controlled trial conducted on 84 patients who underwent splenectomy with lienorenal shunt surgery under general anesthesia. Patients in the study group were given ESPB before extubation, while the control group was managed on conventional analgesics. The primary objective was postoperative opioid requirement by intravenous patient-controlled analgesia (PCA) in both groups. Secondary objectives were static and dynamic Numerical Rating Scale (NRS) scores, hospital stay duration, time first to rescue analgesia, and incidences of adverse events.

RESULTS

Patients in the ESPB group had less requirement of fentanyl in the postoperative period (median of 100 µg as compared to 880 µg in control group in first 24 hours). Static and dynamic pain scores were also less in the ESPB group at all time points (P < 0.001). Adverse events were higher in the control group compared to the ESPB group.

CONCLUSIONS

Ultrasound-guided ESPB provides superior analgesia and recovery with fewer side effects than conventional analgesics.

Ultrasound-guided fascial plane blocks in chronic pain: a narrative review

BACKGROUND

Recent studies have unveiled the intricate and distinctive nature of fascia, no longer regarding it solely as a muscle container. Recent research highlights its complex innervation and structure, signifying its significance in chronic pain pathways.

METHODS

We conducted a systematic literature search (updated on February 2024) to evaluate the role of fascial plane blocks in chronic pain treatment. All article types (randomized clinical trials, prospective and retrospective observational studies along with case reports and case series) were deemed eligible for inclusion if they referenced "fascial plane blocks" for the control of chronic pain conditions (persistent post-surgical, neuropathic, musculoskeletal-myofascial and cancer-related) and were published between 2010 and February 2024.

RESULTS

The search revealed an increasing evidence in the literature for the implementation of fascial blocks in chronic pain management, although still heavily limited to case reports or series.

CONCLUSION

With the integration of ultrasound technology and a deeper understanding of their mechanisms of action, the fascial plane blocks continue to broaden their application also in chronic pain management, as a part of a multimodal strategy or as an alternative to conventional drugs or opioids.

Comparative efficacy of ultrasound-guided erector spinae plane block versus wound infiltration for postoperative analgesia in instrumented lumbar spinal surgeries

OBJECTIVE

This study compared the efficacy of ultrasound-guided erector spinae plane block (ESPB) and wound infiltration (WI) for postoperative analgesia in patients who underwent lumbar spinal surgery with instrumentation.

METHODS

In this randomized controlled trial, 80 patients were divided into two groups: ESPB (n = 40) and WI (n = 40). Postoperative pain intensity was assessed via the visual analog scale (VAS) at multiple time points within 24 h. Additionally, opioid consumption, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV), and patient satisfaction were evaluated.

RESULTS

Both ESPB and WI provided effective postoperative pain management, with no significant differences in VAS scores. However, the ESPB group demonstrated a significantly longer duration of analgesia, a shorter time to first rescue analgesia, and lower total tramadol consumption (50 ± 60 mg vs. 100 ± 75 mg; p = 0.010) than did the WI group. Furthermore, a trend toward reduced PONV incidence was observed in the ESPB group, likely due to its opioid-sparing effect.

CONCLUSION

While both ESPB and WI provided effective postoperative pain management, ESPB demonstrated a distinct advantage by offering a longer duration of analgesia and significantly reducing opioid consumption. These findings suggest that ESPB is more effective than WI for postoperative analgesia in lumbar spinal surgeries, providing prolonged pain relief and improving patient outcomes. Further studies are warranted to explore its long-term benefits and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.govPRS: NCT06567964 Date: 08/21/2024 Retrospectively registered.

Bilateral erector spinae plane block by multiple injection for pain control in pseudomyxoma peritonei surgery: a single-blind randomized controlled trial

OBJECTIVE

Currently, the primary surgical treatment for pseudomyxoma peritonei (PMP) is cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The perioperative period is frequently accompanied by severe pain. Erector spinae plane block (ESPB) can enhance analgesia for abdominal surgery. The purpose of this study was to compare the analgesic effects of bilateral multiple-injection ESPB in patients with PMP.

METHODS

Fifty patients with PMP were randomly divided into two groups: the ESPB combined with general anesthesia group (Group E) and the general anesthesia alone group (Group C). Prior to the induction, patients in Group E underwent ESPB at the T7 and T11 levels. The primary outcome was the visual analog scale (VAS) scores during rest at 6 h post-extubation. Secondary outcomes included intraoperative and postoperative opioid consumption, time for first rescue analgesia, frequency distribution of rescue analgesia, incidence of nausea and vomiting, adverse events associated with ESPB.

RESULTS

The Visual Analogue Scale (VAS) scores in Group E were significantly lower compared to Group C at immediate post-extubation (1.6 ± 0.9 vs. 2.4 ± 1.2, P = 0.008), and at 2 (1.9 ± 1.2 vs. 3.2 ± 1.1, P < 0.001), 4 (2.4 ± 1.5 vs. 3.7 ± 1.0, P = 0.001), and 6 h (2.7 ± 1.1 vs. 3.8 ± 1.4, P = 0.004) post-extubation during rest. Similarly, the VAS scores in Group E were significantly lower than those in Group C at immediate post-extubation (3.0 ± 1.4 vs. 4.6 ± 1.2, P < 0.001), and at 2 (3.8 ± 1.7 vs. 4.9 ± 1.4, P = 0.019), 4 (3.5 ± 1.3 vs. 5.3 ± 1.5, P < 0.001), and 6 h (3.9 ± 1.8 vs. 4.9 ± 1.3, P = 0.004) post-extubation during movement. In Group E, the intraoperative remifentanil administration (2319.3 ± 1089.5 vs. 2984.6 ± 796.1, P = 0.017) and the amount of rescue analgesia within 2 h post-extubation (0 vs. 4, P = 0.037) were significantly less than in Group C, and the first rescue analgesia time was shorter as well (231.4 ± 147.5 vs. 668.8 ± 416.7, P < 0.001).

CONCLUSION

Compared to general anesthesia alone, bilateral multiple-injection ESPB with 0.2% ropivacaine can enhance analgesia and reduce opioid administration in patients with PMP. However, the duration of analgesia with ESPB is relatively short due to the low concentration of the local anesthetic used.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300069504, 20/03/2023.

Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trial

Background

Although laparoscopic cholecystectomy (LC) is a minimally invasive surgery, it can cause moderate to severe postoperative pain. Erector spinae plane (ESP) and transversus abdominis plane (TAP) blocks are considered effective means for pain management in such cases; however, there is inconclusive evidence regarding their analgesic efficacy. This meta-analysis aimed to compare the efficacy of ESP block and TAP block for pain control in LC.

Methods

We systematically searched Medline, PubMed, Scopus, Embase, and Google Scholar until 26 January 2024. All randomized clinical trials compared the efficacy of erector spinae plane block (ESPB) and transversus abdominis plane block (TAPB) for postoperative pain relief after LC. The primary outcomes were pain scores at rest and on movement at 1, 2, 6, 12, and 24 h postoperatively. The secondary outcomes were total opioid consumption, first analgesia request time, and rates of postoperative nausea and vomiting. We analyzed all the data using RevMan 5.4.

Results

A total of 8 RCTs, involving 542 patients (271 in the ESPB group and 271 in the TAPB group), were included in the analysis. The ESP block demonstrated statistically significant lower pain scores at rest and on movement than the TAP block at all-time points except at the 1st and 6th h on movement postoperatively; however, these differences were not considered clinically significant. Additionally, patients who received the ESP block required less morphine and had a longer time before requesting their first dose of analgesia. There were no significant differences in postoperative nausea and vomiting incidence between the two groups.

Conclusion

In patients undergoing LC, there is moderate evidence to suggest that the ESP block is effective in reducing pain severity, morphine equivalent consumption, and the time before the first analgesia request when compared to the TAP block during the early postoperative period.Systematic review registration: PROSPERO CRD42024505635, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024505635.

Ultrasound-guided erector spinae plane block in patients with chronic lumbar facet joint pain: A prospective case-controlled study

PURPOSE

The aim was to evaluate the efficacy of ultrasound-guided erector spinae plane (ESP) block and compare with the conventional physical therapy in chronic low back pain (LBP).

MATERIALS AND METHODS

This prospective case-controlled study included patients with chronic LBP. Their clinical and demographic data were obtained, and they were divided into two groups for conventional physical therapy and ESP blocks. Prior to treatment, on the first day, the second week, and the third month, the Oswestry Disability Index (ODI) and visual analog scale (VAS) pain score were evaluated.

RESULTS

The study included 43 patients, 21 in the ESP block group and 22 in the conventional physical therapy group. The VAS in movement was higher in the ESP block group at baseline (p = 0.047). On the first day after the treatments, the ESP block group showed lower resting (p < 0.001) and movement (p = 0.001) VAS values than the conventional physical therapy group. At the end of 3 months, both groups had improved VAS and ODI scores (all p < 0.001).

CONCLUSION

US-guided ESP block might be considered a successful, safe, and technically simple alternative treatment in patients with chronic LBP to control pain and reduce the cost of physical therapy and lost workdays.

Opioid-sparing effects of ultrasound-guided erector spinae plane block for video-assisted thoracoscopic surgery: a randomized controlled study

BACKGROUND

The erector spinae plane block (ESPB) is a new analgesic method used in thoracic surgery. However, few studies have characterized their effects on perioperative opioid consumption. We aimed to evaluate the effects of ESPB on perioperative opioid consumption in patients who underwent video-assisted thoracoscopic surgery (VATS).

METHODS

This was a randomized, observer-blinded clinical trial at a single-centre academic hospital. Eighty patients were scheduled for thoracoscopic segmentectomy or lobectomy by VATS for lung cancer. Forty participants were randomly assigned to ESPB or control group. All patients received intravenous patient-controlled postoperative analgesia. Perioperative opioid consumption, visual analogue scale (VAS) scores, and adverse events were recorded.

RESULTS

Intraoperative and postoperative opioid consumption and static/dynamic VAS scores were significantly lower in the early hours after VATS in the ESPB group (p < 0.05) than the control group. No significant differences were observed in adverse effects between the two groups.

CONCLUSIONS

ESPB reduced intraoperative opioid consumption and early postoperative pain in patients undergoing VATS. Our findings support the view that ESPB is a safe and highly effective option for regional analgesia for VATS.

TRIAL REGISTRATION

http://www.chictr.org.cn , ChiCTR1800019335.

Comparison of the analgesic efficacy of the ultrasound-guided transversalis fascia plane block and erector spinae plane block in patients undergoing open inguinal hernia repair under spinal anesthesia

BACKGROUND

Open inguinal hernia repair (OIHR) surgery is a common surgical procedure, and ultrasound guided interfascial plane blocks can also be included in current approaches to postoperative multimodal analgesia regimens. This study aimed to compare the postoperative analgesic efficacy of the erector spinae plane block (ESPB) and transversalis fascia plane block (TFPB) in patients undergoing OIHR.

METHODS

This prospective, randomized, assessor-blinded comparative study was conducted in the postoperative recovery room and ward of a tertiary hospital. A total of 80 patients with American Society of Anesthesiologists physical status I-III were enrolled and allocated equally to either the ESPB or TFPB group. The patients received standard multimodal analgesia in addition to an ultrasound-guided ESPB or TFPB. During the first 24 h postoperatively, tramadol consumption was assessed and pain levels at rest and during movement were compared using numeric rating scale (NRS) scores at 1, 3, 6, 9, 12, 18, and 24 h postoperatively.

RESULTS

The results showed no difference in NRS scores at any time point between the groups, except for NRS at rest in the third hour. However, tramadol consumption was lower in the TFPB group than in the ESPB group overall (88 ± 75.2 vs. 131 ± 93.7 mg, respectively; P = 0.027, mean difference: -43, 95% CI [-80.82, -5.18]).

CONCLUSIONS

The TFPB leads to lower tramadol requirements in the first 24 h postoperatively than the ESPB in patients undergoing OIHR.

Efficacy of Erector Spinae Plane (ESP) Block for Non-cardiac Thoracic and Upper Abdominal Surgery: A Single Institute Comparative Retrospective Case Series

Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022. All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD) 1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and required significantly more antiemetic pharmacotherapy (mean 1.4 antiemetics administered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24 hours (95% CI -9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral block techniques in thoracic and upper abdominal surgeries for perioperative pain management.

Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study

Background

Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy.

Objectives

This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches.

Materials and methods

Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05).

Results

Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015).

Conclusion

ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.

Erector spinae plane block for radiofrequency ablation of hepatic focal lesions: Randomized controlled trial

OBJECTIVE

This study evaluated the opioid sparing and pain relief effect of erector spinae plane block (ESPB) for radiofrequency ablation (RFA) of hepatic focal lesions under conscious sedation.

DESIGN

A randomized controlled trial.

SETTING

Tanta University Hospitals.

PATIENTS

Fifty patients aged 30-60 years old and eligible for RFA of hepatic focal lesions were included.

INTERVENTIONS

Patients randomized to receive either local anesthetic infiltration (group I) or ESPB (group II). Both groups received sedation by propofol infusion.

MAIN OUTCOME MEASURE(S)

The primary outcome was total fentanyl consumption. Secondary outcomes were nonverbal pain score (NVPS), time to first analgesic request post-procedure, radiologist's satisfaction, and complications.

RESULTS

In group I, NVPS was significantly increased at 10, 15, 25, and 30 minutes during RFA compared to group II (p = 0.008, <0.001, 0.018, and 0.001, respectively) with no significant differences on arrival to post-anesthesia care unit (PACU) and after 1 hour. Total fentanyl consumption during the procedure was significantly increased in group I compared to group II (160.9 ± 38.2 and 76 ± 21 µg, respectively; p < 0.001) with prolonged time to first analgesia request post-procedure in group II compared to group I (392.7 ± 38.8 and 101.1 ± 13.6 minutes, respectively; p < 0.001). The level of radiologist's satisfaction was significantly increased in the group II (p = 0.010). Three patients in group I and one patient in group II needed general anesthesia. Lower incidence of complications in group II occurred with statistical insignificance.

CONCLUSIONS

The ESPB provided adequate analgesia and reduced opioids consumption during the hepatic RFA, with high radiologist's satisfaction.

Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review

Introduction

Rib fractures are a common sequelae of chest trauma and are associated with significant morbidity. The erector spinae nerve block (ESB) has been proposed as an alternative first-line regional technique for rib fractures due to ease of administration and minimal complication profile. We aimed to investigate the current literature surrounding this topic with a focus on pain and respiratory outcomes.

Methods

A comprehensive literature search was performed on the Medline, Embase, Web of Science, Scopus, and Cochrane databases. Keywords of "erector spinae block" and "rib fractures" were used to form the search strategy. Papers published in English investigating ESB as an analgesic intervention for acute rib fracture were included. Exclusion criteria were operative rib fixation, or where the indication for ESB was not rib fracture.

Results

There were 37 studies which met the inclusion criteria for this scoping review. Of these, 31 studies reported on pain outcomes and demonstrated a 40% decrease in pain scores post administration within the first 24 hours. Respiratory parameters were reported in 8 studies where an increase in incentive spirometry was demonstrated. Respiratory complication was not consistently reported. ESB was associated with minimal complications; only 5 cases of haematoma and infection were (incidence 0.6%) reported, none of which required further intervention.

Discussion

Current literature surrounding ESB in rib fracture management provides a positive qualitative evaluation of efficacy and safety. Improvements in pain and respiratory parameters were almost universal. The notable outcome from this review was the improved safety profile of ESB. The ESB was not associated with complications requiring intervention even in the setting of anticoagulation and coagulopathy. There still remains a paucity of large cohort, prospective data. Moreover, no current studies reflect an improvement in respiratory complication rates compared to current techniques. Taken together, these areas should be the focus of any future research.

Postoperative Analgesia in Breast Cancer Surgery: Efficiency and Safety of Ultrasound Guided Erector Spinae Plane Block, a randomized controlled double blinded trial

INTRODUCTION

Breast cancer surgeries are the mainstay and usually the first step of treatment.

AIM

To assess the efficiency and safety of ultrasound guided Erector Spinae Plane Block (ESPB) for the management of postoperative pain in patients undergoing elective breast cancer surgery.

METHODS

Between December 2018 and June 2019, a prospective, controlled, randomized, double-blinded study was conducted at the maternity and neonatology center of Tunis. We included fifty ASA I-II female patients who were scheduled for elective breast cancer surgery. They were randomly divided into two groups: Group R (n=25) with Ropivacaine, while Group P (n=25) received a placebo. The study recorded PCA morphine consumption and patient demand for PCA. The primary outcome was to compare the visual analogue scale (VAS) pain scores at various points throughout the 24 hours postoperatively (1st, 2nd, 4th, 8th, 12th, 16th, 20th, 24th) between the two groups.

RESULTS

Except for the first hour and 16th hour post-surgery, the mean VAS pain scores were significantly lower in Group R compared to Group P. The 24-hour morphine consumption was significantly lower in Group R (5.5±0.9 mg) compared to Group P (16.6±2.8 mg); p<0.001. Per-operative fentanyl consumption was also significantly lower in Group R (9.1±4.2 mcg; Group P: 50±9.1 mcg; p< 0.001). Moreover, the mean total morphine demand was significantly lower in Group R.

CONCLUSION

ESPB with Ropivacaine is effective and safe for pain management after breast cancer surgery with a consequent morphine sparing and less use of systemic analgesia.

Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Percutaneous Nephrolithotomy

Background Percutaneous nephrolithotomy (PCNL) is presently the preferred method for managing renal calculi. Visceral pain from the kidney and ureter and somatic pain from the incision site are the primary causes of immediate postoperative pain following PCNL. Poor pain control is associated with unwanted consequences such as patient discomfort, delayed recovery, and prolonged hospital stay. Recently, the erector spinae plane (ESP) block has been used in many thoracic and abdominal surgeries for the control of postoperative pain. In this study, we aimed to assess the effectiveness of the ultrasound-guided ESP block following PCNL. Methodology This was a prospective, double-blind, randomized controlled study including 60 patients who were scheduled for elective PCNL under general anesthesia. Patients were randomly divided into two groups. Group E underwent an ultrasound-guided ESP block with 20 mL of the local anesthetic mixture at the T-9 level unilaterally on the side of surgery, and group C was a sham group in which 20 mL of normal saline was injected on the side of surgery. Changes in postoperative pain score were the primary outcome, and the duration of analgesia, the total analgesic requirement in 24 hours, and patient satisfaction were the secondary outcomes. Results The demographic data of both groups were comparable. The Visual Analog Scale score was considerably lower in group E than in group C at two, four, six, and eight hours postoperatively. In group E, the mean analgesic duration was substantially longer than that in group C (8.87 ± 2.45 hours vs. 5.67 ± 1.58 hours, respectively). The tramadol requirement was higher in group C (286.67 ± 62.88 mg) than in group E (133.33 ± 47.95 mg) during the 24-hour postoperative period. At 12 hours, patient satisfaction was considerably higher in group E than in group C (6.73 ± 0.45 vs. 5.87 ± 0.35, respectively). Conclusions The ultrasound-guided ESP block provided efficient postoperative pain relief, prolonged duration of analgesia, and reduced tramadol intake after PCNL surgery.

Analgesic efficacy of a bilateral erector spinae plane block versus a fentanyl constant rate infusion in dogs undergoing hemilaminectomy: a retrospective cohort study

BACKGROUND

Erector spinae plane block (ESPB) is an ultrasound-guided interfascial plane block used to provide analgesia in dogs undergoing hemilaminectomy. The aim of this study is to compare the analgesic efficacy of a bilateral ESPB with a fentanyl constant rate infusion (CRI) in dogs undergoing hemilaminectomy.

METHODS

This is a retrospective cohort study. Anaesthetic records of client-owned dogs undergoing hemilaminectomy (June 2019-August 2020), and in which a bilateral ESPB was performed (group ESPB), were retrieved and compared to a cohort of 39 dogs that underwent hemilaminectomy (September 2014 - June 2017) and in which a fentanyl CRI (2 μg/kg bolus followed by 5 μg/kg/hour) was used as a primary intraoperative analgesia (group CRI). The prevalence of dogs in which intraoperative rescue fentanyl boluses were administered, the total dose of rescue fentanyl boluses administered, the postoperative methadone requirement and anaesthetic complications during the first 24 postoperative hours were evaluated. Univariate statistical analysis was used.

RESULTS

Group ESPB comprised of 93 dogs. The bilateral ESPB was performed using a median (range) levobupivacaine volume of 1 (0.5-1.7) mL/kg per side, at a concentration of 0.125% (0.12-0.25). At least one rescue fentanyl bolus was administered in 54.8% and in 56.4% of dogs in group ESPB and CRI, respectively (p > 0.99). The number of rescue fentanyl boluses was higher in group CRI (p = 0.006), especially during lumbar hemilaminectomy. Rescue fentanyl boluses were more frequently administered from skin incision to end of vertebral lamina drilling in group CRI (p = 0.001), and from end of vertebral lamina drilling to end of surgery in group ESPB (p = 0.0002). During the first 6 (p = 0.0035) and 6-12 (p = 0.0005) postoperative hours, the number of dogs that required at least one dose of methadone was higher in group CRI. In group ESPB, dogs were more likely to become hypothermic (p = 0.04). One dog, not included in the study, developed sinus arrest after performing a caudal thoracic ESPB.

CONCLUSIONS

Under the conditions of this study, a bilateral ESPB was associated with a lower number of rescue fentanyl boluses administered in dogs undergoing hemilaminectomy, especially between skin incision to end of vertebral lamina drilling. Despite ESPB being associated with a reduced opioid consumption during the first 12 hours postoperatively, differences in the postoperative management precluded any firm conclusion regarding its postoperative effect.

Ultrasound-Guided Erector Spinae Plane Block in Emergency Department for Abdominal Malignancy Pain: A Case Report

INTRODUCTION

Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia.

CASE REPORT

In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer.

CONCLUSION

The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

INTERFASCIAL PLANE BLOCKS IN OBSTETRIC AND GYNECOLOGIC SURGERY

Introduction

Interfascial plane blocks (IPB) are truncal blocks with local anesthetic injected into space between two muscle layers. IPBs are easy to learn, simple to perform, provide satisfactory analgesia up to 24 hours, having a minimal risk of complications.

Methods

We present a retrospective analysis of the patients who had IPB as a part of postoperative pain management plan following either CD or hysterectomy in Leskovac General Hospital, Serbia during the period April 2017 - February 2022.

Results

We had 131 patients who had IPB perioperatively. Bilateral QLB type 1 was performed in 53 patients after CD and in 68 patients after hysterectomy. Bilateral ESPB T10-11 was done following one CD case and in 9 patients before hysterectomy. Patients had both acetaminophen and nonsteroidal anti-inflammatory drug for postoperative pain control. Decreased usage of fentanyl and sevoflurane was noticed in the cases where IPB was performed preoperatively. Almost all patients had well-controlled pain, and were very satisfied with pain score of 0-4/10 at numeric rating scale during 24 hours after surgery, with no opioid use. There were no complications regarding block performance.

Conclusion

QLB and ESPB have great potential to improve and facilitate postoperative pain management in obstetric and gynecologic surgery.

Efficacy of Postoperative Analgesia by Erector Spinal Plane Block after Lumbar Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background. In recent years, erector spinae plane block (ESPB) has been increasingly used as a new regional block technique for postoperative analgesia; however, little is known on its benefits. Therefore, we performed a systematic review and meta-analysis to investigate the efficacy and safety of ESPB in lumbar spine surgery. Methods. Databases including PubMed, Embase, Cochrane Library, and Web of Science were systematically searched for randomized controlled trials (RCTs) comparing ESPB with no block in lumbar spine surgery until September 30, 2021. The primary outcome was opioid consumption after surgery. The Cochrane Collaboration’s tool for assessing the risk of bias was used to evaluate the quality of included studies. Results. Fifteen RCTs involving 980 patients were included in the study. Opioid consumption 24 hours after surgery was significantly lower in the ESPB group standardized mean difference ( $\text{SMD}=-2.27$ , 95% confidence interval (95% CI) (-3.21, -1.32); $p<0.01$ ). ESPB reduced pain scores at rest and on movement within 48 hours after surgery and the incidence of the postoperative rescue analgesia ( $\text{RR}=0.32$ , 95% CI (0.31, 0.80); $p=0.02$ ), while it significantly prolonged time to first rescue analgesia ( $\text{SMD}=4.87$ , 95% CI (2.84, 6.90); $p<0.01$ ). Moreover, significantly better patient satisfaction was associated with ESPB ( $\text{SMD}=1.89$ , 95% CI (1.03, 2.74); $p<0.01$ ). Conclusion. EPSB provides effective and safe postoperative analgesia after lumbar spine surgery.

Ultrasound-guided interventions for controlling the thoracic spine and chest wall pain: a narrative review

Ultrasound-guided injection is useful for managing thoracic spine and chest wall pain. With ultrasound, pain physicians perform the injection with real-time viewing of major structures, such as the pleura, vasculature, and nerves. Therefore, the ultrasound-guided injection procedure not only prevents procedure-related adverse events but also increases the accuracy of the procedure. Here, ultrasound-guided interventions that could be applied for thoracic spine and chest wall pain were described. We presented ultrasound-guided thoracic facet joint and costotransverse joint injections and thoracic paravertebral, intercostal nerve, erector spinae plane, and pectoralis and serratus plane blocks. The indication, anatomy, Sonoanatomy, and technique for each procedure were also described. We believe that our article is helpful for clinicians to conduct ultrasound-guided injections for controlling thoracic spine and chest wall pain precisely and safely.

Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Postoperative Analgesia in Abdominal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Regional anesthesia technique has been reported to exert excellent analgesic efficacy for various surgeries. Erector spinae plane block (ESPB) and transversus abdominis plane (TAP) block are good ways to relieve postoperative pain after abdominal surgery. However, the analgesic efficacy between them remains controversial. This meta-analysis evaluated the analgesic effect between these two blocks in abdominal surgery with statistical and clinical interpretation.

METHODS

PubMed, Web of Science, the Cochrane Library, ClinicalTrials.gov register, and Embase databases were systematically searched by two independent investigators from the inception to December 2021.

RESULTS

10 randomized controlled trials (RCTs) comprising 570 patients were included in the final meta-analysis. Meta-analysis revealed that ESPB decreased the opioid consumption and improved the pain scores during the first 24 postoperative hours compared with TAP groups statistically, while the magnitude of this difference did not reach the clinically significant threshold (10 mg of intravenous morphine consumption and 1.3 cm on the VAS scale). In addition, ESPB prolonged blockade duration and decreased the occurrence of postoperative nausea and vomiting (PONV). However, it did not improve the patients' satisfaction.

CONCLUSIONS

Although ESPB does not provide better clinical analgesia than the TAP block, it could be a comparable nerve block technique for abdominal wall analgesia.

Ultrasound-guided erector spinae plane block for pain management after gastrectomy: a randomized, single-blinded, controlled trial

Background

Open gastrectomy causes severe postoperative pain. Therefore, we investigated the opioid-sparing effect of the ultrasound-guided bilateral erector spinae plane block (ESPB) after open gastrectomy.

Methods

Adult patients undergoing open gastrectomy were randomly assigned to either the ESPB group (ESPB + fentanyl based intravenous patient-controlled analgesia [IV-PCA]) or a control group (fentanyl based IV-PCA only). The primary outcome was total fentanyl equivalent consumption during the first 24 hour postoperatively. Secondary outcomes were pain intensities using a numeric rating scale at the postanesthesia care unit (PACU) and at 3, 6, 12, and 24 hour postoperatively, and the amount of fentanyl equivalent consumption during the PACU stay and at 3, 6, and 12 hour postoperatively, and the time to the first request for rescue analgesia.

Results

Fifty-eight patients were included in the analysis. There was no significant difference in total fentanyl equivalent consumption during the first 24 hour postoperatively between the two groups (P = 0.471). Pain intensities were not significantly different between the groups except during the PACU stay and 3 hour postoperatively (P < 0.001, for both). Time to the first rescue analgesia in the ward was longer in the ESPB group than the control group (P = 0.045).

Conclusions

Ultrasound-guided ESPB did not decrease total fentanyl equivalent consumption during the first 24 hour after open gastrectomy. It only reduced postoperative pain intensity until 3 hour postoperatively compared with the control group. Ultrasound-guided single-shot ESPB cannot provide an efficient opioid-sparing effect after open gastrectomy.

Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludağ University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

Continuous Unilateral Erector Spinae Plane Block versus Intravenous Analgesia in Minimally Invasive Cardiac Surgery: A Randomized Controlled Trial

Objectives: the study was conducted to assess the safety and efficacy of anesthesia under the erector spinae plane block (ESPB) in minimally invasive cardiac surgery (MICS). Methods: a prospective, randomized controlled trial was carried out in 56 adult patients who underwent MICS via a right thoracic incision at Vietnam National Heart Institute, Bach Mai hospital, Vietnam. Patients were randomly allocated into two groups: ESPB and conventional analgesia (intravenousmorphine patient-controlled analgesia, PCA). Patients in ESPB group received ultrasound-guided unilateral ESPB at the T4/T5 transverse process level, and the tip of the catheter was advanced 5cm beyond the tip of the needle; injected with 20 ml ropivacaine 0.5%. At the cardiac ICU, patients received paracetamol (1g every 6 hours), continuous infusion ropivacaine 0.1% 0.2ml/kg/hour. Patients in the PCA group received paracetamol (1g every 6 hours) and intravenous morphine PCA. All patients were followed for 72 hours after being extubated. Results: the resting VAS score was significantly lower in ESPB group at the time H4, H8, H12, H16, H36, H42, H48, H54, H60, H66 after extubated compared to that of the PCA group (p< 0.05). The dynamic VAS score at was also significantly lower in the ESPB group at all measured time points (p<0.05). Only 4 patients in the ESPB group required intravenous morphine PCA with the mean amount morphine were statistically lower in the ESPB group compared to the PCA group at 24 hours, 48 ​​hours, 72 hours postoperative. No serious adverse events such as neurological complications, bleeding or infection were observed in both groups. Conclusion: ESPB is an effective analgesic for MICS via thoracic incision in reducing the VAS score and the morphine required. It is also a safe method with no severe ESPB-related complications.

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases

Purpose

Presumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery.

Patients and Methods

We included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018–July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration).

Results

We did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed.

Conclusion

Ultrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

Erector Spinae Plane Block. A narrative review

The erector spinae plane (ESP) block is an interfascial block described in 2016 by Forero and collaborators, with wide clinical uses and benefits when it comes to analgesic control in different surgeries. This block consists of the application of local anesthetic (LA) in a deep plane over the transverse process, anterior to the erector spinae muscle in the anatomical site where dorsal and ventral branches of the spinal nerve roots are located. This review will cover its clinical uses according to different surgical models, the existing evidence and complications described to date.

Comparison of Analgesic Efficacy of Erector Spinae Plane Block and Posterior Quadratus Lumborum Block in Laparoscopic Liver Resection: A Randomized Controlled Trial

Purpose

Ultrasound-guided fascial plane blocks, including the erector spinae plane (ESP) and quadratus lumborum (QL) blocks, provide effective postoperative abdominal analgesia. However, there is limited evidence on the analgesic efficacy of ESP and QL blocks after liver surgery. Therefore, we aimed to compare the cumulative opioid consumption between the ESP and QL blocks in patients with hepatocellular carcinoma undergoing laparoscopic liver resection.

Patients and Methods

Eighty-eight patients scheduled to undergo laparoscopic liver resection were randomized to receive bilateral single injection of ESP block at T8 (ESP group) or bilateral single injection of posterior QL block (QL group; 20 mL of 0.375% ropivacaine for each side, ie, total 150 mg of ropivacaine), in addition to intravenous (IV) fentanyl patient-controlled analgesia and multimodal analgesia. The primary outcome was cumulative opioid consumption over the first 24 h, expressed as IV morphine equivalents. Secondary outcomes included serial plasma ropivacaine concentrations, pain scores, time to first flatus, and Quality of Recovery-15 scores.

Results

Eighty-five patients were analyzed (ESP group, n = 42; QL group, n = 43). Cumulative 24-h opioid consumption was similar between the ESP and QL groups (41.4 ± 22.6 mg vs 44.2 ± 20.0 mg, mean difference (QL-ESP), 2.8 mg, 95% confidence interval, −6.4 to 12 mg, p > 0.99). There were no significant differences in resting pain scores at 24, 48 and 72 h postoperatively or recovery outcomes. The peak plasma ropivacaine concentration 30 min after injection was significantly higher in the ESP group (1.5 ± 0.3 µg/mL) than in the QL group (1.3 ± 0.5 µg/mL, p = 0.035); however, both were lower than the arterial threshold value of systemic toxicity (4.3 µg/mL).

Conclusion

ESP and QL blocks provided similar postoperative analgesia in patients undergoing laparoscopic liver resection.

Efficacy of bilateral erector spinae block for post-operative analgesia in liver hydatid surgery

Background

Erector spinae plane (ESP) block is a recently described interfacial block, and since 2016, studies have shown that it is a safe technique related to the lower risk of neurovascular and pleural injury comparing to epidural or paravertebral blockade. The application of ESP block in abdominal surgery is relatively limited to case reports and small population studies, which is why we believe every new case of its application should be a valuable contribution.

Case presentation

With this present case, we explored the efficacy of bilateral ESP block as a post-operative analgesia technique for liver hydatid surgery on a 56-year-old patient. Ultrasound-guided bilateral ESP block was applied at T₇ level, while the patient was awake before general anaesthesia induction. The local anaesthetic used was 20 mL ropivacaine (0.375%) and 2 mg dexamethasone on each side. After recovery from anaesthesia, she reported mild pain (visual analogue score of 5 on effort). After 12 hours post-operatively, she received only one dose of paracetamol 1 g considered as rescue analgesic. She did not experience nausea and vomiting episodes. We noted a sensory block extending from T₄ to T₁₀.

Conclusion

To our knowledge, it may be the first adult bilateral single-shot case report for this specific procedure. This technique appears to be safe and effective on post-operative analgesia for this type of surgery; however, prospective studies comparing ESP block to other techniques are needed.

Post-thoracotomy analgesia

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

Background

Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery.

Methods

Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events.

Results

There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787).

Conclusion

Our observations found both interventions had an overall similar efficacy.

Trial registration

The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

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.

Comparison of Ultrasound-Guided Erector Spinae Plane Block and Subcostal Transversus Abdominis Plane Block for Postoperative Analgesia after Laparoscopic Cholecystectomy: A Randomized, Controlled Trial

PURPOSE

Laparoscopic cholecystectomy causes moderate to severe pain despite its minimally invasive nature. This study was performed to compare the efficacy of the bilateral erector spinae plane block (ESPB) and the subcostal transversus abdominis plane block (STAPB) under ultrasound guidance.

METHODS

64 patients were included in this prospective, randomized study. The patients were allocated into two groups as those receiving ESPB (n = 32) and those receiving STAPB (n = 32). Pain scores at rest and during movement, fentanyl requirement, postoperative walking time, and duration of hospital stay were compared. The complications which related to block were also recorded.

RESULTS

In the ESPB group, the Numeric Rating Scale (NRS) scores at rest were lower at hour 0 [at the time of post-anesthetic care unit (PACU) admission] and postoperative hours 2, 4, 6, and 12 (p < 0.05). In the same group, the NRS scores at movement were lower at hours 0, 2, 4, 6, 12, and 24 (p < 0.05). In the ESPB group, the time to first analgesic need was longer (p < 0.05), intraoperative and postoperative Fentanyl requirement (p < 0.0001 for both) and PACU rescue analgesic requirement were lower (p < 0.05), the lengths of PACU and hospital stay were shorter (p < 0.0001), and unassisted walking time was shorter (p < 0.0001). There were no complications related to the block in either group.

CONCLUSION

Bilateral ultrasound-guided ESPB provides superior analgesia after laparoscopic cholecystectomy surgery compared to STAPB and further reduces unaided walking time and hospital stay.

Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracic surgery: a study protocol for a prospective randomized open label non-inferiority trial

BACKGROUND

Thoracic epidural analgesia is considered the gold standard for pain relief in video-assisted thoracoscopic surgery. This neuraxial technique blocks pain sensation by injecting a local anesthetic agent in the epidural space near the spinal cord to block spinal nerve roots. Recently, the erector spinae plane block has been introduced as a practical alternative to the thoracic epidural. This interfascial regional anesthesia technique interrupts pain sensation by injecting a local anesthetic agent in between the muscular layers of the thoracic wall. Several case series and three RCTs described it as an effective pain management technique in video-assisted thoracoscopic surgery (Scimia et al., Reg Anesth Pain Med 42:537, 2017; Adhikary et al., Indian J Anaesth 62:75-8, 2018; Kim, A randomized controlled trial comparing continuous erector spinae plane block with thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery, n.d.; Yao et al., J Clin Anesth 63:109783, 2020; Ciftci et al., J Cardiothorac Vasc Anesth 34:444-9, 2020). The objective of this study is to test the hypothesis that a continuous erector spinae plane block incorporated into an opioid-based systemic multimodal analgesia regimen is non-inferior in terms of the quality of postoperative recovery compared to continuous thoracic epidural local anesthetic-opioid analgesia in patients undergoing elective unilateral video-assisted thoracoscopic surgery.

METHODS

This is a prospective randomized open label non-inferiority trial. A total of 90 adult patients undergoing video-assisted thoracoscopic surgery will be randomized 1:1 to receive pain treatment with either (1) continuous erector spinae plane block plus intravenous patient-controlled analgesia with piritramide (study group) or (2) continuous thoracic epidural analgesia with a local anesthetic-opioid infusate (control group). All patients will receive additional systemic multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs. The primary endpoint is the quality of recovery as measured by the Quality of Recovery-15 score. Secondary endpoints are postoperative pain as Numerical Rating Score scores, length of hospital stay, failure of analgesic technique, postoperative morphine-equivalent consumption, itching, nausea and vomiting, total operative time, complications related to surgery, perioperative hypotension, complications related to pain treatment, duration of bladder catheterization, and time of first assisted mobilization > 20 m and of mobilization to sitting in a chair.

DISCUSSION

This randomized controlled trial aims to confirm whether continuous erector spinae plane block plus patient-controlled opioid analgesia can equal the analgesic effect of a thoracic epidural local anesthetic-opioid infusion in patients undergoing video-assisted thoracoscopic surgery.

TRIAL REGISTRATION

Netherlands Trial Register NL6433 . Registered on 1 March 2018. This trial was prospectively registered.

Evaluation of adding the Erector spinae plane block to standard anesthetic care in patients undergoing posterior lumbar interbody fusion surgery

Postoperative analgesia in patients undergoing spinal fusion surgery is challenging due to the invasiveness of the surgical procedure and the frequent use of opioids preoperatively by many patients. Recently, the erector spinae plane (ESP) block has been introduced in our clinical practice as part of a multimodal pain strategy after posterior lumbar interbody fusion surgery. This is a retrospective case–control study evaluating the analgesic efficacy of the ESP block when added to our standard analgesic regimen for posterior lumbar interbody fusion surgery. Twenty patients who received an erector spinae plane block were compared with 20 controls. The primary endpoint was postoperative pain, measured by the numeric rating scale. Secondary outcome measures were opioid use, postoperative nausea and vomiting, and length of stay. Postoperative pain scores in the PACU were lower in patients who received an erector spinae plane block (p = 0.041). Opioid consumption during surgery and in the PACU was not significantly different. Need for patient-controlled analgesia postoperatively was significantly lower in the group receiving an ESP block (p = 0.010). Length of stay in hospital was reduced from 3.23 days (IQR 1.1) in the control group to 2.74 days (IQR 1.6) in the study group (p = 0.012). Adding an erector spinae plane block to the analgesic regimen for posterior lumbar interbody fusion surgery seemed to reduce postoperative pain and length of hospital stay.

Therapeutic Potential of Ultrasound Neuromodulation in Decreasing Neuropathic Pain: Clinical and Experimental Evidence

Background

For more than seven decades, ultrasound has been used as an imaging and diagnostic tool. Today, new technologies, such as focused ultrasound (FUS) neuromodulation, have revealed some innovative, potential applications. However, those applications have been barely studied to deal with neuropathic pain (NP), a cluster of chronic pain syndromes with a restricted response to conventional pharmaceuticals.

Objective

To analyze the therapeutic potential of low-intensity (LIFUS) and high-intensity (HIFUS) FUS for managing NP.

Methods

We performed a narrative review, including clinical and experimental ultrasound neuromodulation studies published in three main database repositories.

Discussion

Evidence shows that FUS may influence several mechanisms relevant for neuropathic pain management such as modulation of ion channels, glutamatergic neurotransmission, cerebral blood flow, inflammation and neurotoxicity, neuronal morphology and survival, nerve regeneration, and remyelination. Some experimental models have shown that LIFUS may reduce allodynia after peripheral nerve damage. At the same time, a few clinical studies support its beneficial effect on reducing pain in nerve compression syndromes. In turn, Thalamic HIFUS ablation can reduce NP from several etiologies with minor side-effects, but some neurological sequelae might be permanent. HIFUS is also useful in lowering non-neuropathic pain in several disorders.

Conclusion

Although an emerging set of studies brings new evidence on the therapeutic potential of both LIFUS and HIFUS for managing NP with minor side-effects, we need more controlled clinical trials to conclude about its safety and efficacy.

Erector Spinae Plane Block for the Treatment of Post Mastectomy Pain Syndrome

Postmastectomy pain syndrome (PMPS) is a common complication after breast cancer surgery and is often challenging to manage. Treatment options include medication management, physical therapy, and interventional procedures. The erector spinae plane block (ESPB) is a regional technique proven to help both acute postoperative analgesia and chronic neuropathic pain conditions. This block is becoming more popular in the chronic pain setting for neuropathic thoracic pain conditions. We describe the utilization of the ESP block for significant neuropathic breast pain after total mastectomy. Our case demonstrates the utility of this block for women suffering from severe PMPS.

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 in various abdominal surgeries: A case series

Erector spinae plane (ESP) block is a regional anesthesia technique, which provides visceral and somatic analgesia for abdominal surgery; during surgery and in the postoperative period. The local anesthetic is injected between the erector spinae muscle and the transverse process and it spreads cranially and caudally into the paravertebral space, affecting the ventral and dorsal branches of the thoracic spinal nerves and the rami communicants that contain sympathetic nerve fibers. ESP block can replace thoracic epidural anesthesia and has a better analgesic effect compared to other plane blocks that are used in abdominal surgery. We described six case series of successfully performed ESP block for postoperative analgesia in various abdominal surgeries such as unilateral open inguinal hernia repair with a supraumbilical hernia, ileostomy reversal surgery, open diaphragmatic hernia repair, laparoscopic cholecystectomy, and abdominal abscess evacuation.

Postoperative "Rescue" Use of Erector Spinae Plane Block After Lumbar Spine Fusion: A Report of 2 Cases

Pain after lumbar spine fusion surgery is often difficult to control in the immediate postoperative period. Historically, opioids have been the mainstay of treatment, but are associated with many unwanted side effects as well as increased hospital length of stay. The ultrasound-guided erector spinae plane block (ESP) is a relatively safe and simple regional option for the management of acute postoperative pain after spine surgery without the technical difficulty or complications noted with paravertebral injection (eg, pneumothorax, hematoma). To date, there have been reports of preoperative placement of ESP block prior to spine surgery with some success. We present a report of two cases that highlight the efficacy of the ESP block as an early postoperative “rescue” regional anesthetic technique in lumbar spine surgery. These cases demonstrate the potential effectiveness of a “rescue” use of the ESP block in patients having uncontrolled or poorly controlled pain in the early postoperative period with no evidence of significant side effects.

The effect of ultrasound-guided erector spinae plane block on postsurgical pain: a meta-analysis of randomized controlled trials

Background

The effect of erector spinae plane block has been evaluated by clinical trials leading to a diversity of results. The main objective of the current investigation is to compare the analgesic efficacy of erector spinae plane block to no block intervention in patients undergoing surgical procedures.

Methods

We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases from their inception through July 2019. Included trials reported either on opioid consumption or pain scores as postoperative pain outcomes. Methodological quality of included studies was evaluated using Cochrane Collaboration’s tool.

Results

Thirteen randomized controlled trials evaluating 679 patients across different surgical procedures were included. The aggregated effect of erector spinae plane block on postoperative opioid consumption revealed a significant effect, weighted mean difference of − 8.84 (95% CI: − 12.54 to − 5.14), (P < 0.001) IV mg morphine equivalents. The effect of erector spinae plane block on post surgical pain at 6 h compared to control revealed a significant effect weighted mean difference of − 1.31 (95% CI: − 2.40 to − 0.23), P < 0.02. At 12 h, the weighted mean difference was of − 0.46 (95% CI: − 1.01 to 0.09), P = 0.10. No block related complications were reported.

Conclusions

Our results provide moderate quality evidence that erector spinae plane block is an effective strategy to improve postsurgical analgesia.

Ultrasound-guided Bilateral Erector Spinae Plane Block for Postoperative Analgesia in Laparoscopic Cholecystectomy: A Randomized Controlled Trial

BACKGROUND

Laparoscopic cholecystectomy (LC) is associated with moderate-to-severe pain in immediate postoperative period. Some patients even suffer from prolonged pain long after surgery.

AIMS

The aim of present study is to determine the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) in patients undergoing LC, time to ambulation after surgery, and incidence of prolonged pain up to 6 months later.

SETTINGS AND DESIGN

This was a double-blinded prospective randomized controlled trial.

MATERIALS AND METHODS

Eighty-five adults posted for elective LC were randomized to receive bilateral ESPB at T7 level with either 20 mL of 0.375% ropivacaine or 20 mL normal saline. Postoperative static and dynamic pain score as per the visual analog scale (VAS), intraoperative requirement of fentanyl, postoperative use of diclofenac, time to ambulation after surgery, and presence of any pain after surgery were noted.

STATISTICAL ANALYSIS

Independent t-test and Mann-Whitney U-test were used for quantitative data, while Chi-square test was used for comparing qualitative data.

RESULTS

Static and dynamic VAS scores were significantly lower in ESPB group (P < 0.05). Intraoperative fentanyl requirement (165 ± 30.72 - ESPB, 180.95 ± 29.12 - controls, P = 0.020) and number of patients requiring diclofenac (28/42 - ESPB, 37/42 - controls, P = 0.019) were lower, while number of patients ambulating by 4 hours (20/42 - ESPB, 9/42 - control, P = 0.012) were higher in ESPB group. Patients suffering from pain at 1 week (22/42 - ESPB and 34/42 - control, P = 0.005) and 1 month (9/42 - ESPB and 13/42 - control, P = 0.207) were lower in ESPB group.

CONCLUSION

ESPB provides effective analgesia and early ambulation after LC. The benefit extends to 1 week thereafter.

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.