Erector Spinae Plane Block for Postoperative Analgesia

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies

OBJECTIVE

To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.

METHOD

A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.

RESULTS

Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I² = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I² = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I² = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I² = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I² = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I² = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I² = 0%]. There have been no reports of complications from ESPB or other blocks.

CONCLUSION

Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.

Comparison of Continuous Thoracic Epidural With Erector Spinae Block for Postoperative Analgesia in Adult Living Donor Hepatectomy

Background: Thoracic epidural analgesia (TEA) is commonly used for pain management in donor hepatectomy. Erector spinae plane block (ESPB) is a newer ultrasound-guided block described for the management of thoracic and abdominal pain. There is limited literature available comparing the two techniques. The objective of this study was to compare the postoperative analgesic efficacy and adverse effects of continuous ESPB to continuous TEA in donor hepatectomy.

Methodology: The randomized controlled trial (RCT) was registered on ClinicalTrials.gov (NCT04151511). A total of 82 patients undergoing donor hepatectomy between January 2020 and December 2020 were recruited, of whom 41 received TEA and 41 received ESPB. Randomization was done by the sealed opaque envelope method.

Results: The mean visual analog scale (VAS) scores in donors who received TEA and ESPB in post-anesthesia care unit (PACU) (2.7 + 0.9 vs. 2.4 + 0.5; P = 0.02) at one hour (2.7 + 0.9 vs. 2.2 + 0.6; P = 0.008), six hours (1.8 + 0.9 vs. 0.8 + 0.5; P < 0.001), 12 hours (0.9 + 0.7 vs. 0.2 + 0.7; P < 0.001), and 24 hours (0.48 + 0.5 vs. 0.08 + 0.3; P < 0.001) were significantly different. Mean opioid consumption was 3.38 ± 6.24 mg in the ESPB group and 10.75 ± 9.64 mg in the TEA group (P < 0.001). Mean lung volume (MLV) at 24 hours in the TEA group and ESPB group was 1543 ml and 1815 ml (P < 0.001). MLV was 2545 ml in the TEA group and 2820 ml in the ESPB group at 48 hours (P < 0.001). Mean nausea and vomiting score at six hours was 0.1 vs. 0.03 (P = 0.02).

Conclusion: ESPB improves pain control after donor hepatectomy with an enhanced safety profile and reduced opioid consumption.

Efficacy of Erector Spinae Plane Block for Analgesia in Thoracic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to determine whether erector spinae plane block (ESPB) can provide an effective analgesia for managing pain after thoracic surgery and compare the efficacy of ESPB with that of other regional analgesic techniques.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

SETTING

PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science were searched.

PARTICIPANTS

Patients undergoing thoracic surgeries.

INTERVENTION

Erector spinae plane block with local anesthetics for postoperative analgesia.

MEASUREMENT AND MAIN RESULTS

Seventeen studies, including 1,092 patients, were included in the final analysis. Erector spinae plane block reduced 24-hour postoperative opioid consumption (mean difference [MD] -17.49, 95% CI -26.87 to -8.12), pain score at rest (MD -0.82, 95% CI -1.31 to -0.33), and pain score at movement (MD -0.77, 95% CI -1.20 to -0.3) compared to no block. Compared with other regional blocks, various results have been observed. Although statistical results showed that ESPB is inferior to thoracic paravertebral block and intercostal nerve block and superior to serratus anterior plan block in postoperative analgesia, clinical differences remain unclear. The incidence of hematoma was lower in the ESPB group than in the other groups (odds ratio 0.19, 95% CI 0.05-0.73).

CONCLUSION

Erector spinae plane block may provide effective analgesia after thoracic surgery. Compared with other techniques, it is a safer method, without clinically important differences, for postoperative pain control. Therefore, ESPB may be considered as a valuable option for postoperative pain management after thoracic surgery.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

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.

Erector spinae plane block combined with local infiltration analgesia for total hip arthroplasty: A randomized, placebo controlled, clinical trial

The erector spinae plane block is an emerging analgesic technique, which is gaining popularity for a large number of procedures. The majority of publications are at the thoracic level and almost all indicate some benefit to patients. However, there have been relatively few randomized controlled trials and even fewer studies at the lumbar level. The aim of this study was to assess whether the erector spinae plane block at the lumbar level would confer early analgesic benefits and improve the quality of recovery in patients undergoing elective unilateral primary hip arthroplasty. Sixty-four patients were randomized to receive an erector spinae plane block at the third lumbar vertebra with either 30milliliters (ml) of 0.2% ropivacaine or 30 ml of 0.9% saline. The patient, anesthetist and assessor were blinded to allocation. The primary outcome was pain on movement at 6 h (numeric rating scale 0-10) with a reduction of 2 points considered clinically significant. Secondary outcomes included quality of recovery (QoR-15 score), mobilization and length of stay. In this study there was no appreciable analgesic benefit to adding an erector spinae plane block to patients who already receive neuraxial blocks, local anesthetic infiltration and oral multimodal analgesia for elective primary total hip arthroplasty. Both groups were found to have relatively low pain scores and a high quality of recovery with no significant difference in mobilization or length of stay.

The Effects of Erector Spinae Plane Block in Terms of Postoperative Analgesia in Patients Undergoing Laparoscopic Cholecystectomy: A Meta-Analysis of Randomized Controlled Trials

Ultrasound-guided erector spinae plane block (ESPB), a recent regional analgesic technique, has been used to manage acute pain after surgery. The aim of this meta-analysis is to identify the benefits of ESPB in patients undergoing laparoscopic cholecystectomy (LC). The authors searched PubMed, EMBASE, CENTRAL, CINAHL, and Web of Science to identify all randomized controlled trials (RCTs) evaluating the effects of ESPB on postoperative pain after LC. Primary outcome was defined as 24 h cumulative opioid consumption. Secondary outcomes were pain scores and the incidence of postoperative nausea and vomiting (PONV). We estimated mean differences (MD) and odds ratio (OR) using a random-effects model. A total of 8 RCTs, including 442 patients, were included in the final analysis. Postoperative opioid consumption was significantly lower in the ESPB group than in the control group (MD −4.72, 95% CI −6.00 to −3.44, p < 0.001). Compared with the control group, the ESPB group also showed significantly lower pain scores and incidence of PONV. A separate analysis of RCTs comparing ESPB with oblique subcostal transversus abdominis plane (OSTAP) block showed that the analgesic efficacy of ESPB was similar to that of OSTAP block. The results of this meta-analysis demonstrated that ESPB may provide effective postoperative analgesia in patients undergoing LC.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.