Fluoroscopic-guided erector spinae plane block: A feasible option

Erector Spinae Plane Block Placement Utilizing Fluoroscopic Guidance Improves Efficiency in Lumbar Surgery

OBJECTIVE

The erector spinae plane block (ESPB) is a novel regional analgesic technique which improves postoperative outcomes in lumbar surgery patients including length of hospitalization, days to ambulation, and postoperative opioid use. Traditionally, the block is administered by anesthesiologists trained in the ultrasound guidance technique. The use of fluoroscopic guidance may improve the efficiency and accessibility of the ESPB for spine surgeons. We aim to measure the time to administer an ESPB using fluoroscopic guidance and localize the anesthetic using intraoperative three-dimensional (3D) imaging.

METHODS

Two neurosurgeons administered an ESPB to patients undergoing lumbar surgery. Time from insertion of the spinal needle to localize the erector spinae plane using C-arm guidance to time of complete injection and removal of the needle from the skin was recorded. One patient underwent O-arm imaging following injection of an Isovue-Exparel solution at the L3 level to visualize spread of the anesthetic.

RESULTS

A total of 21 patients were enrolled in this study. The average duration to perform an ESPB under fluoroscopic guidance was 1.2 minutes. The Isovue-Exparel solution was injected at the L3 level and was well distributed along the ESP on intraoperative O-arm imaging. The anesthetic dissected the erector spinae muscle from the transverse process at L2, L3, and L4.

CONCLUSIONS

Fluoroscopic guidance allows efficient and appropriate delivery of the anesthetic to the erector spinae plane. Performing an ESPB with fluoroscopic guidance improves efficiency and accessibility of the analgesic technique for spine surgeons, reducing dependence on anesthesiology personnel trained in administering the block.

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 (ESP) Block for Postoperative Pain Management after Open Oncologic Abdominal Surgery

Patients undergoing abdominal oncologic surgical procedures require particular surgical and anesthesiologic considerations. Traditional pain management, such as opiate treatment, continuous epidural analgesia, and non-opioid drugs, may have serious side effects in this patient population. We evaluated erector spinae plane (ESP) blocks for postoperative pain management following elective oncologic abdominal surgeries. In this single-center, prospective, and randomized study, we recruited 100 patients who underwent elective oncological abdominal surgery between December 2020 and January 2022 at Soroka University Medical Center in Beer Sheva, Israel. We compared postoperative pain levels in patients who were treated with a preincisional ESP block in addition to traditional pain management with intravenous opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, compared to patients who were only given traditional pain management (control). Patients who were treated with a preincisional ESP block demonstrated significantly lower Visual Analog Scale scores at 60 minutes and 4, 8, and 12 hours following the surgery, compared to the control group (p < 0.001). Accordingly, patients in the ESP group required less morphine from 60 minutes to 12 hours after surgery, but they required increased non-opioid postoperative analgesia management at 4, 8, and 12 hours after surgery (p from 0.002 to <0.001) compared to the control group. In this study, we found ESP blocks to be a safe, technically simple, and effective treatment for postoperative pain management after elective oncologic abdominal procedures.

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.

NEW CONCEPT OF FUSION TECHNICS IN REGIONAL ANESTHESIA

The aim of this review article is to introduce a newer approach to multimodal anesthesia. In addition to the usual combination of epidural catheter and general anesthesia as standard techniques in surgical procedures accompanied by intense postoperative pain, we want to encourage reflection on the application of various regional techniques in equally complex surgical conditions. By simply modifying the standard neuraxial technique with a higher thoracic approach, excellent abdominal surgery can be performed to awake the patient. However, placement of an epidural catheter is not always possible due to technical difficulties or patient-related conditions that contraindicate its insertion. Trunk-level fascia blocks (PVB, ESPB, RLB) are simple, safe alternative to an epidural catheter because the transverse process, which is the target of ultrasound, is easily visualized and the injection site is away from neuroaxis, pleura, and large vascular structures. In addition, extensive craniocaudal diffusion of anesthetics allows wide coverage with a single injection. It has been confirmed that PVB, ESPB, RLB blocks act on visceral and somatic pain. Therefore, their ultrasound-guided use in laparoscopic and other abdominal surgeries may be useful. With a well-designed fusion of regional techniques in operations of the upper and lower abdomen, it is possible to achieve hemodynamically and respiratory stable anesthesia in an awake patient with reduced postoperative pain.

Bilateral Radioscopically-Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Randomized Clinical Trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare two perioperative pain management procedures: a radioscopically-guided erector spinae plane (ESP) block versus the standard wound infiltration technique with local anaesthetics, in patients undergoing lumbosacral spine surgery.

METHODS

A randomized, double-blind clinical trial was performed, in which adults at our hospital undergoing lumbosacral surgery without fixation were randomly assigned to receive either the standard wound infiltration technique, employing long-term anaesthetics, or a radioscopically-guided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilised due to wound pain, length of hospitalisation, and complications were recorded.

RESULTS

Over the first seven postoperative hours, pain relief was superior in the ESP block group among patients who underwent discectomies or one-level decompression (p<0.0001). Using an ESP block also was statistically superior at decreasing all postoperative variables recorded in patients scheduled for multi-level decompression: VAS pain severity over the first seven hours after the procedure (p=0,0004); number of patients with wound pain 1 (p=0.049), 7 (p<0.0001) and 24 hours (p=0.007) after surgery; length of hospitalisation (p=0.0007), number of patients immobilised for wound pain (p=0.0004) and rescue morphine consumption (p<0.0001).

CONCLUSION

The ESP block is a safe procedure which seems to outperform the infiltration wound technique for postoperative pain management in patients undergoing open spinal surgery. Future studies are needed to verify its effectiveness for arthrodesis/fixation and minimally-invasive procedures, and for chronic spine pain relief.

Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks

STUDY OBJECTIVE

This narrative review discusses the anatomy, mechanism of action, techniques, pharmacology, indications, complications and substitutes for erector spinae plane (ESP) blocks.

INTERVENTIONS

The Medline, Embase and Google Scholar databases (inception-last week of April 2020) were searched. For indications and alternative blocks, a systematic analysis of the available evidence was carried out. In order to highlight the best evidence available, only randomized trials with prospective registration, blinded assessment and sample size justification were retained for analysis.

MAIN RESULTS

The collective body of anatomical studies suggests that ESP block may work through a combination of different mechanisms (e.g., local anesthetic spread to the thoracic paravertebral space, epidural space, and dorsal ramus). Compared to control, the available evidence suggests that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal surgical interventions. Erector spinae plane blocks and thoracic paravertebral blocks seem to provide comparable benefits for thoracoscopic and breast cancer surgery when performed with a similar number of injections. Currently, ESP blocks should be favored over intercostal blocks since, at best, the latter provide similar analgesia to ESP blocks despite requiring multiple-level injections.

CONCLUSIONS

In recent years, ESP blocks have become the topic of considerable clinical interest. Future trials are required to investigate their optimal technique, dose of local anesthetic and perineural adjuvants. Moreover, additional investigation should compare ESP blocks with robust multimodal analgesic regimens as well as truncal blocks such as thoracic epidural block, midpoint transverse process to pleura block, PECS block, quadratus lumborum block, and transversus abdominis plane block.

Pericapsular nerve group (PENG) block: A feasibility study of landmark based technique

Background:

Pericapsular nerve group (PENG) block is a new ultrasound guided nerve block. It was used primarily to relieve pain in hip fracture; now, many new indications have been added. However, dependency on ultrasound guidance for this block limits its use where ultrasound facility is poor or not available. We have suggested a landmark based technique to increase the benefit of this novel nerve block.

Aim and Objectives:

To do a feasibility study to assess the successful placement of block needle, clinical efficacy of the block and block-related complications.

Material and Methods:

Total 10 patients (4 males and 6 females) with fracture hip and scheduled for hip surgery under spinal anaesthesia were selected for the study. In 4 patients ultrasound guided PENG block using out-of-plane approach and in 6 patients landmark based nerve stimulator guided block was given with 20ml 0.25% bupivacaine and 8mg dexamethasone. Pain relief before and after 30 minutes of block was assessed by numeric rating scale (NRS) and comfort during spinal position was assessed by ease of spinal position score (EOSP).

Results:

All 10 patients had successful block; NRS at rest was 6 (6-9) Vs 2 (0-2) and on 15 °limb elevation was 8 (8-10) Vs 3 (2-4). All patients could sit comfortably during spinal anaesthesia and median (range) EOSP sore was 3 (2-3). No complication was observed.

Conclusion:

Landmark based technique for PENG block is a feasible option and can be used safely where ultrasound facility is not available.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The erector spinae plane block: a narrative review

Regional anesthesia and pain management have experienced advances in recent years, especially with the advent of fascial plane blocks. The erector spinae plane block is one of the newest techniques to be described. In the past two years, publications referring to ESP block have increased significantly. The objective of this review is to analyze the articles about ESP block that have been published to date. We performed a search in the main databases and identified 368 articles. After a selection of the relevant articles, 125 studies were found eligible and were included in the review. The ESP block is performed by depositing the local anesthetic in the fascial plane, deeper than the erector spinae muscle at the tip of the transverse process of the vertebra. Many cases of its use have been described with satisfactory results in the treatment of both acute pain and chronic pain. The applicability of the technique covers many clinical scenarios. Of the 98 case reports reviewed, 12 and 87 articles, respectively described the technique as a treatment for chronic pain and acute pain. The single-shot was the most frequently used technique. As described in the articles published to date, the technique is easy to perform and has a low rate of complications. However, despite the effectiveness of the technique, further studies are necessary to obtain more evidence of its actions.