Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial

[Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series]

OBJECTIVE AND BACKGROUND

Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients.

METHOD

Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded.

RESULTS

Pain scores ranged from 0 to 4 among the three patients and 48h opioid consumption in oral morphine equivalents of 4, 6 and 18mg. No adverse events were recorded up to patient discharge from the hospital.

CONCLUSIONS

Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Bilateral lower thoracic erector spinae plane block in open abdominal gynecologic oncology surgery: a cases series

Objective and background

Erector spinae plane block is a novel analgesic truncal block that has been popularized due to its ease of performance and perceived safety. Erector spinae plane block has been postulated to target the ventral rami and rami communicates of spinal nerves, thus providing somatic and visceral analgesia. In this case series, we describe our experience of bilateral erector spinae plane block placed at the low thoracic level in open gynecologic oncology surgery in three patients.

Method

Under ultrasound guidance, erector spinae plane blocks were done, preoperatively, at the 8th thoracic transverse process bilaterally. Numeric rating scale for pain and opioid consumption of the first 48 postoperative hours were recorded.

Results

Pain scores ranged from 0 to 4 among the three patients and 48 h opioid consumption in oral morphine equivalents of 4, 6 and 18 mg. No adverse events were recorded up to patient discharge from the hospital.

Conclusions

Erector spinae plane block provided effective analgesia in our case series. While its true mechanism of action remains obscure, the available case reports show encouraging analgesic results with no adverse events recorded. Formal prospective randomized trials are underway to provide further evidence on its efficacy, failure rate and safety.

Bilateral Erector Spinae Plane Block for Surgery on the Posterior Aspect of the Neck: A Case Report

The erector spinae plane block is an interfascial plane block whereby local anesthetic is injected within the plane deep to the erector spinae muscle and superficial to the transverse process. To date, it has been used to provide analgesia in thoracic, abdominal, and lumbar regions. We present the first reported case of bilateral erector spinae plane block being used to provide surgical anesthesia in the cervical region.

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.

Interfascial plane blocks

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.

Defining the Indications and Levels of Erector Spinae Plane Block in Pediatric Patients: A Retrospective Study of Our Current Experience

Aim  The primary aim of this study was to evaluate the indications, effectiveness, application levels, and local anesthetic (LA) dosages used in erector spinae plane block (ESPB) in pediatric patients
 based on our clinical data. The secondary aim was to compare previously reported pediatric ESPBs with our data and to prepare a mini-guide for future clinical applications. Materials and methods One hundred and forty-one pediatric patients who received ESPB and were operated by the Department of Pediatric Surgery were included in this retrospective observational study. ESPB is routinely performed with 0.5 ml/kg 0.25% bupivacaine (max 20 ml). Demographic data and the type of surgery were recorded. Face, Legs, Activity, Cry, and Consolability (FLACC) or Numeric Rating Scale (NRS) scores, analgesic requirements, and the type of analgesic administered at postoperative period were recorded. Results ESPB was applied using three different techniques, the classic approach, the transverse approach, and the Aksu approach. Unilateral ESPB was performed on 112 patients, while 29 received a bilateral block. ESPB used for 13 different indications. Conclusion ESPB is a relatively safe and effective procedure for achieving opioid-free postoperative analgesia in many different surgical procedures in pediatric patients.

Ultrasound-Guided Bilateral Erector Spinae Block Versus Tumescent Anesthesia for Postoperative Analgesia in Patients Undergoing Reduction Mammoplasty: A Randomized Controlled Study

PURPOSE

The aim of this prospective, randomized, double-blind study was to compare the tumescent anesthesia method and erector spinae block with respect to postoperative analgesia consumption, pain scores and patient satisfaction, in patients receiving breast reduction surgery under general anesthesia.

METHODS

The study included 44 females, aged 20-65 years, who were to undergo breast reduction surgery, without adjunctive liposuction on the breast. Using the closed envelope method, the patients were randomly separated into two groups to receive tumescent anesthesia or erector spinae block (ESB). Patients in the ESB group received the block before general anesthesia by a single anesthetist (G.Ö.).

RESULTS

The 24-h tramadol consumption with PCA, which was the primary outcome of the study, was determined to be statistically significantly less in the ESB group (p < 0.001). The NRS scores were compared at 30 min postoperatively and then at 1, 2, 4, 6, 12 and 24 h. At all the measured time points, the pain scores of the ESB group were statistically significantly lower (p < 0.001). Additional analgesia was required by one patient in the ESB group and by seven patients in the tumescent group and was applied as 1 g paracetamol. The requirement for additional analgesia was statistically significantly lower in the ESB group (p < 0.024). Patient satisfaction was statistically significantly better in the ESB group (p < 0.001).

CONCLUSIONS

According to the results of this study, bilateral ESB performed under ultrasound guidance in breast reduction surgery was more effective than tumescent anesthesia concerning postoperative analgesia consumption and pain scores. ESB could be an appropriate, effective and safe postoperative analgesia method for patients undergoing reduction mammoplasty surgery.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Clinical Efficacy and Anatomical Investigation between Retrolaminar Block and Erector Spinae Plane Block

Retrolaminar block (RLB) and erector spinae plane block (ESPB) are alternative approaches to paravertebral block (PVB) and are advantageous in that they are easier and safer techniques compared with the traditional PVB. Many clinical reports of these blocks have described their efficacy for ipsilateral thoracic analgesia. The local anesthetic injection points of RLB and ESPB are the lamina and transverse process, respectively. Despite the similarity of the puncture sites, there have been no clinical studies comparing RLB and ESPB. In addition, the underlying mechanism of these blocks has not been clarified. Recent anatomical investigations indicated that the injectate was distributed in the paravertebral space and spread laterally into the intercostal spaces. The limited distribution into the paravertebral space indicated that compared to PVB, RLB and ESPB exert their effects via a different mechanism. In this review, we describe the features of and differences between RLB and ESPB based on current clinical and anatomical reports. We also propose the clinical indication and discuss the differences, clinical outcomes, and anatomical mechanisms of the techniques.

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.

Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study

BACKGROUND

Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsal-ventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery.

METHODS

Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n = 30) received ultrasound-guided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n = 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patient-controlled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated.

RESULTS

Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 ± 73.27 mg and 268.33 ± 71.44 mg; P < 0.001, respectively) and the difference was 28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group.

CONCLUSIONS

ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial

Background

Breast cancer surgery is one of the most common surgeries among the female population. Nearly half of the patients suffer chronic pain following breast cancer surgery, and 24% of them categorizing their pain as moderate to high. In this study, effects of ultrasound-guided erector spinae plane (ESP) block performed using two different concentrations of bupivacaine on postoperative tramadol consumption, pain scores, and intraoperative fentanyl requirements among patients who underwent radical mastectomy surgery were compared.

Methods

This double-blinded, prospective, and randomized study included patients with age ranged 18–70, American Society of Anesthesiologist physical status I–II, and scheduled for unilateral modified radical mastectomy surgery. The patients were randomly allocated into two groups. In group I, ESP block was performed with 0.375% bupivacaine. In group II, ESP block was performed with 0.25% bupivacaine. General anesthesia was induced in both groups according to the standard procedures. When the pain score was ≥4, patients received intravenous (i.v.) 25 mcg fentanyl in the recovery room or 4 mg of morphine in the surgical ward as a rescue analgesia. The main measurements were postoperative tramadol consumption; Numerical Rating Scale (NRS) scores 15, 30, and 60 min and 12 and 24 h postoperatively; and intraoperative fentanyl requirements.

Results

In total, 42 patients (21 patients in each group) were included in the study. The mean tramadol consumption at the postoperative 24th h was 149.52 ± 25.39 mg in group I, and 199.52 ± 32.78 mg in group II (p = 0.001). In group I, the NRS scores were significantly lower at every time points compared with those in group II. The mean intraoperative fentanyl requirement was similar in the two groups.

Conclusion

Although ESP block performed with both concentrations of bupivacaine provided effective postoperative analgesia, the higher concentration of bupivacaine significantly reduced postoperative tramadol consumption after radical mastectomy surgery.

Clinical trial registration

The study was registered prospectively with the Australian New Zealand Clinical Trials Registry (trial ID: ACTRN12618001334291at 08/08/2018).

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

INTRODUCTION

Erector spinae plane block (ESPB) is a novel regional anesthesia technique used in postoperative pain and chronic neuropathic pain of the thoracoabdominal region. There are no previously published large case series. This retrospective review aimed to report the indications, levels of block, success of block and complications, and also to evaluate the effect of ESPB on postoperative/chronic pain.

METHODS

We retrospectively evaluated the charts and medical records of 182 patients who had ESPB in the last one year. All records were collected in the postoperative recovery room, ward, and pain unit.

RESULTS

ESPB performed at several different levels and for several different indications led to effective postoperative analgesia when part of a multimodal analgesia plan. Few complications were noted.

CONCLUSION

ESPB is an interfascial plane block with many indications. The possibility of complications must be considered.

Bilateral erector spinae plane blocks using a small volume of local anesthetic for acute pain control after single-port laparoscopic surgery

In the era of enhanced recovery after surgery, clinicians are encouraged to develop optimized programs for patients who require surgery. Minimal intervention with laparoscopic surgery and multimodal pain management mostly with peripheral nerve block are key components. We are developing a departmental program for enhanced recovery after surgery for single-port laparoscopic surgery. We applied an erector spinae plane block, a novel, newly recognized block, bilaterally at the T10 transverse process with a small dose (10 mL) of local anesthetic. This method was effective and safe and resulted in successful analgesia in a patient who received single-port surgery. This surgery requires a 3–5 cm horizontal or longitudinal periumbilical incision, which was performed in this case, and our results were promising and encouraging.

Evaluation of Ultrasound-Guided Erector Spinae Plane Block and Oblique Subcostal Transversus Abdominis Plane Block in Laparoscopic Cholecystectomy: Randomized, Controlled, Prospective Study

Background:

Oblique subcostal transversus abdominis plane block (OSTAP) is a recently described regional anesthetic technique used in upper abdominal surgeries such as laparoscopic cholecystectomy (LC). Erector spinae plane block (ESPB) has also been reported for postoperative analgesia in LC.

Aim:

We aimed to compare the effectiveness of OSTAP and ESPB in providing postoperative analgesia in patients undergoing these surgeries.

Setting and Design:

This study was designed as a double-blinded, prospective, randomized, efficiency study in a tertiary university hospital, postoperative recovery room, and ward.

Materials and Methods:

A total of 72 patients were recruited and 60 patients were randomized into three equal groups (ESPB, OSTAP, and control group). Pain intensity between groups was compared using Numeric Rating Scale (NRS) scores. In addition, consumption of paracetamol and tramadol and additional rescue analgesic requirement were measured. Standard multimodal analgesia was performed in all groups, while ESPB block was also performed in Group ESPB and OSTAP block was also performed in group OSTAP.

Statistical Analysis Used:

Descriptive statistics were expressed as mean ± standard deviation. Independent t-test, Mann–Whitney U-test, Chi-square test, Fisher's exact test, Shapiro–Wilk test, one-way ANOVA, and post hoc Tukey's analysis were used for statistical analysis.

Results:

NRS was lower in block groups during the first 3 h. There was no difference in NRS scores at other hours. Analgesic consumption and rescue analgesic requirement were lower in groups ESPB and OSTAP when compared to those of control group. Block groups were similar.

Conclusion:

Bilateral ultrasound-guided ESPB and OSTAP performed at the end of LC lead to akin analgesia requirement and improve the quality of multimodal analgesia.

Erector Spinae Block. A Narrative Review

The erector spinae plane block is a novel ultrasound-guided technique that has recently been described for the management of acute and chronic thoracic pain. Currently an increasingly number of indications for the ESP block have been published. Nevertheless, the anatomy, mechanism of action, doses and volume of local anesthetic needed are still unclear. The aim of this narrative review is study this new block with base on the updated medical literature.