Evaluation of the Efficacy of the Erector Spinae Plane Block for Postoperative Pain in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Trial

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Erector spinae plane block prior to extracorporeal shock wave lithotripsy decreases fluoroscopy time and promise a comfortable procedure for renal stones: A prospective randomized study

INTRODUCTION AND OBJECTIVES

To compare the efficacy of erector spinae plane block (ESPB) and intramuscular (i.m.) diclofenac sodium in regard to pain management and impact on stone-free status in patients undergoing SWL.

PATIENTS AND MATERIALS

The study included patients who underwent SWL for kidney stones in our institution. The patients were randomly assigned to the ESPB (Group 1: n = 31) and i.m. 75 mg diclofenac sodium (Group 2: n = 30) groups. The demographic data of the patients, fluoroscopy time during SWL, number of need of targeting, total shocks given, voltage, stone free rates (SFR), analgesy method, number of SWL sessions, VAS score, stone location, maximum stone size, stone volume and Hounsfield unit (HU) were also recorded.

RESULTS

A total of 61 patients were included the study. There was no statistically significant difference between the two groups according to stone size, volume and density, SWL duration, total shocks given, voltage, BMI, stone-free status and stone location. Fluoroscopy time and number of need for stone targeting were significantly lower in group 1 than group 2 (p = 0.002, p = 0.021, respectively). The VAS score was significantly lower for group 1 compared to group 2 (p < 0.001).

CONCLUSIONS

We observed that the VAS score was lower in the ESPB group compared to i.m. diclofenac sodium group and although it was not statistically significant, we achieved a higher rate of stone-free status in the first session in ESPB group. Most importantly, the patients in the ESPB group were exposed to less fluoroscopy and radiation.

The safety and efficacy of ultrasound-guided erector spinae plane block in postoperative analgesic of PCNL: A systematic review and meta-analysis

BACKGROUND

The patients received percutaneous nephrolithotomy (PCNL) with severe postoperative pain and discomfort. The erector spinae plane block (ESPB), as a new anesthesia method of plane block, has a positive effect on postoperative analgesia. But evidence of ESPB in PCNL is still lacking. The objective of this study was to systematically analyze the postoperative analgesic effect of ESPB in patients receiving PCNL.

METHODS

The literature searching was conducted in PubMed, EMBASE, Cochrane Library and Clinical Trial Database (clinicaltrials.gov). Two independent researchers screened the included studies and extracted data. Meta-analysis was conducted by using the random-effect model with 95% confidence intervals. Chi-squared test with a significance level of 0.1 was utilized to evaluate the heterogeneity of included studies. The subgroup analysis and meta-regression analysis were conducted in studies with high heterogeneity. The publication bias was assessed based on whether there were discrepancies between prospective trial registration and reported protocols.

RESULTS

There were 8 studies involving 456 patients assessing the efficacy of ESPB in reducing postoperative pain score of PCNL compared with no block or other blocks, such as subcutaneous infiltration, general anesthesia or TPVB intrathecal morphine. ESPB was a significantly effective and safe anesthesia method, which not only improved postoperative pain response (MD -1.76; 95% CI -2.57 to -0.94; I 2 = 85%; p<0.01), but also reduced analgesic consumption (MD -16.92; 95% CI -26.25 to -7.59; I 2 = 92.2%; p<0.01) and prolonged the time of first request for postoperative analgesia (MD 93.27; 95% CI 35.79 to 150.75; I 2 = 85.3%; p = 0.001) in patients receiving PCNL without significant postoperative complications (MD 0.80; 95% CI 0.31 to 2.03; I 2 = 0%; p = 0.404).

CONCLUSIONS

Compared with no block or other blocks, the ESPB was a safe and effective anesthesia for patients receiving PCNL.

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.

Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery: A systematic review and meta-analysis of randomized trials

Objectives

Erector spinae plane block (ESPB) has been used for many thoracic and abdominal surgeries. However, evidence of its analgesic efficacy following abdominal surgery, compared with that of thoracic analgesia, is insufficient. Our study explored the analgesic effect of ESPB after abdominal surgery.

Methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Primary outcomes were pain scores at 6, 12 and 24 h and 24-h opioid consumption. Secondary outcomes included time to first rescue analgesia, length of hospital stay, and incidence of postoperative nausea and vomiting (PONV). We calculated standardized mean differences (SMDs) with 95% confidence intervals (CIs) for primary outcomes and mean differences (MDs) and risk ratios (RRs) with 95% CIs for secondary outcomes.

Results

We systematically included 1,502 cases in 24 trials. Compared with placebo, ESPB significantly reduced pain scores at 6 h (SMD -1.25; 95% CI -1.79 to -0.71), 12 h (SMD -0.85; 95% CI -1.33 to -0.37) and 24 h (SMD -0.84; 95% CI -1.30 to -0.37) and 24-h opioid consumption (SMD -0.62; 95% CI -1.19 to -0.06) post-surgery. ESPB prolonged the time to first rescue analgesia and decreased the incidence of PONV. Compared with transversus abdominal plane block (TAPB), ESPB significantly reduced pain scores at 6, 12, and 24 h and 24-h opioid consumption and prolonged the time to first rescue analgesia postsurgically. Furthermore, subgroup analysis showed that ESPB significantly reduced pain scores at various time points and opioid consumption within 24 h after laparoscopic cholecystectomy, percutaneous nephrolithotomy and bariatric surgery.

Conclusion

Compared with placebo, ESPB improves the postoperative analgesic efficacy after abdominal surgery. Furthermore, our meta-analysis confirmed that ESPB provides more beneficial analgesic efficacy than TAPB.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPEROFILES/301491_STRATEGY_20220104.pdf], identifier [CRD42022301491].

Applications of the ultrasound-guided nerve block technique for nonanalgesic effects

The nerve block technique guided by ultrasound has been able to accurately block tiny nerves throughout the body in recent years. It has been increasingly used to treat multisystem diseases or analgesia in surgical patients, but the latter accounted for the vast majority of cases. The nonanalgesic effect of nerve blocks is also in wide demand. After searching ultrasound-guided nerve block works on the PubMed database, we systematically summarized the current clinical application of the nerve block technique and the unique role and related mechanism of nerve block in the prevention and treatment of multi-system diseases or symptoms, including disorders of the circulatory and respiratory systems, postoperative cognitive dysfunction, immune function, posttraumatic stress disorder, and postoperative digestive system, to put forward the potential prospective application in future and serve as a reference for future research of nerve block therapy in these diseases mentioned.

Efficiency and safety of erector spinae plane block in percutaneous nephrolithotomy: a meta-analysis based on randomized controlled trials

OBJECTIVES

To pool the data of published studies using the meta-analysis method to provide a high level evidence for the use of ESPB in pain control after PCNL.

METHODS

Two main stream databases, Pubmed and Embase, were used to identify potentially included studies. Primary outcomes included pain visual analogue scale (VAS) at different time points, intraoperative fentanyl use, time to first rescue analgesia and total tramadol or paracetamol consumption. Secondary outcome was defined as side effects of nausea and vomiting.

RESULTS

Fourteen studies were identified after database searching and 6 studies were included in the quantitative analysis. Overall, ESPB could significantly reduce the postoperative short-time (1-2h) and long-time (24h) VAS values (MD: -1.35, 95%CI: -1.71, -1.00 for short-time and MD: -0.39, 95%CI: -0.61, -0.17 for long-time) without significant heterogeneity. When it came to other primary outcomes, ESPB still showed its advantages in less intraoperative fentanyl use and total tramadol/paracetamol consumption, and longer time to first rescue analgesia. Complications were similar between groups (OR:0.90, 95%CI:0.38-2.14).

CONCLUSIONS

ESPB was an efficient and safe procedure for postoperative pain management in PCNL. More RCTs with larger sample size are still needed.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study

OBJECTIVES

Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited.

METHODS

In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects.

RESULTS

Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) μg and 240.0 (145.0, 370.0) μg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] μg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] μg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups.

CONCLUSIONS

Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

The Effect of Single-Shot Erector Spinae Plane Block (ESPB) on Opioid Consumption for Various Surgeries: A Meta-Analysis of Randomized Controlled Trials

Study Objective

Design

Setting

Patients

Intervention

Measurements

Results

Conclusion

Should the Erector Spinae Plane Block Be Applied in the Pain Management of Percutaneous Nephrolithotomy?

Introduction

This prospective, randomized controlled study aimed to investigate the efficacy and respiratory effects of postoperative pain management with an erector spinae plane block in patients undergoing percutaneous nephrolithotomy.

Methods

Sixty American Society of Anesthesiologists (ASA) I-II patients aged 18-65 years, scheduled to undergo percutaneous nephrolithotomy, were randomized either to the erector spinae plane block (ESPB) or control group. Fifteen mL 0.5% bupivacaine at the T11 level was administered preoperatively using the in-plane technique in the ESPB group. In both groups, 1 gr of intravenous paracetamol was administered intraoperatively. Postoperative pain and agitation were evaluated using the visual analog scale (VAS), dynamic VAS at zero, six, and 24 hours, and the Riker sedation-agitation scale at the 0th hour after surgery. Peak expiratory flow rate (PEFR) and oxygen saturation (SpO₂) were measured in preoperative examination and at the 0th, 6th, and 24th hours postoperatively. The time and number of the analgesic requirement, mobilization, and discharge time were also recorded.

Results

A significantly lower VAS and dynamic VAS were observed at the 0th, 6th, and 24th hours in the ESPB group (p<0.05 for each timepoint). The postoperative/preoperative PEFR ratio was lower and there were more agitated patients in the control group (p<0.05).

Conclusion

An erector spinae plane block may have additional clinical advantages while providing effective analgesia in patients who underwent percutaneous nephrolithotomy compared to intravenous analgesia.

Effectiveness of erector spinae plane block in patients with percutaneous nephrolithotomy

Background

Percutaneous nephrolithotomy operation is a minimally invasive surgical procedure for the treatment of kidney stones.

Aim

This study aimed to evaluate the effectiveness of ultrasound-guided erector spinae plane block (ESPB) on analgesic consumption in patients who underwent percutaneous nephrolithotomy.

Subjects and Methods

The data of 60 cases who underwent percutaneous nephrolithotomy operation between 01.01.2020 January and 12.01.2020 were retrospectively analyzed. Hemodynamic parameters, verbal analogue scale adjectives, total morphine consumption, additional analgesic and antiemetic need, duration of hospitalization, and patient satisfaction score were compared in patients who had ESPB and did not have block.

Results

Demographic data and hemodynamic parameters were similar between the two groups. Verbal rating scale values were lower for Group I at 2, 6, 12, and 24 h (P < 0.05). Patient satisfaction score was significantly higher in Group I over 24 h (P = 0.039). Total morphine consumption at postoperative 2^nd, 6^th, and 24^th h was less than that of Group II (P < 0.05). Analgesia consumption in postoperative 24 h of group I was less than that of Group II (P = 0.001). The amount of fentanyl given intraoperatively was significantly higher in Group II (P = 0.001). Nausea and vomiting rates were significantly lower for Group I (P = 0.002).

Conclusion

Ultrasound-guided ESPB reduced postoperative morphine consumption and the rate of nausea and vomiting.

Opioid-sparing effects of ultrasound-guided erector spinae plane block for adult patients undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Erector spinae plane block (ESPB) is a new method of administering analgesics to patients perioperatively. The aim of this meta-analysis was to evaluate the opioid-sparing effects of erector spinae plane block in patients during the perioperative period compared to conventional analgesia and identify its role in the development of opioid-free anesthesia.

METHODS

Relevant study articles were retrieved from PubMed, the Web of Science, Medline via Ovid, Embase via Ovid, and the Cochrane Central Register of Controlled Trials (CENTRAL) on June 11, 2020. We included randomized controlled trials (RCTs) comparing the use of ESPB with control (no/sham block). The primary outcome was opioid consumption at 24 h after surgery and intraoperative opioid consumption. A random-effects model was used to calculate the standardized mean difference (SMD) and odds ratio (OR) with 95% confidence interval (CI) if there was significant heterogeneity in the data; otherwise, the fixed-effect model was used.

RESULTS

A total of 25 randomized controlled trials involving 1461 patients were included. The use of ultrasound-guided ESPB was associated with reduced opioid consumption at 24 h after surgery [SMD: -2.14, 95% CI: -2.61 to -1.67, p < 0.001] and during the intraoperative period [SMD: -2.30, 95% CI: -3.21 to -1.40, p < 0.001]. In addition, it took a longer time to administer the first rescue analgesia in the ESPB group [SMD: 3.60, 95% CI: 2.23-4.97, p < 0.001] and the group was associated with lower incidences of postoperative nausea or vomiting (PONV) [OR: 0.50, 95% CI: 0.34-0.72, p < 0.001].

CONCLUSIONS

Ultrasound-guided ESPB could provide an opioid-sparing effect and effective analgesia in adults undergoing surgeries with general anesthesia, and then promote opioid-free anesthesia development.

Postoperative Pain Relief Following Lumbar Erector Spinae Plane Block in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Trial

OBJECTIVE

To test whether lumbar Erector Spinae Plane Block (ESPB) provides superior analgesia compared to placebo in patients undergoing Percutaneous Nephrolithotomy (PCNL), using reduction in postoperative opioid consumption, delay in rescue analgesia demand and reduction of pain scores as outcome measures.

METHODS

34 adult (18-60 years) ASA I and II patients undergoing unilateral PCNL were randomized into two groups (Bupivacaine and Saline) - both receiving ipsilateral ESPB at L1 vertebral level with either 20 ml 0.25% Inj. Bupivacaine or 20 ml normal saline respectively, at the start of the surgery under general anesthesia. The primary outcome measure was total 24-hour rescue opioid analgesic requirement, while time to first demand of rescue analgesic and pain scores at 2, 12 and 24 hours postoperatively were secondary outcomes.

RESULTS

The 24-hour requirement of rescue analgesic Tramadol was significantly lower (53.5 ± 29.6 vs 121.2 ± 51.1 mg) [mean ± SD] (P = .001) and time to first demand of rescue analgesia was more (14.1 ± 8.4 vs 6.0 ± 5.6 hours) [mean ± SD] (P = .001) in the Bupivacaine group as compared to placebo. The pain scores were significantly lower in the Bupivacaine group at 12-hour post-operatively [4 (3,4) vs 5.5 (5,6)] [median (IQR)] (P = .001), while the stone-load, surgical duration and intraoperative opioid use were comparable between the two groups and no block-related complications were noted in any patient.

CONCLUSION

Post-PCNL, ipsilateral lumbar ESPB reduced 24-hour opioid consumption and delayed time to demand for rescue analgesia as compared to placebo.

Opioid-sparing analgesic effects of peripheral nerve blocks in percutaneous nephrolithotomy: a systematic review

INTRODUCTION

Multimodal analgesia regimens incorporating peripheral nerve blocks (PNB) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNB in PCNL.

METHODS

A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) versus GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded.

RESULTS

Seventeen trials evaluating 1012 procedures were included. Five different blocks were identified and evaluated: paravertebral (n=8), intercostal nerve (n=3), quadratus lumborum (n=2), transversus abdominis plane (n=1), and erector spinae (n=3). 9/16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNB were limited to the early (<6 hours) recovery period in 5 studies and 2 found no difference. Total analgesia and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial.

CONCLUSION

While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNB may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.

Comparison of erector spinae plane block and local anaesthetic infiltration of the incision site for postoperative analgesia in percutaneous nephrolithotomy - A randomised parallel-group study

Background and Aims:

Erector spinae plane block (ESPB) has been found effective in providing postoperative analgesia following a myriad of surgeries. This study was designed to evaluate the effectiveness of ultrasonography (USG) guided erector spinae plane block to provide postoperative analgesia following percutaneous nephrolithotomy (PCNL).

Methods:

This was a prospective, double-blinded, randomised parallel-group study conducted in patients undergoing PCNL. Patients in Group C (n = 33) received subcutaneous infiltration of 20 mL of 0.25% bupivacaine at the incision site and Group B (n = 33) received USG guided ESPB with 20 mL of 0.25% bupivacaine postoperatively. Numeric rating scale (NRS) scores were assessed at intervals of 30 min, 60 min, then hourly for six h, followed by four-hourly up to 24 h. The primary objective of the study was to compare postoperative pain relief using the NRS score between the two groups. Secondary objectives were to compare the analgesic requirement and to assess the incidence of complications. Normally distributed data were expressed as mean and standard deviation and analysed using Student's t-test. Data following non-normal distribution were expressed as median and interquartile range and analysed using Mann- Whitney U-test. For categorical data, the Chi-square test was used.

Results:

NRS scores were lower in Group B than Group C. There was significant prolongation in time for first analgesia in Group B (12 h) compared to Group C (30 min). There was a significant reduction in total tramadol consumption at 24 h postoperatively in the ESPB group.

Conclusion:

Ultrasound-guided ESPB is an efficacious analgesic technique with an opioid-sparing effect following PCNL.

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.