A cadaveric study of the erector spinae plane block in a neonatal sample

Effectiveness of the Bilateral and Bilevel Erector Spinae Plane Block (ESPB) in Pediatric Idiopathic Scoliosis Surgery: A Randomized, Double-Blinded, Controlled Trial

BACKGROUND

This study aimed to compare the effect of the ultrasound-guided bilateral and bilevel erector spinae plane block (ESPB) on pain scores, opioid requirement, intraoperative motor-evoked potentials (MEPs), and stress response to surgery expressed by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) versus standard analgesia methods following idiopathic scoliosis surgery.

METHODS

This was a prospective, double-blinded, randomized controlled trial. Sixty patients aged 10 to 18 years and physical status ASA 1 or 2 were randomized into 2 equal groups, each receiving an ESPB or sham block. The primary outcome was the pain scores (Numerical Rating Scale, NRS) within 48 hours after spinal correction and fusion surgery for idiopathic thoracic scoliosis. The secondary outcomes were total opioid consumption, NLR, and PLR levels at 12 and 24 hours postoperatively and intraoperative MEPs.

RESULTS

ESPB patients presented lower NRS scores, signifying less pain, at all time points (30, 60, 90, 120 min; and 6, 12, 24, and 48 h after surgery), all P <0.0001. The total opioid consumption, the incidence of nausea or vomiting, and the need for remifentanil and propofol during surgery were significantly lower in the ESPB group. The surgery-induced stress response expressed by NLR and PLR was considerably lower in the ESPB group. ESPB did not affect the intraoperative MEP's amplitude.

CONCLUSIONS

ESPB is effective for postoperative analgesia, can reduce opioid consumption in patients undergoing scoliosis surgery, and reduces the stress response to surgery. ESPB does not interfere with neuromonitoring.

LEVEL OF EVIDENCE

Level I.

Anatomical Studies Evaluating Pediatric Regional Anesthesia: A Scoping Review

BACKGROUND

Pediatric regional anesthesia has been driven by the gradual rise in the adoption of opioid-sparing strategies and the growing concern over the possible adverse effects of general anesthetics on neurodevelopment. Nonetheless, performing regional anesthesia studies in a pediatric population is challenging and accounts for the scarce evidence. This study aimed to review the scientific foundation of studies in cadavers to assess regional anesthesia techniques in children.

METHODS

We searched the following databases MEDLINE, EMBASE, and Web of Science. We included anatomical cadaver studies assessing peripheral nerve blocks in children. The core data collected from studies were included in tables and comprised block type, block evaluation, results, and conclusion.

RESULTS

The search identified 2409 studies, of which, 16 were anatomical studies on the pediatric population. The techniques evaluated were the erector spinae plane block, ilioinguinal/iliohypogastric nerve block, sciatic nerve block, maxillary nerve block, paravertebral block, femoral nerve block, radial nerve block, greater occipital nerve block, infraclavicular brachial plexus block, and infraorbital nerve block.

CONCLUSION

Regional anesthesia techniques are commonly performed in children, but the lack of anatomical studies may result in reservations regarding the dispersion and absorption of local anesthetics. Further anatomical research on pediatric regional anesthesia may guide the practice.

Erector spinae plane blocks: A narrative update

The erector spinae plane block (ESPB) is perhaps one of the most interesting of the tissue plane blocks described recently. There has been an exponential increase in the number of publications for both adults and children over the past 5 years. Single-shot, intermittent bolus, and continuous infusion techniques have been used effectively. Both the efficacy and safety of the procedure are widely accepted, but the exact mechanism by which the local anesthetic spreads from the tip of the transverse process to block the dorsal and ventral rami of the spinal nerves is controversial and needs clarification. Anatomical differences in children, particularly in neonates and infants, may explain the spread in this age group. In most pediatric studies, erector spinae plane block was opioid sparing, and noninferiority was observed when compared with other regional techniques.

Epidural-Like Effect of a Continuous Right-Sided Erector Spinae Plane Blockade for Complicated Pediatric Abdominal Surgery

The erector spinae plane block (ESPB) is increasingly gaining popularity in pediatric anesthesiology as it provides an alternative to neuraxial anesthesia in those with relative and absolute contraindications. Recent studies show craniocaudal spread in cadavers and multi-level spread impacting neural structures in live subjects. We present a case report of a pediatric patient with a history of abdominal surgeries, contraindication to neuraxial anesthesia, and thoracic vertebrae fractures. Bilateral ESPB catheters were initially placed but the left catheter was accidentally dislodged. Each ESPB catheter was initially programmed to flow at rate of 2 cc/h of ropivacaine 0.1% for a max combined rate of 4 cc/h. Once the left ESPB catheter was dislodged, the right ESPB catheter was programmed to flow at 4 cc/h which surprisingly continued to provide adequate bilateral analgesia for the patient without the need for additional narcotics. In cases where a unilateral ESPB catheter is the only option due to catheter displacement or contamination, administering a higher volume of local anesthetic may still yield satisfactory pain relief for managing postoperative discomfort following abdominal surgery.

Unilateral Right-Sided Ultrasound-Guided Erector Spinae Plane Block for Post-Laparoscopic Cholecystectomy Analgesia: A Randomized Control Trial

Background

Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively.

Objectives

We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption.

Methods

This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours.

Results

Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively).

Conclusions

A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Analgesia and spread of erector spinae plane block in breast cancer surgeries: a randomized controlled trial

Background

To evaluate the analgesic efficacy and spread of variable volumes of local anesthetics (LA) in Erector spinae plane block (ESPB).

Methods

Sixty patients aged between 18 and 50 years with an ASA I-II and scheduled for breast cancer surgery were randomized to receive either ESPB with 20 ml 0.25% bupivacaine (Standard volume ESPB), or with 40 ml 0.125% bupivacaine (High volume ESPB), or no ESPB (GA only group). The primary outcome was pain intensity evaluated by the visual analogue scale (VAS), 12 hours after surgery. P-values < 0.05 were considered the cutoff point for statistical significance. The secondary outcomes were pain at rest and pain on movement evaluated by the VAS, craniocaudal injectate spread, to paravertebral (PV) and epidural spaces assessed by CT, clinical dermatomal spread, level of sedation or agitation, and patient satisfaction with anesthesia and analgesia.

Results

VAS at rest 12 h after surgery was less in both intervention groups compared to the control (1.75 ± 0.79 vs. 1.6 ± 0.88 vs. 3.4 ± 1.96, p = 0.001). The LA had extended further in the high volume group than the standard volume group (11.20 ± 3.07 vs. 9.15 ± 2.54 vertebral levels, p = 0.027). No difference of the spread to PV or epidural spaces between the 2 intervention groups. More dermatomes were covered in the high volume group (7.20 ± 2.12 vs. 5.75 ± 1.37 dermatomes, p = 0.014). Agitation was higher in the GA only group than both ESPB groups in the first 8 postoperative hours. Patients were more satisfied in both ESPB groups than the GA only group.

Conclusions

Preoperative ESPB is an excellent analgesic modality and it can also attenuate both postoperative agitation and sedation. Doubling the injectate volume enhances the craniocaudal spreading and may be useful for surgeries requiring multiple dermatomes. However, larger volume has no effect on analgesic efficacy or patient satisfaction as there is no further spread to the PV, epidural spaces or spinal nerve rami.

Trial registration

NCT04796363 (12/3/2021).

Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature

Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.

Ultrasound-guided erector spinae plane block improve opioid-sparing perioperative analgesia in pediatric patients undergoing thoracoscopic lung lesion resection: a prospective randomized controlled trial

BACKGROUND

Pediatric patients often experience severe pain after thoracic surgery, especially in the early postoperative period. Recently, the focus has been on regional analgesia with the introduction of ultrasound-guided erector spinae plane blocks. We assumed that preoperative erector spinae plane block (ESPB) in children undergoing video-assisted thoracoscopic surgery (VATS) would reduce the consumption of perioperative opioids.

METHODS

This randomized, double-blind study enrolled 60 children aged 1-3 years who underwent thoracoscopic lung lesion resection. The patients were enrolled in the study and randomly divided into two groups. The general anesthesia (GA) group received GA alone, and the GA + ESPB group received ESPB. The consumptions of remifentanil and sufentanil were recorded, and the children's face, legs, activity, cry, consolability (FLACC) scores were assessed after awakening. The time to first rescue analgesia, length of hospital stay, parental satisfaction and adverse events were also recorded.

RESULTS

The consumptions of remifentanil and sufentanil in the GA + ESPB group were significantly lower than those in the GA group, mean difference [95% confidence interval (CI)]: -26.57 (-31.98 to -21.17) and -0.21 (-0.27 to -0.17), respectively, (both P<0.001); while the time to first rescue analgesia and parental satisfaction scores were significantly longer and higher, respectively, in the GA + ESPB group than those in the GA group, mean difference (95% CI): 2.37 (1.77 to 2.97) and 2.47 (1.79 to 3.15), respectively, (both P<0.001). The FLACC scores in the GA + ESPB group were significantly lower than those in the GA group 1 to 24 hours postoperatively (P=0.023 at 1 h, and P<0.001 at 3 h, 6 h, 12 h, 18 h, 24 h), but not at immediate admission to the post-anesthesia care unit (PACU) (P=0.189 at 0 h). The GA + ESPB group had significantly lower incidence rates of postoperative nausea and vomiting (P=0.037 and P=0.020).

CONCLUSIONS

In pediatric Thoracoscopic surgery, the results of this study confirm our hypothesis that ESPB decreases the consumptions of intraoperative remifentanil and postoperative sufentanil in 24 hours and demonstrates better postoperative analgesia compared with a control group.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200056166.

Randomized trial comparing the spread of erector spinae block with the combination of erector spinae block and retrolaminar block in soft embalmed Thiel cadavers

BACKGROUND

Erector spinae plane (ESP) and retrolaminar (RL) blocks show unreliable spread. We hypothesize that the combination of ESP and RL blocks provides more extensive and reliable spread of dye than single ESP blocks. Our primary objective was to compare the spread of dye to the paravertebral spaces after the combination block and ESP block in Thiel embalmed cadavers. Spread, the primary end point, was defined as the number of paravertebral spaces colored with dye per injection.

MATERIALS AND METHODS

A single anesthetist performed ultrasound-guided ESP (20 mL) and combination of ESP and RL (10 mL each) blocks at the third thoracic vertebra of eight soft embalmed Thiel cadavers. Tissue displacement was visualized on an adjacent strain elastography image. Cadavers were dissected 24 hours later and anatomical structures were inspected for the presence of dye.

FINDINGS

Dye was visualized in more paravertebral spaces with the combination block (median 3 (IQR 3-5 (range 0-8)) vs 1.5 (IQR 0.25-2.75 (range 0-3) and difference (1.5 (0-4), p=0.04). Six out of seven (86%) combined erector spinae and RL blocks spread to at least three paravertebral spaces compared with two out of eight (25%) ESP blocks (RR 3.4, 95% CI 1.0 to 11.8; p=0.04). Contralateral spread occurred in three combination blocks and in one ESP block (OR 9.0, 95% CI 4.0 to 21.1; p<0.001).

CONCLUSIONS

In conclusion, the combination of ESP and RL blocks was more extensive and reliable than ESP block alone.

Cadaveric study investigating the phrenic-sparing volume for anterior suprascapular nerve block

BACKGROUND

This cadaveric study investigated the maximum effective volume of dye in 90% of cases (MEV90), required to stain the suprascapular nerve while sparing the phrenic nerve during the performance of an anterior suprascapular nerve block.

METHODS

In cadaveric neck specimens, using ultrasound guidance, the block needle was advanced until its tip was positioned underneath the omohyoid muscle next to the suprascapular nerve. The dye was injected in order to achieve circumferential spread around the latter. Successful phrenic-sparing suprascapular nerve block was defined as the non-staining of the phrenic nerve on dissection. Volume assignment was carried out using a Biased Coin Design, whereby the volume of dye administered to each cadaveric specimen depended on the response of the previous one. In case of failure (ie, stained phrenic nerve), the next one received a lower volume (defined as the previous volume with a decrement of 2 mL). If the previous cadaveric specimen had a successful block (ie, non-stained phrenic nerve), the next one was randomized to a higher volume (defined as the previous volume with an increment of 2 mL), with a probability of b=0.11, or the same volume, with a probability of 1 - b=0.89.

RESULTS

Thirty-one cadavers (56 cadaveric neck specimens) were included in the study. Using isotonic regression and bootstrap CI, the MEV90 for phrenic-sparing anterior suprascapular nerve block was estimated to be 4.2 mL (95% CI 3.0 to 5.0 mL). The probability of a successful response was estimated to be 0.90 (95% CI 0.84 to 0.96).

CONCLUSION

For ultrasound-guided anterior suprascapular nerve block, the MEV90 of dye required to spare the phrenic nerve is 4.2 mL. Further studies are required to correlate this finding with the MEV90 of local anesthetic in live subjects.

The Role of Interfascial Plane Blocks in Paediatric Regional Anaesthesia: A Narrative Review of Current Perspectives and Updates

Regional anaesthesia has been increasingly used for analgesia in the perioperative period in paediatric anaesthesia for better pain control and improved patient outcomes. Interfascial plane blocks are considered as a subgroup of peripheral nerve blocks. The advent of ultrasound in modern regional anaesthesia practice has led to the evolution of various interfascial plane blocks. The ease of their performance and the low complication rates, compared with neuraxial anaesthesia, have led to their increased use in the perioperative period. Interfascial plane blocks are often incorporated in the multimodal analgesia regimen in the early recovery and ambulation after surgery protocols for various chest wall and abdominal surgeries. This achieves better pain control and decreases the requirements of opioids in the perioperative period, thereby facilitating early mobilization and discharge. This narrative review focuses on the relevant anatomic considerations, technique for the performance of each block along with its current applications and limitations, and includes a review of the current literature on various interfascial plane blocks in paediatric regional anaesthesia.

New peripheral nerve blocks: are they worth the hype?

The advent of portable ultrasound technology has revolutionised our ability to place peripheral nerve blocks within tissue planes. Ultrasound guidance has facilitated the introduction of new innovative approaches to deeper nerves not previously attempted using landmark-based techniques. The majority of these truncal blocks involve the branches of the spinal nerves.

The anatomical features of an ultrasound-guided erector spinae fascial plane block in a cadaveric neonatal sample

BACKGROUND

Since its inception, the erector spinae plane block has been used for a variety of truncal surgeries with success in both adults and children. However, the anatomical features, route of spread, and dermatomal coverage are still not fully understood in a pediatric population.

OBJECTIVES

To identify the anatomical features of the erector spinae fascial plane space by replicating an erector spinae plane block in a fresh neonatal cadaveric sample. The primary aim was to determine the spread of the dye within the fascial plane, while the secondary aims were to determine whether the needle direction or entry site affected the spread.

METHODS

The block was replicated bilaterally using 0.1 mL/kg of iodinated contrast dye in nine fresh unembalmed preterm neonatal cadavers. The dye was introduced under ultrasound guidance at vertebral level T5 and T8. Additionally, the needle was oriented cranial-caudal vs caudal-cranial to determine if the needle orientation influenced the spread of dye. The block was also replicated midway between the adjacent transverse processes as opposed to the lateral tip of the transverse process to determine the spread.

RESULTS

From the total sample size, 14 "blocks" were successfully replicated, while 4 "blocks" were either incomplete or failed blocks. Contrast dye was found in the paravertebral, intercostal, and epidural spaces, including posteriorly over the neural foramina. Results revealed that the needle direction or entry site did not influence the spread within the fascial plane.

CONCLUSION

Contrast material was found in the paravertebral, epidural, and intercostal spaces over an average of 5 vertebral levels when using 0.1 mL/kg.

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.

Erector spinae catheter for post-thoracotomy pain control in a premature neonate

Ensuring respiratory stability with early tracheal extubation and adequate pain control is challenging in premature neonates after thoracotomy. Continuous erector spinae plane (ESP) block, a relatively new truncal nerve block, has the potential to provide analgesia for thoracic surgeries while reducing opioid use. However, there have been only a few reports utilising this technique in infants, and none in preterm neonates. We present the perioperative pain management of a preterm neonate requiring thoracotomy. Epidural analgesia was deemed contraindicated due to coexisting coagulopathy; therefore, an ESP catheter was placed. The patient was extubated at the end of the surgery and had excellent pain control with rectal acetaminophen, chloroprocaine infusion via the ESP catheter and with minimal opioid requirement. Continuous ESP block may be safe and effective for postoperative pain management in coagulopathic premature neonates. Chloroprocaine is an effective local anaesthetic in the erector spinae compartment, which has not been previously reported.

Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: a randomized, double-blind, placebo-controlled trial

Background

Postoperative pain after pediatric cardiac surgery is usually treated with intravenous opioids. Recently, the focus has been on postoperative regional analgesia with the introduction of ultrasound-guided erector spinae plane blocks (ESPBs). We hypothesized that bilateral ESPB with a programmed intermittent bolus (PIB) regimen decreases postoperative morphine consumption at 48 hours and improves analgesia in children who undergo cardiac surgery.

Methods

This randomized, double-blind, placebo-controlled study comprised 50 children who underwent cardiac surgery through midline sternotomy. The patients were allocated randomly into two groups: ultrasound-guided bilateral ESPB at the level of T3–T4 transverse process then PIB with saline infusion (group 1, n=23) or PIB with 0.2% ropivacaine (group 2, n=27). Intravenous morphine at 30 µg/kg/hour was used as rescue analgesia. Postoperative pain was assessed using the COMFORT-B score for extubation, drain removal, and mobilization, and the FLACC (Face, Legs, Activity, Cry, Consolability) scale at 0, 2, 4, 6, 8, 12, 16, 20, 24, 36, and 48 hours after surgery. Adverse events were noted.

Results

The total dose of morphine in 48 hours was significantly decreased in patients receiving a bilateral ESPB with ropivacaine (120±320 µg/kg) compared with patients with saline infusion (512±560 µg/kg; p=0.03). Fourteen per cent of patients required rescue analgesia with morphine in group 2 compared with 41% in group 1 (p=0.05). The patients in group 2 demonstrated significantly reduced COMFORT-B scores at extubation, drain removal, and mobilization compared with those in group 1 and had reduced FLACC scale levels at 20 and 24 hours postoperatively (p=0.05 and p=0.001, respectively). No differences were reported for extubation and drain removal times or for length of hospital stay. In addition, vomiting episodes were decreased in group 2 (p=0.01).

Conclusions

In pediatric cardiac surgery, the results of this study confirm our hypothesis that bilateral ESPB analgesia with ropivacaine decreases the postoperative morphine consumption at 48 hours and demonstrates better postoperative analgesia compared with a control group.

Trial registration numberNCT03593642.

Early experience with erector spinae plane blocks in children

BACKGROUND

An erector spinae plane block is a relatively new regional anesthetic technique. Apart from case reports and small series, the literature regarding pediatric use is limited.

AIM

Our objective was to determine the efficacy of the erector spinae plane block in children by measuring the heart rate response to incision. Secondary objectives included feasibility, safety, opioid consumption, and pain scores. Furthermore, we reviewed this block in children published since 2016.

STUDY DESIGN

Case Series; Level of evidence, IV.

METHODS

With Institutional Review Board approval, a retrospective chart review was conducted on all patients who received erector spinae plane block for surgery between October 2017 and May 2019 at a single institution. Blocks were performed under anesthesia, using ultrasound guidance prior to surgical incision. Block details and hemodynamic and analgesic data were collected. In addition, a PubMed literature review was conducted to identify all erector spinae plane block related publications in patients ≤18 years of age.

RESULTS

About 164 patients, 2 days-19.4 years, weighing 2.3-94.7 kg, received erector spinae plane blocks. For more than 79% of single injection blocks, placement time was ≤10 minutes. Using a heart rate increase of <10% at skin incision as criterion, 70.1% of patients had a successful block. Only 20% required long-acting opioids intraoperatively. In a subset of infants who underwent gastrostomy surgery using a dose of 0.5 mL/kg, a local anesthetic spread of at least five dermatomes (0.1 mL/kg/dermatome) was achieved. Per the literature review, 33 publications described erector spinae plane block in 128 children. No complications were reported.

CONCLUSION

Erector spinae plane blocks are relatively easy to perform in children with no complications reported to date. The efficacy of the block for a broad spectrum of surgeries, involving incisions from T1 to L4, is encouraging.