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

Effect of bupivacaine concentration on ultrasound-guided pericapsular group nerve block efficacy in hip surgery patients: comparative, randomized, double-blinded clinical trial

Background

The pericapsular nerve group (PENG) block offers effective postoperative pain relief following hip fracture surgery. This research investigated three doses of bupivacaine, all administered in the same total volume, for performing ultrasound-guided PENG blocks during hip fracture procedures.

Methods

This randomized, double-blinded clinical trial was conducted on 135 patients aged between 18 and 70 years of both sexes who underwent hip fracture surgeries. Participants were randomized into three groups (n = 45). Ultrasound-guided PENG block was applied, the groups received 20 mL of local anesthetics. The first group received 0.5% bupivacaine, the second group received 0.375% bupivacaine, and the third group received 0.25% bupivacaine. The following parameters were recorded: onset of sensory block, resting NRS after passively raising the limb by 15° half an hour post-procedure, quality of recovery score (QoR-15) at 24 h postoperative.

Results

The 0.25% bupivacaine group exhibited a longer sensory block onset than the other groups (p ≤ .05). Significant differences were demonstrated between the groups regarding the time to 1st analgesia (p = .033) and total morphine consumption (p = .025). NRS at baseline and T30 post-block did not show significant differences between the studied groups. No significant differences were detected postoperatively in rest and dynamic NRS (p ≤ .05). Patient satisfaction, QoR-15 score, and ease of spinal positioning did not differ between the groups.

Conclusion

Compared to 0.25% bupivacaine, PENG block with 0.5% and 0.375% bupivacaine provided a rapid onset sensory block, delayed first analgesic requirements, and reduced total morphine consumption after hip surgeries.

Protocol Registration

The trial was registered at the clinicaltrials.gov with study number (Trial ID: NCT05788458).

Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Matched cohort comparison.

OBJECTIVE

To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF.

MATERIALS AND METHODS

Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups.

RESULTS

Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1.

CONCLUSIONS

In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF.

LEVEL OF EVIDENCE

Level 3.

The Use of Erector Spinae Plane Block Reduces Opioid Consumption and Pain Score in Postoperative Period After Hip Surgery: A Meta-Analysis

Erector spinae plane block (ESPB) is a relatively new regional anesthesia block that has been used in thoracic and abdominal surgeries with variable success. ESPB can easily be administered using an ultrasound technique with a safer profile. Recently, there have been few randomized controlled trials (RCTs) regarding the role of ESPB in hip surgeries. A current meta-analysis was done to evaluate the role of ESPB block in controlling postoperative pain after hip surgeries. PRISMA guidelines were followed to perform this meta-analysis. We used online databases including Science Direct, PubMed, Google Scholar, and Cochrane Library. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database as ID-CRD42023445516 in July 2023. We included studies that reported opioid use, pain control after surgery, and side effects associated with ESPB for hip surgeries. The ReviewManager software, i.e., RevMan for Mac 5.4 (Cochrane Collaboration, Oxford, UK), was utilized to conduct this meta-analysis. We included five RCTs during this meta-analysis. Our results demonstrated that the use of ESPB in hip surgery caused a significant decrease in 24-hour postoperative opioid consumption (p=0.02). ESPB also resulted in a significant decrease in pain scores up to nine hours postoperatively (p<0.05).

Ultrasound-guided erector spinae plane block versus port site infiltration for postoperative pain and quality of recovery in adult patients undergoing laparoscopic cholecystectomy: An assessor-blinded randomised controlled trial

Background and Aim

Pain following laparoscopic cholecystectomy (LC) is common and results in poor quality of recovery. Our study aimed to compare the analgesic efficacy of port site local infiltration, novel erector spinae plane (ESP) block, and standard regimen in patients undergoing LC and its impact on functional recovery.

Methods

After ethical approval and registering the trial, we randomly allocated 105 adult patients undergoing LC to three groups: Group I (n = 35), received multimodal analgesia; Group II (n = 35), received pre-incisional port site infiltration with 20 ml of 0.375% bupivacaine; and Group III (n = 35), preoperative bilateral ESP block with 20 ml of 0.375% bupivacaine bilaterally was administered. Pain severity, fentanyl consumption, and time to first rescue analgesia were recorded over 24 h. Quality of recovery (QoR-15) was assessed at baseline and 24 h postoperatively.

Results

Pain in the first 6 h was lowest in the ESP group (P < 0.001). Although static pain in the infiltration group was comparable with that in the ESP group after 6 h (P > 0.05), dynamic pain was better in the ESP group till 20 h postoperatively (P < 0.05). Fentanyl consumption was significantly lower in the ESP group (P < 0.001). Global and sub-dimensional QoR-15 scores were significantly higher only in the ESP group at 24 h compared to the other two groups (P < 0.001). The infiltration group did better than the control group in terms of total opioid requirement (P < 0.001) and Visual Analogue Scale (VAS) score after 6 h (P < 0.001).

Conclusion

ESP block provided lower postoperative pain scores with opioid-sparing and better quality of recovery in patients undergoing LC.

Optimal ropivacaine concentration for ultrasound-guided erector spinae plane block in patients who underwent video-assisted thoracoscopic lobectomy surgery

Background

An ultrasound-guided erector spinae plane block (ESPB) has emerged as an effective way to control postoperative pain and may be a good alternative way to an epidural block. However, relevant research on the appropriate concentration of local anesthetics for an ESPB remains scarce.

Aims

This study aimed to investigate the optimal concentration of ropivacaine for an ESPB in patients undergoing video-assisted thoracoscopic surgery (VATS).

Methods

A total of 68 patients who underwent a VATS lobectomy were enrolled. An ipsilateral ultrasound-guided ESPB was performed with three different ropivacaine concentrations as a local anesthetic: 0.189% (G1), 0.375% (G2), and 0.556% (G3). The total amount of perioperative remifentanil administered, patient-controlled analgesia (PCA) applied, and rescue drugs for postoperative analgesia during the 24 h after surgery were acquired, and numeric rating scale (NRS) scores were obtained.

Results

The total amount of intraoperative remifentanil administered was 7.20 ± 3.04 mcg/kg, 5.32 ± 2.70 mcg/kg, and 4.60 ± 1.75 in the G1, G2, and G3 groups, respectively. G2 and G3 had significantly lower amounts of remifentanil administered than the G1 group (P = 0.02 vs. G2; P = 0.003 vs. G3). The G3 group needed more inotropes than the G1 and G2 groups in the perioperative period (P = 0.045). The NRS scores, PCA, and rescue drug were not significantly different in the three groups.

Conclusion

The optimal concentration of ropivacaine recommended for an ESPB was 0.375%, which was effective in controlling pain and reducing the intraoperative opioid requirements with minimal adverse reactions such as hypotension.

Postoperative Analgesia in Breast Cancer Surgery: Efficiency and Safety of Ultrasound Guided Erector Spinae Plane Block, a randomized controlled double blinded trial

INTRODUCTION

Breast cancer surgeries are the mainstay and usually the first step of treatment.

AIM

To assess the efficiency and safety of ultrasound guided Erector Spinae Plane Block (ESPB) for the management of postoperative pain in patients undergoing elective breast cancer surgery.

METHODS

Between December 2018 and June 2019, a prospective, controlled, randomized, double-blinded study was conducted at the maternity and neonatology center of Tunis. We included fifty ASA I-II female patients who were scheduled for elective breast cancer surgery. They were randomly divided into two groups: Group R (n=25) with Ropivacaine, while Group P (n=25) received a placebo. The study recorded PCA morphine consumption and patient demand for PCA. The primary outcome was to compare the visual analogue scale (VAS) pain scores at various points throughout the 24 hours postoperatively (1st, 2nd, 4th, 8th, 12th, 16th, 20th, 24th) between the two groups.

RESULTS

Except for the first hour and 16th hour post-surgery, the mean VAS pain scores were significantly lower in Group R compared to Group P. The 24-hour morphine consumption was significantly lower in Group R (5.5±0.9 mg) compared to Group P (16.6±2.8 mg); p<0.001. Per-operative fentanyl consumption was also significantly lower in Group R (9.1±4.2 mcg; Group P: 50±9.1 mcg; p< 0.001). Moreover, the mean total morphine demand was significantly lower in Group R.

CONCLUSION

ESPB with Ropivacaine is effective and safe for pain management after breast cancer surgery with a consequent morphine sparing and less use of systemic analgesia.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial

BACKGROUND

Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery.

MATERIALS AND METHODS

Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications.

RESULTS

The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction.

CONCLUSION

In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone.

TRIAL REGISTRATION NUMBER

NCT03621345 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 .

Analgesic effect of erector spinae plane block after cesarean section: A randomized controlled trial

Background

Ultrasound-guided bilateral erector spinae plane block is also a technique for providing analgesia after a cesarean section.

Aim

We hypothesized that bilateral erector spinae plane block applied from the transverse process of T9 who underwent elective cesarean section could provide effective postoperative analgesia.

Patients and Methods

Fifty parturients who were scheduled to undergo elective cesarean section under spinal anesthesia were included in the study. Group SA (n = 25) was categorized as the group in which spinal anesthesia alone (SA) was performed, and Group SA+ESP (n = 25) was categorized as the group in which SA + ESP block was performed. All patients were given a solution containing 7 mg isobaric bupivacaine + 15 μg fentanyl intrathecally through spinal anesthesia. In the SA + ESP group, the bilateral ESPB was performed at level T9 with 20 ml 0.25% bupivacaine + 2 mg dexamethasone immediately after the operation. Total fentanyl consumption in 24 h, the visual analogue scale for pain, and time to the first analgesic request were evaluated postoperatively.

Results

The total fentanyl consumption in 24 h was statistically significantly lower in the SA + ESP group than the SA group (279 ± 242.99 μg vs. 423.08 ± 212.55 μg, respectively, P = 0.003). The first analgesic requirement time was statistically significantly shorter in the SA group than the SA + ESP group (150.20 ± 51.83 min vs. 197.60 ± 84.49 min, respectively, P = 0.022). Postoperative VAS scores at 4^th, 8^th, and 12^th h at rest were statistically significantly lower in group SA + ESP than in group SA (P = 0.004, P = 0.046, P = 0.044, respectively). VAS scores during the postoperative 4^th, 8^th, and 12^th h cough were statistically significantly lower in group SA + ESP than in group SA (P = 0.002, P = 0.008, P = 0.028, respectively).

Conclusion

Ultrasound-guided bilateral ESP provided adequate postoperative analgesia and significantly decreased postoperative fentanyl consumption in patients having cesarean section. Also, it has a longer analgesia time than the control group, and it has been shown to delay the first analgesic requirement.

Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind, randomized controlled trial

PURPOSE

The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery.

METHODS

A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10-15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded.

RESULTS

The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred.

CONCLUSION

The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

A Comparative Study of Placebo Versus Opioid-Free Analgesic Mixture for Mastectomies Performed Under General Anesthesia Along With Erector Spinae Plane Block

Background and objectives Breast cancer is the most frequent cancer among women, globally. Postoperative pain after mastectomy not only causes slow recovery and prolonged hospital stay but can also increase the risk of chronic pain. For patients undergoing breast surgery, effective perioperative pain management is required. Various approaches have been introduced to overcome this, such as opioids, non-opioid analgesics, and regional blocks. The erector spinae plane block is a new regional anesthesia technique used in breast surgery to provide adequate intraoperative and postoperative analgesia. Opioid-free anesthesia is a multimodal analgesia technique that does not use opioids and thus prevents opioid tolerance after surgery. This study aims to investigate whether administering an opioid-free analgesic mixture lowers the pain score and the need for analgesics during and after surgery. Material and methods In this randomized prospective comparative clinical study, 66 patients of the American Society of Anesthesiologists (ASA) psychological status (PS) class 1 and 2, aged 18 to 80, were included. Group M received erector spinae plane block + general anesthesia + opioid-free analgesic mixture (1 mcg/cc dexmedetomidine + 1 mg/cc ketamine + 100 mg/cc magnesium sulfate prepared in a 20 ml syringe). Group N received erector spinae plane block + general anesthesia + 20ml of normal saline infusion. The primary outcome was to assess pain scores in the perioperative period. The secondary outcomes were to compare the time for the first rescue analgesia requirement perioperatively, intraoperative hemodynamic profile, and postoperative patient satisfaction. A p<0.05 was considered to be statistically significant. Results All patients were females undergoing modified radical mastectomy or breast conservative surgery + axillary sampling + latissimus dorsi flap reconstruction. The visual analog scale (VAS) scores were less than or equal to 3 in zero, first, and second hours postoperatively in both groups. The pain was moderate i.e., less than 4 in almost all time intervals in both groups. Group M had a better intraoperative hemodynamic profile, including mean arterial pressure and heart rate when compared to group N. In group M, the time of request for rescue analgesia was 726.67±390.99 minutes, while it was 468±278.79 minutes in group N. The total analgesic requirement was less in group M than in group N, but this was not statistically significant. Conclusion Multimodal analgesia with erector spinae plane block and opioid-free analgesic mixture provides effective perioperative analgesia and a better intraoperative hemodynamic profile in patients undergoing breast cancer surgery under general anesthesia.

Erector spinae plane block versus thoracic paravertebral block for the prevention of acute postsurgical pain in breast cancer surgery: A prospective observational study compared with a propensity score-matched historical cohort

BACKGROUND

Preventing acute postsurgical pain (PSP) following breast cancer surgery is a major issue. Thoracic paravertebral block (TPVB) has been widely studied for this indication. Erector spinae plane block (ESPB) has been assumed to be effective. We aimed to compare the efficacy and safety of ESPB over TPVB in preventing acute PSP.

METHODS

In this prospective observational study, 120 patients admitted for unilateral major oncologic breast surgery received T2/T3 ESPB (ropivacaine 0.75%, 0.35 ml.kg-1), and 102 were analysed. Then, the ESPB cohort was compared to a TPVB cohort from the experimental arm of a randomized controlled study with the same protocol (NCT02408393) using propensity score matching analysis. The primary outcome was the need for morphine consumption in the PACU. Secondary outcomes were the morphine total dose, the incidence of ESPB and TPVB complications, and discontinuous visual analogue scale measurement trends at rest and at mobilization in the 24 hours after surgery.

RESULTS

A total of 102 patients completed the study between December 2018 and August 2019. Propensity score matching formed 94 matched pairs. The proportion of morphine titration in the PACU was higher in the ESPB group than in the TPVB group (74.5% vs. 41.5%, p<0.001), with a between-group difference of 33.0% (95% CI [19.3%, 46.7%]). No ESPB-related complications were observed.

CONCLUSION

ESPB is less effective in preventing morphine consumption in the PACU than TPVB. Our findings do not support the use of ESPB as the first-line regional anaesthesia for major breast cancer surgery. Randomized trials comparing ESPB and TPVB are needed.

Analgesic efficacy of a bilateral erector spinae plane block versus a fentanyl constant rate infusion in dogs undergoing hemilaminectomy: a retrospective cohort study

BACKGROUND

Erector spinae plane block (ESPB) is an ultrasound-guided interfascial plane block used to provide analgesia in dogs undergoing hemilaminectomy. The aim of this study is to compare the analgesic efficacy of a bilateral ESPB with a fentanyl constant rate infusion (CRI) in dogs undergoing hemilaminectomy.

METHODS

This is a retrospective cohort study. Anaesthetic records of client-owned dogs undergoing hemilaminectomy (June 2019-August 2020), and in which a bilateral ESPB was performed (group ESPB), were retrieved and compared to a cohort of 39 dogs that underwent hemilaminectomy (September 2014 - June 2017) and in which a fentanyl CRI (2 μg/kg bolus followed by 5 μg/kg/hour) was used as a primary intraoperative analgesia (group CRI). The prevalence of dogs in which intraoperative rescue fentanyl boluses were administered, the total dose of rescue fentanyl boluses administered, the postoperative methadone requirement and anaesthetic complications during the first 24 postoperative hours were evaluated. Univariate statistical analysis was used.

RESULTS

Group ESPB comprised of 93 dogs. The bilateral ESPB was performed using a median (range) levobupivacaine volume of 1 (0.5-1.7) mL/kg per side, at a concentration of 0.125% (0.12-0.25). At least one rescue fentanyl bolus was administered in 54.8% and in 56.4% of dogs in group ESPB and CRI, respectively (p > 0.99). The number of rescue fentanyl boluses was higher in group CRI (p = 0.006), especially during lumbar hemilaminectomy. Rescue fentanyl boluses were more frequently administered from skin incision to end of vertebral lamina drilling in group CRI (p = 0.001), and from end of vertebral lamina drilling to end of surgery in group ESPB (p = 0.0002). During the first 6 (p = 0.0035) and 6-12 (p = 0.0005) postoperative hours, the number of dogs that required at least one dose of methadone was higher in group CRI. In group ESPB, dogs were more likely to become hypothermic (p = 0.04). One dog, not included in the study, developed sinus arrest after performing a caudal thoracic ESPB.

CONCLUSIONS

Under the conditions of this study, a bilateral ESPB was associated with a lower number of rescue fentanyl boluses administered in dogs undergoing hemilaminectomy, especially between skin incision to end of vertebral lamina drilling. Despite ESPB being associated with a reduced opioid consumption during the first 12 hours postoperatively, differences in the postoperative management precluded any firm conclusion regarding its postoperative effect.

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).

Incidence, risk factors, prevention and treatment of postmastectomy pain syndrome in breast cancer: A multicenter study

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a common postoperative condition after breast cancer surgery.

PURPOSE

The aim of this study was to investigate the incidence rate and risk factors of PMPS, and to propose prevention and treatment methods.

METHODS

The study included 1790 postoperative breast cancer patients from three hospitals from 2017 to 2021, of which 302 (13.0%) patients with PMPS were included in the study.

RESULTS

Age, breast surgery type, axillary surgery type and radiotherapy are the risk factors of PMPS. Age, radiotherapy and chemotherapy affect the pain degree of PMPS during movement.

CONCLUSIONS

For breast cancer patients with high risk factors, pain should be actively prevented during perioperative period. Oral pharmacological agents, multidisciplinary combination therapy, local anesthetics and regional anesthesia are the most common treatment of PMPS.

Effects of ultrasound-guided erector spinae plane block with dexmedetomidine combined with ropivacaine of the same dose and different concentrations on analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung: a prospective, randomized, controlled trial

Objective

To investigate the analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung under erector spinae plane (ESP) block with dexmedetomidine combined with the same dose and different concentrations of ropivacaine.

Methods

Seventy patients undergoing thoracoscopic wedge resection were randomly divided into groups A (n = 35) and B (n = 35). To perform ESP block, the groups were administered dexmedetomidine (0.5 μg/kg) combined with 30 mL of 0.33% ropivacaine or 20 mL of 0.5% ropivacaine, respectively, half an hour before general anesthesia induction. We compared the onset time of anesthesia, the block level, and the duration of the block between the two groups. The number of compressions of the analgesic pump within 24 h and 48 h postoperatively and the time of the first compression were noted. The visual analog scale (VAS) scores of static and cough at 0.5 h, 6 h, 12 h, 24 h, and 48 h postoperatively were noted. Furthermore, the 40-item quality of recovery questionnaire (QoR-40) score was recorded at 24 h postoperatively. In addition, we noted the time taken to get out of the bed for the first time, the length of hospital stay, analgesia satisfaction, and the occurrence of related adverse reactions and complications within 48 h postoperatively.

Results

The range of ESP block was wider in Group A than in Group B (P < 0.05). Group B had a significantly shorter onset time (P < 0.05) and lower static and cough VAS scores at 6 h and 12 h postoperatively (P < 0.05); this was associated with significantly fewer compressions of the analgesic pump within 24 h and 48 h postoperatively and significantly more time until the first compression of the analgesic pump was required (P < 0.05). Group B was associated with significantly superior QoR-40 scores 24 h postoperatively and significantly shorter time to get out of the bed for the first time than Group A (P < 0.05).

Conclusion

Dexmedetomidine combined with 0.5% ropivacaine for ESP block is better than 0.33% ropivacaine for overall analgesia and postoperative rehabilitation of patients undergoing thoracoscopic wedge resection.

Trial registration

ChiCTR2200058114, Date of registration: 30/03/2022.

Erector Spinae Plane Block Versus PECS Block Type II for Breast Surgery: A Randomized Controlled Trial

Background: Regional anesthetic techniques are the primary analgesic techniques in breast cancer surgery. Novel techniques include the pectoralis (PECS) block and the erector spinae plane (ESP) block. Objectives: This study compared the analgesic efficacy of ultrasound-guided ESP and PECS-II blocks in patients undergoing unilateral modified radical mastectomy (MRM). Methods: The current prospective randomized controlled trial investigated 60 females scheduled for unilateral MRM under general anesthesia. The participants were randomized into two groups, namely a single-shot ESP block (n = 30) and a PECS-II block (n = 30). The ESP block was conducted at the level T4 using an in-plane approach. A volume of 20 ml of bupivacaine 0.25% was administered in both blocks. The outcome measures were total morphine consumption, analgesia duration, postoperative pain intensity, and nausea and vomiting. Results: More ESP participants required rescue morphine analgesia than those in the PECS group (P = 0.028). The ESP group showed significantly higher total morphine consumption (P = 0.005) and a shorter time to request analgesia (P = 0.003). Pain intensity was higher in the ESP group 1, 2, and 6 hours after the surgery. Conclusions: The PECS-II block is more effective in postoperative pain control after breast cancer surgery than the ESP block. It also prolongs the duration of analgesia and reduces the need for morphine 24 hours after the surgery.

Erector Spinae Plane Block in Abdominal Surgery: A Meta-Analysis

Background

Abdominal surgery is one of the most definitive and mainstay treatment options for abdominal pathologies in clinical practice. Acute postoperative pain is a major challenge in the postoperative period. Although opioids are commonly used for analgesia after major abdominal surgeries, they can lead to side effects, such as nausea and vomiting, constipation, pruritus, and life-threatening respiratory depression. Regional anesthetic techniques are commonly used to prevent or minimize these side effects. The objective of this meta-analysis is to assess the effectiveness of erector spinae plane block (ESPB) and standard medical (no block) pain management after major abdominal surgeries.

Methods

We searched for articles reporting the results of randomized controlled trials on ESPB and no block in pain control published before May 2021.

Results

The systematic search initially yielded 56 publications, 49 articles were excluded, and seven randomized clinical trials were included and analyzed. We extracted the data on postoperative opioid consumption, the efficacy of pain relief, time to the first opioid demand, and the rate of postoperative complications in the ESPB group and no block group.

Conclusions

Opioid requirement and time to first analgesic request were significantly reduced in the ultrasound-guided ESPB group, but pain scores, nausea, and vomiting did not differ significantly after pooling the results of the block and no block studies. There were no reports on serious complications related to ESPB.

New techniques of regional anaesthesia for renal laparoscopic surgeries

Renal procedures are performed within the realm of urology, general and transplant surgery. The implementation of new operating techniques imposes on anaesthetists the need to adapt their methods, aiming to improve the patient's perioperative comfort and safety. Laparoscopy is gaining increasing interest as a less invasive procedure; however clinical research shows that pain after the procedure is underestimated and therefore poorly controlled. Multimodal analgesia is very promising, though, as it allows better pain control, expedites discharge and enhances recovery. This is achieved through a combination of general and regional anaesthesia with administration of adjuvant drugs intraoperatively, resulting in reduced opioid requirements in the recovery room with diminished side effects of pain treatment. Good communication between the surgeon and the anaesthetist is the key to effective anaesthesia and analgesia.

Erector Spinae Plane Block. A narrative review

The erector spinae plane (ESP) block is an interfascial block described in 2016 by Forero and collaborators, with wide clinical uses and benefits when it comes to analgesic control in different surgeries. This block consists of the application of local anesthetic (LA) in a deep plane over the transverse process, anterior to the erector spinae muscle in the anatomical site where dorsal and ventral branches of the spinal nerve roots are located. This review will cover its clinical uses according to different surgical models, the existing evidence and complications described to date.

Ultrasound-guided bilateral erector spinae plane block in laparoscopic colon cancer surgery : A randomized controlled prospective trial

BACKGROUND

The efficacy of erector spinae plane block (ESPB) for pain control in other surgeries remains an interesting topic of discussion. This study aimed to evaluate the safety and efficacy and quality of recovery of ultrasound-guided bilateral ESPB in laparoscopic surgery for colon cancer.

MATERIAL AND METHODS

In this study 50 patients were included and randomly divided into the intervention group (E group, n = 25) and the control group (C group, n = 25). Patients in the E group received general anesthesia with preoperative bilateral ultrasound-guided ESPB, whereas patients in the C group received general anesthesia with saline injection in the erector spinae plane preoperatively. Data on intraoperative and postoperative anesthetic effects and the effect on enhanced recovery after surgery were recorded and analyzed.

RESULTS

Rocuronium consumption in the intervention group was 82.80 ± 21.70 mg, which was lower than that in the control group (P < 0.05). Visual analog scale scores at 2, 6, and 24 h after surgery in the intervention group were lower than those in the control group (F_between = 34.034, P = 0.000). The time to ambulation, consumption of ketorolac tromethamine, time to oral intake and hospital stay after operation in the intervention group were significantly lower than those in the control group (P < 0.05). The block area at the different baselines was significant (F_between = 3.211, P = 0.009). The association between baseline and time was significant (F_{baseline * time} = 3.268, P = 0.001).

CONCLUSION

This study confirmed that ultrasound-guided ESPB technology is safe and beneficial for patients with colon cancer undergoing laparoscopic colon surgery.

Erector Spinae Blocks for Spine Surgery: Fact or Fad? Systematic Review of Randomized Controlled Trials

BACKGROUND

Patients undergoing spine surgery may experience substantial postoperative pain. The aim of this systematic review is to examine the clinical efficacy of a newly introduced regional anesthetic block, the erector spinae plane block (ESPB), for adults undergoing posterior spine surgeries.

METHODS

A formal systematic database search was conducted in PubMed, Ovid Medline, Embase, Cochrane library, and Google Scholar for randomized controlled trials comparing ESPB with control or placebo.

RESULTS

Our systematic review demonstrates a reduction of postoperative pain and opioid consumption in patients who had ESPB compared with control groups for lumbar spine surgery. However, the effect obtained revealed only a short-term benefit.

CONCLUSIONS

Current evidence is insufficient to support the widespread use of ESPB for spine surgery. More studies are warranted to confirm or refute its role in clinical practice.

Effects of ultrasound-guided erector spinae plane block on the immune function and postoperative recovery of patients undergoing radical mastectomy

BACKGROUND

To explore the effects of ultrasound-guided erector spinae plane (ESP) block on the immune function and postoperative recovery of patients undergoing radical mastectomy.

METHODS

One hundred and four patients with breast cancer were randomly divided into the observation group and control group, with 52 cases in each group. The control group underwent induction of routine general anesthesia and thoracic paravertebral block, while the observation group underwent ultrasound-guided ESP block combined with general anesthesia. The recovery of autonomous respiration, eye opening, extubation time, postoperative eating, first anal exhaust, leaving bed and hospitalization time in both groups were statistically analyzed after surgery. The immune function indexes [CD4+, CD8+, interferon-γ (IFN-γ)] and the expression levels of serum neuropeptide Y (NPY), prostaglandin E2 (PGE2) and serotonin (5-HT) were compared between the two groups at 24 and 48 h before and after surgery. The visual analog scale (VAS) scores at rest and during exercise were recorded at 6, 12, 24, and 48 h after surgery.

RESULTS

There was no significant difference in the recovery of autonomous respiration, eye opening, and extubation time between the two groups (P>0.05). However, postoperative eating, first anal exhaust, leaving bed, and hospitalization time in the observation group were shorter than those in the control group (P<0.05). At 24 and 48 h after surgery, compared with the control group, CD4+ and IFN-γ levels were increased significantly (P<0.05), CD8+ and levels of serum NPY, PGE2, 5-HT and the incidence of postoperative complications was decreased significantly in the observation group (P<0.05). VAS scores at rest and during exercise in the observation group were lower than those in the control group (P<0.05). At 5 and 10 min after intubation, the observation group had higher epinephrine (E) level and lower serum cortisol (Cor) level than the control group (P<0.05).

CONCLUSIONS

The analgesic effect of ultrasound-guided ESP block is significant after radical mastectomy. There are few adverse reactions and few effects on immune function, and it can promote the postoperative recovery of patients.

Use of Erector Spinae Fascial Plane Blocks in Enhanced Recovery for Open Abdominal Surgery

BACKGROUND

Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery.

MATERIALS AND METHODS

This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared.

RESULTS

Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P< 0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019).

CONCLUSIONS

ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic liver resection: A prospective, randomised controlled, patient and observer-blinded study

BACKGROUND

Erector spinae plane block (ESPB) has been reported to manage postoperative pain effectively after various types of surgery. However, there has been a lack of study on the effect of ESPB after liver resection.

OBJECTIVES

To investigate the analgesic effects of ESPB on pain control after laparoscopic liver resection compared with conventional pain management.

DESIGN

Prospective, randomised controlled study.

SETTING

A single tertiary care centre from February 2019 to February 2020.

PATIENTS

A total of 70 patients scheduled to undergo laparoscopic liver resection.

INTERVENTIONS

In the control group (n = 35), no procedure was performed. In the ESPB group (n = 35), ESPB was performed after induction of general anaesthesia. A total of 40 ml of ropivacaine 0.5% was injected at the T9 level bilaterally. After surgery, intravenous fentanyl patient-controlled analgesia was initiated. Fentanyl and hydromorphone were administered as rescue analgesics.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative postoperative opioid consumption at 24 h (morphine equivalent). The secondary outcomes were rescue opioid (fentanyl) dose in the postanaesthesia care unit (PACU) and pain severity at 1, 6, 12, 24, 48 and 72 h, assessed using a numerical rating scale (NRS) score.

RESULTS

The median [IQR] postoperative opioid consumption during 24 hours following surgery was 48.2 [17.1] mg in the control group and 45.5 [35.8] mg in the ESPB group (median difference, 4.2 mg; 95% CI, -4.2 to 13.3 mg; P = 0.259). Conversely, rescue opioid in PACU was 5.3 [5.0] mg in the control group and 3.0 [1.5] mg in the ESPB group (median difference, 2.5 mg; 95% CI, 1.0 to 5.0 mg; P < 0.001). There was no significant difference in NRS scores point between the groups at any time.

CONCLUSION

ESPB does not provide analgesic effect within 24 h after laparoscopic liver resection.

TRIAL REGISTRATION

Clinical Trial Registry of Korea (https://cris.nih.go.kr.), identifier: KCT0003549).

Mechanisms of action of fascial plane blocks: a narrative review

BACKGROUND

Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks.

OBJECTIVES

This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research.

FINDINGS

There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain.

CONCLUSION

Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Erector spinae plane block in acute interventional pain management: a systematic review

Erector Spinae Plane Block (ESPB) was described by Forero in 2016. ESPB is currently widely used in acute postoperative pain management. The benefits of ESPB include simplicity and efficacy in various surgeries. The aim of this review was to conduct a comprehensive overview of available evidence on erector spinae plane block in clinical practice. We included randomized controlled trials and systematic reviews reporting the ESPB in human subjects. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-one articles including five systematic reviews and 16 randomized controlled trials were included and analyzed. ESPB appears to be an effective, safe, and simple method for acute pain management in cardiac, thoracic, and abdominal surgery. The incidence of side effects has been reported to be rare. A critical issue is to make sure that new evidence is not just of the highest quality, in form of well powered and designed randomized controlled trials but also including a standardized and homogeneous set of indicators that permit to assess the comparative effectiveness of the application of ESPB in acute interventional pain management.

Mode of Anesthesia and Quality of Recovery After Breast Surgery: A Case Series of 100 Patients

PURPOSE

Regional anesthesia techniques may improve patient recovery beyond treating postoperative pain alone and may facilitate patients in their return to functional, psychological as well as emotional baselines. We hypothesized that the quality of recovery (QoR) experienced by patients following breast surgery was associated with the type of anesthesia received as well as the use of a regional anesthesia technique during surgery.

METHODS

We performed a single-center prospective, observational cohort study of patients undergoing elective breast procedures (both cancer and non-cancer surgery).

RESULTS

 One hundred patients completed baseline QoR-15 questionnaires prior to surgery, of which 96 also completed QoR-15 questionnaires on postoperative day 1. The median (IQR) QoR-15 score at baseline was 133 (124-141), decreasing to 121 (106.75-136.25) on postoperative day 1. In multivariable linear regression analysis, paravertebral blocks (PVB) were associated with a 16.7 point higher overall QoR-15 score on postoperative day 1 compared to no block (95% Confidence Interval [CI]: 7.7-25.8, p<0.001); while the use of combination blocks was associated with a 21.8 point higher postoperative QoR-15 score compared to no block (95% CI: 12.8-30.8, p<0.001). PVB and combination blocks were further associated with better postoperative pain, physical comfort, physical independence and emotional state scores, compared with no block. The use of total intravenous anesthetic was not associated with differences in postoperative QoR-15 score versus volatile anesthetic, after covariate adjustment.

CONCLUSION

Breast surgery patients receiving PVB or a combination of regional blocks during surgery have higher postoperative QoR-15 scores, after adjustment for other factors.

Analgesic efficacy and safety of erector spinae plane block in breast cancer surgery: a systematic review and meta-analysis

Background

Surgical resection is considered to be the primary and most effective therapy for breast cancer, postoperative pain is an issue gaining significant attention. In recent years, erector spinae plane block (ESPB) has attracted much attention in postoperative analgesia, but its effectiveness is still controversial. This meta-analysis was implemented to verify the clinical analgesic efficacy and safety of erector spinae plane block in patients undergoing breast cancer surgery.

Methods

We searched PubMed, EMBASE, Web of Science, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing ESPB with general anesthesia (GA) in breast cancer surgery that were published before December 25, 2020. The primary outcome was opioid consumption at the first 24 h after surgery, while secondary outcomes included pain scores at 1, 6,12 and 24 h after surgery, opioid consumption at 1, 6 and 12 h after surgery, intraoperative opioid consumption, number of patients who need for rescue analgesia, and the incidence of postoperative nausea and vomiting (PONV).

Results

Eleven randomized controlled trials involving 679 patients met the study inclusion criteria and were included in this study. In comparison to GA group, the ESPB group showed a significant reduction in morphine consumption at the first 24 h after surgery by a mean difference (MD) of − 7.67 mg [95% confidence interval (CI) − 10.35 to − 5.00] (P <  0.01). In addition, the ESPB group showed lower pain scores than the GA group in the four time periods (1, 6, 12 and 24 h after surgery). ESPB group significantly reduce the intraoperative consumption of fentanyl, the need for postoperative rescue analgesia, and the incidence of PONV.

Conclusions

Ultrasound-guided ESPB is an effective approach for reducing morphine consumption and pain intensity within the first 24 h after breast cancer surgery, compared with GA alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01277-x.

Perioperative Analgesic Modalities for Breast Cancer Surgeries: A Prospective Randomized Controlled Trial

Purpose

Various analgesic modalities are adopted for perioperative analgesia in breast cancer surgeries. This study aimed to compare the efficacy of intravenous morphine versus serratus anterior plane block (SAPB) and erector spinae plane block (ESPB) in breast cancer surgeries.

Patients and Methods

Seventy-five breast cancer patients undergoing modified radical mastectomy from January 2020 to June 2020 were randomly allocated into 3 groups; the morphine group received morphine 0.1 mg/kg, the SAPB group received ultrasound-guided SAPB with 25 mL bupivacaine 0.25% and the ESPB group received ultrasound-guided ESPB with 25 mL bupivacaine 0.25%. A visual analogue scale (VAS) 0–10 was used to evaluate pain postoperatively, where 0 denotes no pain and 10 worst pain. If any patient in the 3 studied groups reported breakthrough pain with VAS ≥ 4 then a bolus of 3 mg morphine was given.

Results

There was no difference in VAS scores between the 3 groups postoperatively. Morphine consumption was higher in the morphine group (9.19 ± 2.32 mg) than the SAPB group (4.00 ± 1.55 mg) and the ESPB group (4.20 ± 1.64 mg), respectively. First time to receive postoperative morphine was significantly longer for the ESPB and SAPB groups than the morphine group (20.40 ± 4.98 hours), (19.00 ± 5.9 hours), (5.00 ± 4.62 hours), respectively. Intraoperative hemodynamics and fentanyl consumption showed no difference between groups, whereas postoperative mean arterial blood pressure values at 2 and 4 hours were higher in the morphine group. Ramsay sedation score and postoperative nausea and vomiting values in the post anesthesia care unit were higher for the morphine group compared to the SAPB and ESPB groups. No complications related to the blocks were reported.

Conclusion

SAPB and ESPB can be used as an effective and safe alternative to opioids with fewer side effects in breast cancer patients undergoing modified radical mastectomy.

Trial Registration

This trial was prospectively registered at Clinical Trials.gov on 22 January 2020 with registration number NCT04248608 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JS5&selectaction=Edit&uid=U0004LIG&ts=7&cx=−81xkwa).

Statistically significant but clinically unimportant: a systematic review and meta-analysis of the analgesic benefits of erector spinae plane block following breast cancer surgery

The novel erector spinae plane block (ESPB) has been reported to provide important postoperative analgesic benefits following a variety of truncal and abdominal surgical procedures. However, evidence of its analgesic efficacy following breast cancer surgery, compared with parenteral analgesia, is unclear. This meta-analysis evaluates the analgesic benefits of adding ESPB to parenteral analgesia following breast cancer surgery.Databases were searched for breast tumor resection trials comparing ESPB to parenteral analgesia. The two co-primary outcomes examined were 24-hour postoperative oral morphine equivalent consumption and area-under-curve of rest pain scores. We considered reductions equivalent to 3.3 cm.h and 30 mg oral morphine in the first 24 hours postoperatively for the two co-primary outcomes, respectively, to be clinically important. We also assessed opioid-related side effects and long-term outcomes, including health-related quality of life, persistent postsurgical pain and opioid dependence. Results were pooled using random effects modeling.Twelve trials (699 patients) were analyzed. Moderate quality evidence suggested that ESPB decreased 24-hour morphine consumption and area-under-curve of rest pain by a mean difference (95% CI) of -17.60 mg (-24.27 to -10.93) and -2.74 cm.h (-3.09 to -2.39), respectively; but these differences were not clinically important. High-quality evidence suggested that ESPB decreased opioid-related side effects compared with parenteral analgesia by an OR (95% CI) of 0.43 (0.28 to 0.66). None of the studies evaluated long-term block benefits.Adding ESPB to parenteral analgesia provides statistically significant but clinically unimportant short-term benefits following breast cancer surgery. Current evidence does not support routine use of ESPB. Given the very modest short-term benefits and risk of complications, the block should be considered on a case-by-case basis.

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.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis

The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) -1.63 (-2.97 to -0.29), 6 studies, 329 patients, high-quality evidence, I²  = 98%, p = 0.02); at 6 hours (mean difference (95% CI) -0.90 (-1.49 to -0.30), 5 studies, 250 patients, high-quality evidence, I²  = 91%, p = 0.003); at 12 hours (mean difference (95% CI) -0.46 (-0.67 to -0.25), 5 studies, 250 patients, high-quality evidence, I²  = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) -0.50 (-0.70 to -0.30), 6 studies, 329 patients, high-quality evidence, I²  = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) -21.55mg (-32.57 to -10.52), 7 studies, 429 patients, high-quality evidence, I²  = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.

The erector spinae plane block causes only cutaneous sensory loss on ipsilateral posterior thorax: a prospective observational volunteer study

BACKGROUND

Ultrasound-guided erector spine plane (ESP) block is widely used in perioperative analgesia for back, chest and abdominal surgery. The extent and distribution of this block remain controversial. This study was performed to assess the analgesia range of an ultrasound-guided ESP block.

METHODS

This prospective observational volunteer study consisted of 12 healthy volunteers. All volunteers received an erector spinae plane block at the left T5 transverse process using real-time ultrasound guidance. Measured the cutaneous sensory loss area (CSLA) and cutaneous sensory declination area (CSDA) using cold stimulation at different time points after blockade until its disappearance. The CSLA and CSDA were mapped and then calculated. The block range was described by spinous process level and lateral extension. The effective block duration for each volunteer was determined and recorded.

RESULTS

The cold sensory loss concentrates at T6-T9. The decline concentrates primarily at T4-T11. The lateral diffusion of block to the left side did not cross the posterior axillary line, and reached the posterior median line on the right. The area of cutaneous sensory loss was (172 ± 57) cm², and the area of cutaneous sensory decline was (414 ± 143) cm². The duration of cutaneous sensory decline was (586 ± 28) minutes.

CONCLUSION

Ultrasound-guided erector spine plane block with 20 mL of 0. 5% ropivacaine provided a widespread cutaneous sensory block in the posterior thorax, but did not reach the anterior chest, lateral chest, or abdominal walls. The range of the blockade suggested that the dorsal branch of spinal nerve was blocked.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, CHiCTR1800014438. Registered 13 January 2018.

Safe and Effective Use of Bilateral Erector Spinae Block in Patient Suffering from Post-Operative Coagulopathy Following Hepatectomy

Patient: Male, 75-year-old

Final Diagnosis: Cholangiocarcinoma

Symptoms: Postoperative pain

Medication:—

Clinical Procedure: Continuous erector spinae nerve block

Specialty: Oncology

Efficacy of single-shot ultrasound-guided erector spinae plane block for postoperative analgesia after mastectomy: A randomized controlled study

Background

The aim of this study is to understand the effect of ultrasound (US) guided erector spinae plane block (ESPB) in improving the intraoperative and postoperative analgesia in patients undergoing mastectomies, decreasing the use of opioids and in reducing postoperative nausea and vomiting.

Methods

After local ethics committee approval, 100 patients were divided randomly into two groups. Group A with 50 patients received US guided ESPB with 30 ml of 0.25% of bupivacaine under US guidance. Group B with 50 patients received no block. Visual analogue scale (VAS) was used to assess pain postoperatively. All patients received 1 g intravenous intravenous paracetamol 8th hourly and morphine was used as rescue analgesia if VAS score is more than 4. Patients were monitored for VAS scores, postoperative nausea/ vomiting and total morphine consumption for a 24-hour period in a high dependency unit.

Results

Postoperative morphine consumption was found to be significantly less in patients who received US-guided ESPB compared to control group (0.12 mg ± 0.59 mg in ESPB group compared to 1.70 ± 2.29 mg which was statistically significant, p=0.000). Only 3 patients in ESP group received rescue analgesia in the form of morphine whereas 22 patients in the control group received morphine. There was no difference in PONV score in either groups. There were no complications like vascular puncture, pneumothorax, or respiratory depression in both groups.

Conclusion

US guided ESPB is quite effective in reducing perioperative pain in patients undergoing mastectomy. The trial was registered prospectively with CTRI with registration number: CTRI/2018/09/015668.

Role of erector spinae plane block versus paravertebral block in pain control after modified radical mastectomy. A prospective randomised trial

BACKGROUND AND AIMS

Thoracic paravertebral block (TPVB) provides effective analgesia in breast surgery. Recently, use of erector spinae plane block (ESPB) in controlling post-operative pain has proved effective. This study aimed to compare the effect of ESPB with TPVB in post-mastectomy acute pain control.

METHODS

A prospective, randomised double-blinded study enrolled 70 adult female patients, scheduled for modified radical mastectomy. Patients were randomised into two groups, receiving 20 ml of 0.25% bupivacaine: group I (TPVB) and group II (ESPB). Post-operative 24 h morphine consumption, intra-operative fentanyl consumption, time of the first request for analgesia and post-operative visual analogue scale (VAS), heart rate (HR), mean blood pressure (MBP) and complications were recorded.

RESULTS

Post-operative 24 h morphine consumption and time of the first request for analgesia were comparable between both groups (P = 0.32 and 0.075, respectively). There was no significant difference in the intra-operative fentanyl consumption. There was also no significant difference in VAS between both groups over the 24 h of study. Four patients in group I developed pneumothorax with no significant differences between both groups (P = 0.114). Incidence of nausea and vomiting was comparable between both groups. All patients displayed a stable haemodynamic profile.

CONCLUSION

Both TPVB and ESPB can be effectively used in controlling post-mastectomy pain and reduce intra-operative and post-operative opioid consumption.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.