Comparison between erector spinae plane block and paravertebral block regarding postoperative analgesic consumption following breast surgery: a randomized controlled study

The analgesic efficacy of erector spinae plane block versus paravertebral block in thoracic surgeries: a meta-analysis

Background

Acute postoperative pain after thoracic surgery might lead to chronic postsurgical pain (PSP), which lowers quality of life. The literature suggests thoracic paravertebral block (PVB) as a pain management approach. The ESPB (erector spinae plane block) is regarded to be an effective PVB alternative. The analgesic efficacy of the two analgesic therapies is controversial. The purpose of this study is to compare the analgesic efficacy of ESPB and PVB in preventing acute PSP.

Methods

We searched relevant articles in PubMed, Cochrane Library, Embase, Web of Science, and Google Scholar databases. The primary outcome was postoperative pain score, with secondary outcomes including analgesic consumption, the frequency of rescue analgesia, and postoperative nausea and vomiting.

Results

This meta-analysis included ten RCTs with a total of 670 patients. PVB significantly lowered the pain scores at movement at 12 h following surgery as compared to the ESPB. The PVB group used much less opioids within 24 h after surgery compared to the ESPB group. However, there were no significant differences between the groups in terms of postoperative rescue analgesia or in the incidence of postoperative nausea and vomiting (p > 0.05).

Conclusion

PVB produced superior analgesia than ESPB in patients who underwent thoracic surgeries. In addition, PVB demonstrated greater opioid sparing effect by consuming much less opioids.

Systematic review registration

This trial is registered on PROSPERO, number CRD42023412159.

Blockade of intercostobrachial nerve by an erector spinae plane block at T2 level: a case report

BACKGROUND

The intercostobrachial nerve blockade is required, in addition to brachial plexus block, to anesthetize the entire upper arm. No studies have described the use of erector spinae plane (ESP) block for an intercostobrachial nerve block.

CASE PRESENTATION

A 72-year-old man was scheduled to undergo left brachial vein transposition-arteriovenous fistula creation for hemodialysis access. An ultrasound-guided infraclavicular brachial plexus block was performed using a mixture of 0.5% levobupivacaine (12.5 ml) and 2% lidocaine (12.5 ml). An ESP block was implemented using 10 ml of the same local anesthetic at the T2 level. A pinprick test showed that the entire upper arm and lateral aspect of the left upper chest wall were anesthetized 20 min after the blocks. Surgery was successfully performed without the need for general anesthesia.

CONCLUSIONS

In the present case, an ESP block performed at the T2 level provided sensory loss of the area innervated by the intercostobrachial nerve.

Erector spinae plane block versus paravertebral block in analgesic outcomes following breast surgery

This article represents the response to the inquiries adopted by Dr. Raghuraman M Sethuraman, M.D., regarding our recently published study which compared the erector spinae plane block (ESPB) versus paravertebral block (PVB) regarding postoperative analgesic consumption following breast surgeries (Elewa et al, BMC Anesthesiol 22: 1-9, 2022). We would like to introduce our appreciation and gratitude to the author for his interest in our work, despite being inaccurate in some of his comments.

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.

Erector spinae plane block versus paravertebral block in breast surgeries

This article (Correspondence) is in response to the recently published study by Elewa et al. in BMC Anesthesiology that compared the erector spinae plane block (ESPB) versus paravertebral block (PVB) regarding postoperative analgesic consumption following breast surgeries. I greatly appreciate the authors for publishing this study which is one among a very few studies available on this topic. I wish to present my reflections on this article as well as add a few more points on this topic.

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).