Anesthetic Techniques: Focus on Lumbar Erector Spinae Plane Block

Relationship between injectate volume and disposition in erector spinae plane block: a cadaveric study

INTRODUCTION

Erector spinae plane (ESP) blocks can be used to provide analgesia following thoracoabdominal and lumbar spine surgical procedures. However, the influence of injectate volume and injection location on the spread of anesthetic with ESP blocks remain unclear.

METHODS

Ultrasound-guided ESP injections were performed on two fresh cadavers using a solution of iopamidol radiographic contrast, indocyanine green or methylene blue dye, and saline. The relationship between injectate volume and cephalocaudal spread was assessed using real-time fluoroscopic recordings after incremental ESP injections to the lumbar and thoracic region. Cadavers were then dissected to expose tissue staining and document the precise disposition of the dye within the ES muscle, paravertebral space, dorsal and ventral rami, and other relevant structures.

RESULTS

Larger injection volumes resulted in more extensive cephalocaudal spread in most cases, with fluoroscopic images revealing a small but direct relationship between injectate volume and contrast spread. Dissection reinforced the radiographic findings, with staining ventral to the ES muscle ranging from 4 to 7 paravertebral levels with injections of 30-40 mL vs 12-13 levels following injections of 60-80 mL. No spread of dye to the lamina, transverse processes, paravertebral space, epidural space, or pleura was observed following any injection.

CONCLUSIONS

Increased ESP injection volumes resulted in more extensive cephalocaudal spread, resulting in anesthetic spread to the dorsal rami and ventral ES muscle without involvement of the ventral rami or other anterior structures. Injection volumes of 30 mL may be optimal for ESP blocks requiring analgesia across 4-7 levels.

Surgical vs ultrasound-guided lumbar erector spinae plane block for pain management following lumbar spinal fusion surgery

PURPOSE

Spinal surgery is associated with severe diffuse pain in the postoperative period. Effective pain management plays an essential role in reducing morbidity and mortality. This study is designed to compare the ultrasound-guided erector spinae plane (ESP) block and surgical infiltrative ESP block for postoperative analgesia management after lumbar spinal fusion surgery.

METHODS

The patients who underwent two or three levels of posterior lumbar spinal fusion surgery were randomly allocated into one of three groups with 30 patients each (Group SE = Surgical ESP block; Group UE = ultrasound-guided ESP block; Group C = Controls). The primary aim was to compare postoperative opioid consumption, and the secondary aim was to evaluate postoperative dynamic and static pain scores and the incidence of opioid-related adverse effects.

RESULTS

There was a significant difference in terms of opioid consumption, rescue analgesia on demand, and both static and dynamic pain scores between groups at all time periods (p < 0.05). Group SE and Group UE had lower pain scores and consumed fewer opioids than the controls (p < 0.05). However, the Group UE had lower pain scores and opioid consumption than the Group SE. The sedation level of patients was significantly higher in the control group than in the other two groups. Also, nausea was more common in controls than in the other groups.

CONCLUSION

While both surgical and ultrasound-guided ESP blocks reduced opioid consumption compared to the controls, the patients who received ultrasound-guided ESP blocks experienced better postsurgical pain relief than those in the other groups (surgical ESP and controls).

The efficacy of lumbar erector spinae plane block for postoperative analgesia management in patients undergoing lumbar unilateral bi-portal endoscopic surgery: a prospective randomized controlled trial

BACKGROUND

The efficacy and reliability of erector spinae plane block (ESPB) in posterior open lumbar spine surgery has been demonstrated; however, few randomized controlled trials of lumbar ESPB (L-ESPB) in lumbar unilateral bi-portal endoscopic (UBE) surgery have been reported.

METHODS

A total of 120 patients, aged 18 to 65 (who underwent elective lumbar UBE surgery under general anesthesia and exhibited an American Society of Anesthesiologists physical status of I to III) were randomly assigned in a 1:1 ratio to the ESPB group and the Control group. Ultrasound(US)-guided unilateral single-shot 0.25% ropivacaine L-ESPB was performed in the ESPB group, but not in the control group. Postoperative analgesic strategy for all patients: patient controlled intravenous analgesia (PCIA, diluted and dosed with fentanyl alone) was initiated immediately after surgery combined with oral compound codeine phosphate and ibuprofen sustained release tablets (1 tablet containing ibuprofen 200 mg and codeine 13 mg, 1 tablet/q12h) commenced 6 h postoperatively. We collected and compared patient-centred correlates intraoperatively and 48 h postoperatively. The primary outcomes were intraoperative and postoperative opioid consumption and postoperative quality of recovery-15 (QoR-15) scores.

RESULTS

Compared to the control group (n = 56), the ESPB group (n = 58) significantly reduced intraoperative remifentanil consumption (estimated median difference - 280 mcg, 95% confidence interval [CI] - 360 to - 200, p < 0.001, power = 100%); significantly reduced fentanyl consumption at 24 h postoperatively (estimated median difference - 80mcg, 95%[CI] - 128 to - 32, p = 0.001, power = 90%); and significantly enhanced the QoR-15 score at 24 h postoperatively (estimated median difference 11, 95%[CI] 8 to 14, p < 0.001, power = 100%). Compared to the control group, the ESPB group enhanced the resting numeric rating scale (NRS) score up to 8 h postoperatively, and the active movement NRS score up to 4 h postoperatively. The incidence of postoperative nausea and vomiting (PONV) (p = 0.015, power = 70%), abdominal distension (p = 0.024, power = 64%), and muscular calf vein thrombosis (MCVT) (p = 0.033, power = 58%) was lower in the ESPB group than in the control group. Moreover, the occurrence of L-ESPB related adverse reactions was not found herein.

CONCLUSION

US-guided L-ESPB reduces intraoperative and 24 h postoperative opioid consumption and improves patients' QoR-15 scores at 24 h postoperatively. L-ESPB can be safely and effectively utilized in lumbar UBE surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200061908 , date of registration: 10/07/2022. Registry URL.

Continuous Ultrasound-Guided Lumbar Erector Spinae Plane Block for Thigh Cellulitis Analgesia: A Case Report

The management of refractory acute medical pain can be challenging, especially if severe and decompensated systemic pathologies contraindicate neuraxial techniques and deep peripheral blocks. In this case report, we propose a continuous ultrasound-guided lumbar erector spinae plane block (ESPB) for multimodal analgesia of thigh cellulitis. The patient was an 80-year-old male, admitted to the intensive care unit due to septic shock originating from cellulitis of the right lower limb, associated with multiorgan dysfunction. To address refractory pain in the thigh, an ultrasound-guided lumbar ESPB at L3 was performed, with the placement of a perineural catheter and administration of 30 mL of 0.5% ropivacaine, followed by 30 mL boluses of 0.375% ropivacaine every six hours with progressive weaning. The patient maintained controlled pain without the need for rescue analgesia. Continuous ultrasound-guided lumbar ESPB is an effective and safe alternative for thigh analgesia in patients with refractory acute medical pain and systemic pathologies that contraindicate other regional techniques.

Comparison of Intrathecal Morphine Versus Erector Spinae Plane Block for Perioperative Analgesia in Patients Undergoing Lumbar Spine Surgery: A Randomized Control Trial

BACKGROUND

Lumbar spine surgery is associated with a significant degree of moderate-to-severe perioperative pain which can be alleviated by using different pain-relieving modalities; of these, erector spinae plane block and intrathecal morphine have promise.

PURPOSE

To compare the analgesic efficacy between intrathecal morphine (ITM) versus erector spinae plane block (ESPB) for perioperative analgesia in patients undergoing lumbar spine surgery.

METHOD

A total of 74 patients aged between 20 and 65 years of either sex were posted for elective lumbar spine surgery. Patients were divided into two groups: Group A patients received 0.3 mg intrathecal morphine and Group B received bilateral erector spinae plane block at L3 level by using 30 mL of 0.5% ropivacaine before starting the surgery for perioperative analgesia. In the perioperative period, pain was assessed by hemodynamic parameters (heart rate and mean arterial pressure), numeric rating scale (NRS), and patient satisfaction score.  Result: The difference in heart rate and mean arterial pressure was found to be statistically significant between groups at three, six, 12, and 24 hours (p<0.05). The patients who required rescue analgesia in Group A and Group B were 23 (62.2%) and 37 (100%) patients in the first 24 hours. The rate of complication was higher in Group A than in Group B (45% vs 5.4%). The patient satisfaction score was found to be better in Group A than in Group B.

CONCLUSION

Intrathecal morphine provides more substantial and extended analgesia up to 48 hours postoperatively as compared to erector spinae plane block.

Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study

Background

Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy.

Objectives

This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches.

Materials and methods

Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05).

Results

Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015).

Conclusion

ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.

Narrative review: erector spinae block in spine surgery

Background

Lumbar spine surgery is an ever-increasing procedure with multiple analgesia techniques utilized for postoperative pain control. More recently, erector spinae plane (ESP) blocks have been used to limit the use of opioids after surgery. The authors aimed to review the current literature on ESP blocks and its potential use in the outpatient setting.

Methods

Several randomized controlled trials were evaluated that compared erector spinae block to traditional anesthesia where the primary outcome of postoperative opioid use was assessed. Randomized control trials comparative studies were also evaluated to assess erector spinae block effect on outpatient procedures. Secondary outcomes include, postoperative pain, patient satisfaction, patient length of stay, and post-operative complications.

Key Content and Findings

Erector spinae block was found in general to lower postoperative opioid use compared to traditional anesthesia. In addition, the authors found improved patient satisfaction and less postoperative pain in the erector spinae cohort. Post-operative complications were lower in the erector spinae block group compared to traditional anesthesia, especially in regards to vomiting and nausea.

Conclusions

While these studies do possess their limitations due to the low number of randomized control studies on erector spinae block, early data does suggest that erector spinae block appears to be superior to that of traditional anesthesia for those undergoing spine surgery.

Erector spinae plane block versus local infiltration anaesthesia for transforaminal percutaneous endoscopic discectomy: A prospective randomised controlled trial

BACKGROUND

Around 60%-80% of the population suffers from back pain, making it one of the most common health complaints. Transforaminal percutaneous endoscopic discectomy (TPED) is an effective treatment for low back pain that can be performed using different anaesthesia techniques. Our primary objective was to test the hypothesis that bilateral Erector spinae plane block (ESP) plus sedation is equally effective as traditional local infiltration anaesthesia plus sedation in TPED.

MATERIALS AND METHODS

Fifty-two patients undergoing TPED were randomly assigned to 2 groups: G1 - intravenous sedation with local infiltration anaesthesia; G2 - intravenous sedation with bilateral ESP.

PRIMARY OUTCOME

volume of fentanyl and propofol administered during surgery.

SECONDARY OUTCOMES

adverse events during sedation reported using the World Society of Intravenous Anaesthesia (SIVA) adverse sedation event tool, level of postoperative sedation measured on the Richmond Agitation-Sedation Scale (RASS), intensity of postoperative pain on a visual analogue scale (VAS), mechanical pain threshold (MPT) measured with von Frey monofilaments on both lower extremities, patient satisfaction with analgesia on 5-point Likert scale.

RESULTS

Volume of fentanyl, propofol, and level of postoperative sedation was significantly lower in G2 (p < 0.001). There was no difference between groups in intensity of pain, patient satisfaction with analgesia, and mechanical pain threshold after surgery. There were no adverse events in G2, but in G1 2 patients presented minimal risk descriptors, 5 presented minor risk descriptors, and 1 presented sentinel risk descriptors that required additional medication or rescue ventilation.

CONCLUSIONS

The ESP was equal to local infiltration anaesthesia in terms of intensity of pain, mechanical pain threshold after surgery, and patient satisfaction; however, ESP reduced the volume of intraoperative fentanyl and propofol, thereby reducing the adverse effects of sedation.

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) levels following erector spinae plane block (ESPB) in posterior lumbar decompression: a randomized, controlled trial

PURPOSE

Neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are the inflammatory biomarkers of the stress response. In this study, we aimed to evaluate the effects of erector spinae plane block (ESPB) on posterior lumbar decompression and stabilization by comparing NLR, PLR, postoperative pain, opioid consumption, and functional recovery between sham block and ESPB.

METHODS

This was a prospective, double-blinded, randomized controlled trial in a tertiary referral hospital. Sixty patients were randomized into two equal groups, each receiving either a sham block or ESPB. The primary outcome was the NLR and PLR 12 h and 24 h after lumbar posterior decompression and stabilization. The secondary outcomes were total opioid consumption and pain score 24 h postoperatively. Also, functional recovery determined by getting out of bed, verticalization, and walking by the balcony were reviewed as secondary outcomes.

RESULTS

Significant differences existed between the sham block and ESPB group in NLR (29.08 ± 12.29 vs. 16.97 ± 10.38; p < 0.0001) and PLR (556.77 ± 110.32 vs. 346.43 ± 117.34; p < 0.0001) 12 h after surgery. Also, there was a significant difference in NLR (p = 0.0466) and PLR (p < 0.0001) 24 h after surgery. In addition, there was a substantial difference in pain score, total opioid consumption, and functional recovery.

CONCLUSION

ESPB performance during spinal surgery lowers NRL and PLR ratios 12 h and 24 h after surgery. In addition, ESPB provides better analgesia and improves functional recovery compared to sham block following posterior lumbar decompression and stabilization.

Ultrasound guided lumbar erector spinae block: A case series on a novel technique for the treatment of acute low Back pain

Low back pain is among one of the most common presentations to the emergency department (ED). Regional anesthesia has recently gained traction as an option for analgesia in ED patients, especially in the wake of the opioid epidemic. Data on lumbar application of the ESPB in the setting of acute, refractory low back pain in the ED is scarce. We describe a series of three cases of patients who presented to the ED with severe low back pain refractory to traditional therapy, successfully treated using lumbar ESPB. Lumbar ESPB may be an effective approach to achieving rapid analgesia in patients who present with low back pain who may otherwise be poor candidates for more traditional therapy, such as with opioids or NSAIDs, or who may have refractory pain despite use of these medications.

Erector Spinae Plane Block and Chronic Pain: An Updated Review and Possible Future Directions

Chronic pain is a common, pervasive, and often disabling medical condition that affects millions of people worldwide. According to the Global Burden of Disease survey, painful chronic conditions are causing the largest numbers of years lived with disability worldwide. In America, more than one in five adults experiences chronic pain. Erector spinae plane block is a novel regional anesthesia technique used to provide analgesia with multiple possible uses and a relatively low learning curve and complication rate. Here, we review the erector spinae plane block rationale, mechanism of action and possible complications, and discuss its potential use for chronic pain with possible future directions for research.

Systemic Analgesia versus Continuous Erector Spinae Plane Block (ESPB) Infusion During Paediatric Nephrectomy: A Randomized, Controlled Trial

Purpose

A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy.

Methods

Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T₉ (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours.

Results

A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points.

Conclusion

Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.

Development and validation of a nomogram for postoperative sleep disturbance in adults: a prospective survey of 640 patients undergoing spinal surgery

BACKGROUND

Postoperative sleep disturbance (PSD) is a prevalent clinical complication that may arise due to various factors. The purpose of this investigation is to identify the risk factors for PSD in spinal surgery and establish a risk prediction nomogram.

METHODS

The clinical records of individuals who underwent spinal surgery from January 2020 to January 2021 were gathered prospectively. The least absolute shrinkage and selection operator (LASSO) regression, along with multivariate logistic regression analysis, was employed to establish independent risk factors. A nomogram prediction model was devised based on these factors. The nomogram's effectiveness was evaluated and verified via the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA).

RESULTS

A total of 640 patients who underwent spinal surgery were analyzed in this investigation, among which 393 patients experienced PSD with an incidence rate of 61.4%. After conducting LASSO regression and logistic regression analyses using R software on the variables in training set, 8 independent risk factors associated to PSD were identified, including female, preoperative sleep disorder, high preoperative anxiety score, high intraoperative bleeding volume, high postoperative pain score, dissatisfaction with ward sleep environment, non-use of dexmedetomidine and non-use of erector spinae plane block (ESPB). The nomogram and online dynamic nomogram were constructed after incorporating these variables. In the training and validation sets, the area under the curve (AUC) in the receiver operating characteristic (ROC) curves were 0.806 (0.768-0.844) and 0.755 (0.667-0.844), respectively. The calibration plots indicated that the mean absolute error (MAE) values in both sets were respectively 1.2% and 1.7%. The decision curve analysis demonstrated the model had a substantial net benefit within the range of threshold probabilities between 20% and 90%.

CONCLUSIONS

The nomogram model proposed in this study included eight frequently observed clinical factors and exhibited favorable accuracy and calibration.

TRIAL REGISTRATION

The study was retrospectively registered with the Chinese Clinical Trial Registry (ChiCTR2200061257, 18/06/2022).

Erector spinae plane block: the ultimate 'plan A' block?

The erector spinae plane block (ESPB) is one of seven 'Plan A' blocks proposed by Regional Anaesthesia UK, covering the key areas of commonly encountered surgeries and acute pain. Unlike the other six blocks, the ESPB can be performed at all levels of the spine and provides analgesia to most regions of the body, leading to the argument that the ESPB is the ultimate Plan A block. Current studies show a high level of evidence supporting use in thoracoabdominal surgery but a lack of benefit in upper and lower limb surgery compared with local infiltration and other Plan A blocks. Thus, there is insufficient evidence to support the claim that the erector spinae plane block is the ultimate Plan A block.

Onset Time of Lumbar Erector Spinae Plane Block Compared with Its Thoracic Counterpart: Case Reports

The erector spinae plane block (ESPB) at the level of the fifth thoracic vertebra (T5) is a novel technique, first published in 2016, which was found to be effective in both acute and chronic pain control. The mechanism of action and spread of local anesthetic of the ESPB at the lumbar region are thought to differ from those of the thoracic ESPB; however, the difference in onset time has never been evaluated. As for the onset of lumbar ESPBs, we presented three cases: two received lumbar ESPBs (one with chronic low back pain and one with acute postoperative hip pain), and the third one with chronic back pain received a thoracic ESPB. We administered 30 mL of 0.3% ropivacaine in all three patients, but the analgesic effect did not reach its maximum until 3 and 1.5 h, respectively, in the lumbar ESPB cases. On the contrary, the thoracic ESPB case experienced noticeable pain relief within 30 min. The onset time was considerably longer than that reported in earlier reports on ESPBs, and the lumbar ESPB achieved its peak effect much later than the thoracic ESPB using the same formula of local anesthetic. While the delayed-onset lumbar ESPB may have some drawbacks for treating acute postoperative pain, it still could produce significant analgesia, once it took effect, when given to patients suffering from hip surgery with large incisions and intractable low back pain. The current data suggested that the onset time of a lumbar ESPB may be delayed compared with its thoracic counterpart. Therefore, the local anesthetic formula and injection timing should be adjusted for a lumbar ESPB when applied in the perioperative period to make the onset of the analgesic effect coincide with the immediate postoperative pain. Without this concept in mind, clinicians may consider a lumbar ESPB to be ineffective before it takes effect, and consequently treat the patients inadequately with this technique. Future randomized controlled trials should be designed according to our observations to compare lumbar ESPB with its thoracic counterpart regarding onset time.

Sacral Erector Spinae Plane Block As the Main Anesthetic Method for Parasacral Reconstructive Surgeries: A Single-Center Retrospective Cohort Feasibility Study

Study objective Sacral erector spinae plane block (ESPB) is a regional anesthesia technique defined for the blockade of the posterior branches of the sacral nerves. In this study, we aimed to retrospectively evaluate our sacral ESPB applications as an anesthetic method in patients who underwent parasacral and gluteal reconstructive surgery. Methodology The design of our study is a retrospective cohort feasibility study. This study was conducted at a tertiary university hospital, and patient files and electronic data systems were used to obtain data for analysis. In total, the data of 10 patients who underwent parasacral or gluteal reconstructive surgery were evaluated. Main results During reconstructive procedures for sacral pressure ulcers and lesions in the gluteal region, the sacral ESP block was utilized. Small doses of perioperative analgesics/anesthetics were required, but moderate or deep sedation or conversion to general anesthesia was not required. Conclusion Sacral ESP block is a viable regional anesthetic technique in reconstructive surgeries of the parasacral and gluteal regions.

Effects of bilateral erector spinae plane block for posterior lumbar spine surgery in elderly patients

OBJECTIVES

With the rapid development of aging population, the number of elderly patients undergoing posterior lumbar spine surgery continues to increase. Lumbar spine surgery could cause moderate to severe postoperative pain, and the conventional opioid-based analgesia techniques have many side effects, which are barriers to the recovery after surgery of the elderly. Previous studies have demonstrated that erector spinae plane block (ESPB) could bring about favorable analgesia in spinal surgery. As far as the elderly are concerned, the analgesic and recovery effects of ESPB on posterior lumbar spine surgery are not completely clear. This study aims to observe the effects of bilateral ESPB on elderly patients undergoing posterior lumbar spine surgery, and to improve the anesthesia techniques.

METHODS

A total of 70 elderly patients of both sex, who were selected from May 2020 to November 2021, scheduled for elective posterior lumbar spine surgery, and in the age of 60-79 years, with American Society of Anesthesiologists class Ⅱ-Ⅲ, were divided into a ESPB group and a control (C) group using a random number table method, with 35 patients each. Before general anesthesia induction, 20 mL 0.4% ropivacaine was injected to the transverse process of L3 or L4 bilaterally in the ESPB group and only saline in the C group. The score of Numerical Rating Scale (NRS) indicating pain at rest and on movement within 48 h after operation, time of first patient control analgesia (PCA), cumulative consumptions of sufentanil within 48 hours, Leeds Sleep Evaluation Questionnaire (LSEQ) scores on the morning of day 1 and day 2 after operation, Quality of Recovery-15 (QoR-15) scores at 24 and 48 h after operation, full diet intake times, perioperative adverse reactions such as intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation were compared between the 2 groups.

RESULTS

A total of 70 patients were enrolled and 62 subjects completed the study, including 32 in the ESPB group and 30 in the C group. Compared with the C group, the postoperative NRS scores at rest at 2, 4, 6, and 12 h and on movementat at 2, 4, and 6 h were lower, time of first PCA was later, sufentanil consumptions were significantly decreased during 0-12 h and 12-24 h after operation, LSEQ scores on the morning of day 1 and QoR-15 scores at 24 and 48 h after operation were higher, full diet intakes achieved earlier in the ESPB group (all P<0.05). There were no significant differences in the incidences of intraoperative hypotension, postoperative dizziness, nausea, vomiting, and constipation between the 2 groups (all P>0.05).

CONCLUSIONS

Providing favorable analgesic effects with reduced opioids consumption, bilateral ESPB for posterior lumbar spine surgery in the elderly patients could also improve postoperative sleep quality, promote gastrointestinal functional restoration, and enhance recovery with few adverse reactions.

Comparison of the feasibility and validity of a one-level and a two-level erector spinae plane block combined with general anesthesia for patients undergoing lumbar surgery

Background

Spinal surgery causes severe postoperative pain. An erector spinae plane (ESP) block can relieve postoperative pain, but the optimal blocking method has not been defined. The aim of this study is to compare the feasibility of a one-level and a two-level lumbar ESP block and their effect on intraoperative and postoperative analgesia in lumbar spinal surgery.

Methods

A total of 83 adult patients who were scheduled for posterior lumbar interbody fusion were randomly divided into two groups. Patients in Group I (n = 42) received an ultrasound-guided bilateral one-level ESP block with 0.3% ropivacaine, while patients in Group II (n = 41) received a bilateral two-level ESP block. Blocking effectiveness was evaluated, including whether a sensory block covered the surgical incision, sensory decrease in anterior thigh, and quadriceps strength decrease. Intraoperative anesthetic dosage, postoperative visual analogue scale scores of pain, opioid consumption, rescue analgesia, and opioid-related side effects were analyzed.

Results

Of the total number, 80 patients completed the clinical trial and were included in the analysis, with 40 in each group. The time to complete the ESP block was significantly longer in Group II than in Group I (16.0 [14.3, 17.0] min vs. 9.0 [8.3, 9.0] min, P = 0.000). The rate of the sensory block covering the surgical incision at 30 min was significantly higher in Group II than in Group I (100% [40/40] vs. 85.0% [34/40], P = 0.026). The rate of the sensory block in the anterior thigh was higher in Group II (43.8% [35/80] vs. 27.5% [22/80], P = 0.032), but the rate of quadriceps strength decrease did not differ significantly between the groups. The mean effect-site remifentanil concentration during intervertebral decompression was lower in Group II than in Group I (2.9 ± 0.3 ng/ml vs. 3.3 ± 0.5 ng/ml, P = 0.007).There were no significant differences between the groups in terms of intraoperative analgesic consumption, postoperative analgesic consumption, and postoperative VAS pain scores at rest and with movement within 24 h. There were no block failures, block-related complications, and postoperative infection.

Conclusions

Among patients undergoing posterior lumbar interbody fusion, the two-level ESP block provided a higher rate of coverage of the surgical incision by the sensory block when compared with the one-level method, without increasing the incidence of procedure-related complications.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2100043596.

Thoracic surgery with erector spinae plane block in a patient with Duchenne muscular dystrophy

The management of general anesthesia is very difficult in patients with Duchenne muscular dystrophy (DMD) due to the potential for difficult airway problems, malignant hyperthermia, and cardiorespiratory complications. Therefore, peripheral nerve and plane blocks may be a good choice in DMD patients. In this case, we aimed to show the anesthetic efficiency of erector spinae plane (ESP) block in an 18-year-old male patient with DMD scheduled for video-assisted thoracoscopy surgery (VATS) exploration due to prolonged air leak. On surgery day, ultrasound (US)-guided one-sided ESP block (ESPB) was performed under sedation. Decortication surgery was performed in 3 hours. The patient’s intraoperative hemodynamic parameters were stable, and no pain or complications were recorded. The patients’ visual analog scale (VAS) scores were recorded at postoperative hour 0, 2, 6, and 12 as 0, 0, 2, and 2, respectively. In conclusion, safe and effective anesthesia can be provided by ESPB with US guidance in thoracic surgery.

Chronic Pain: An Update of Clinical Practices and Advances in Chronic Pain Management

Chronic pain affects a significant amount of the population and represents a heavy personal and socioeconomic burden. Chronic pain mechanisms can be categorized as nociceptive, neuropathic, or nociplastic. Although mechanism-based pain treatment is optimal, different types of pain mechanisms may overlap in patients. Recently, the biopsychosocial model with the multidisciplinary pain management program is widely accepted as one of the most effective methods to assess and manage chronic pain. The treatment of chronic pain consists of a personalized, stepwise, and multimodal approach that includes pharmacotherapy, psychotherapy, integrative treatments, and interventional procedures. Somatic and peripheral nerve blocks for the treatment of chronic pain are often deferred. With the increasing use of ultrasound in pain medicine, newly defined interfascial plane blocks, which may be performed alone or as an adjuvant to multimodal management, have gained popularity. Adequate pain management can improve physical functioning, mental health and quality of life indicators, and reduce pain chronification. The aim of this current article is to perform a comprehensive and updated review of existing treatment options, particularly interfascial plane blocks in chronic pain syndromes.

The Shining Star of the Last Decade in Regional Anesthesia Part-I: Interfascial Plane Blocks for Breast, Thoracic, and Orthopedic Surgery

Regional anesthesia has benefits beyond just treating acute postoperative pain. Interfascial plane blocks, which have been very popular with ultrasound in recent years, function primarily by administering a high volume of a local anesthetic to the fascial plane. Contrary to traditional peripheral nerve blocks, the targeted nerve or structure in interfacial plane blocks is not fully defined, and the indications have not been fully revealed yet. Anatomical, cadaveric, and radiological studies show how effective the interfascial plane blocks play a role. This review focuses on the benefits, techniques, indications, and complications of interfascial plane blocks in the context of breast, thoracic, and orthopedic surgery.

Erector spinae block: beyond the torso

PURPOSE OF REVIEW

This article aims to summarize the current literature describing the application of erector spinae plane (ESP) blocks for regional anesthesia of upper and lower limbs and to discuss the advantages and limitations.

RECENT FINDINGS

Investigations are still at an early stage but results are promising. High thoracic ESP blockade can relieve acute and chronic shoulder pain through local anesthetic diffusion to cervical nerve roots, although it may not be as effective as direct local anesthetic injection around the brachial plexus. It does, however, preserve motor and phrenic nerve function to a greater extent. It will also block the T2 innervation of the axilla which can be a source of pain in complex arthroscopic shoulder surgery. Lumbar ESP blocks provide effective analgesia following hip arthroplasty and arthroscopy, and appear comparable to lumbar plexus, quadratus lumborum, and fascia iliaca blocks. Unlike the latter, they are motor-sparing and are associated with improved postoperative ambulation.

SUMMARY

High thoracic and lumbar ESP blocks have the potential to provide adequate analgesia of the upper and lower limbs respectively, without causing significant motor block. They are thus alternative methods of regional anesthesia when other techniques are not feasible or have undesirable adverse effects.

Efficacy of Postoperative Analgesia by Erector Spinal Plane Block after Lumbar Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background. In recent years, erector spinae plane block (ESPB) has been increasingly used as a new regional block technique for postoperative analgesia; however, little is known on its benefits. Therefore, we performed a systematic review and meta-analysis to investigate the efficacy and safety of ESPB in lumbar spine surgery. Methods. Databases including PubMed, Embase, Cochrane Library, and Web of Science were systematically searched for randomized controlled trials (RCTs) comparing ESPB with no block in lumbar spine surgery until September 30, 2021. The primary outcome was opioid consumption after surgery. The Cochrane Collaboration’s tool for assessing the risk of bias was used to evaluate the quality of included studies. Results. Fifteen RCTs involving 980 patients were included in the study. Opioid consumption 24 hours after surgery was significantly lower in the ESPB group standardized mean difference ( $\text{SMD}=-2.27$ , 95% confidence interval (95% CI) (-3.21, -1.32); $p<0.01$ ). ESPB reduced pain scores at rest and on movement within 48 hours after surgery and the incidence of the postoperative rescue analgesia ( $\text{RR}=0.32$ , 95% CI (0.31, 0.80); $p=0.02$ ), while it significantly prolonged time to first rescue analgesia ( $\text{SMD}=4.87$ , 95% CI (2.84, 6.90); $p<0.01$ ). Moreover, significantly better patient satisfaction was associated with ESPB ( $\text{SMD}=1.89$ , 95% CI (1.03, 2.74); $p<0.01$ ). Conclusion. EPSB provides effective and safe postoperative analgesia after lumbar spine surgery.

Bilateral ultrasound-guided erector spinae plane block for postoperative persistent low back pain in lumbar disc surgery

BACKGROUND

Persistent low back pain is an important disability after lumbar disc surgery. Erector spinae plane block (ESPB) is highly effective in providing post-surgical pain control, but its effectiveness in long-term persistent low back pain has not been investigated. The aim of this randomized controlled trial was to investigate the effect of ESPB on the reduction of persistent low back pain after surgery.

METHODS

162 patients who were operated for lumbar disc herniation under spinal anaesthesia were divided into two groups according to the following criteria; ESPB block group (Group A); applied before surgery and 1 month after surgery and non-ESPB block group (Group B). The preoperative and postoperative 6th month Visual Analogue Scale (VAS), Oswestry Low Back Pain Disability Questionnaire (ODI) and Japan Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores of the patients were evaluated, and it was examined whether there was a difference.

RESULTS

In two groups with similar patient characteristics and no significant difference in preoperative pain scores, a significant improvement was observed in pain scores in Group A compared to Group B at the end of the 6th month.

CONCLUSIONS

ESPB, which has a low risk of complications and is simple to perform, has been found useful in the treatment of persistent low back pain after disc surgery.

Efficacy of Erector Spinae Nerve Block for Pain Control After Spinal Surgeries: An Updated Systematic Review and Meta-Analysis

Background

Erector spinae plane block (ESPB), as a regional anesthesia modality, is gaining interest and has been used in abdominal, thoracic and breast surgeries. The evidence on the efficacy of this block in spinal surgeries is equivocal. Recently published reviews on this issue have concerning limitations in methodology.

Methods

A systematic search was conducted using the PubMed, Scopus, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized controlled trials (RCTs) that were done in patients undergoing spinal surgery and had compared outcomes of interest among those that received ESPB and those with no block/placebo were considered for inclusion. Statistical analysis was performed using STATA software. GRADE assessment was done for the quality of pooled evidence.

Results

A total of 13 studies were included. Patients receiving ESPB had significantly reduced total opioid use (Standardized mean difference, SMD −2.76, 95% CI: −3.69, −1.82), need for rescue analgesia (Relative risk, RR 0.38, 95% CI: 0.22, 0.66) and amount of rescue analgesia (SMD −5.08, 95% CI: −7.95, −2.21). Patients receiving ESPB reported comparatively lesser pain score at 1 h (WMD −1.62, 95% CI: −2.55, −0.69), 6 h (WMD −1.10, 95% CI: −1.45, −0.75), 12 h (WMD −0.78, 95% CI: −1.23, −0.32) and 24 h (WMD −0.54, 95% CI: −0.83, −0.25) post-operatively. The risk of postoperative nausea and vomiting (PONV) (RR 0.32, 95% CI: 0.19, 0.54) was lower in those receiving ESPB. There were no differences in the duration of surgery, intra-operative blood loss and length of hospital stay between the two groups. The quality of pooled findings was judged to be low to moderate.

Conclusions

ESPB may be effective in patients with spinal surgery in reducing post-operative pain as well as need for rescue analgesic and total opioid use. In view of the low to moderate quality of evidence, more trials are needed to confirm these findings.

Systematic Review Registration:http://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021278133.

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Erector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.

DESIGN

A meta-analysis of randomized controlled trials.

SETTING

Perioperative setting.

PATIENTS

Patients undergoing lumbar spine surgery under general anesthesia.

INTERVENTIONS

We searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.

MEASUREMENTS

The primary outcome was opioid consumption in the first 24 h after surgery.

MAIN RESULTS

Twelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = -14.55; 95% confidence interval (CI), -21.03 to -8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0-10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = -1.24 days; 95% CI, -2.31 to -0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.

CONCLUSIONS

ESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required. PROSPERO registration number: CRD42021233362.

Fluoroscopic-guided erector spinae plane block for spine surgery

Erector spinae plane block (ESPB) is an ultrasound-guided block that can be also done under fluoroscopic guidance, which is usually used to manage postoperative pain of the thoracic and abdominal regions. We describe a successful Fluoroscopic-guided lumbar erector spinae plane block for lower back spinal surgery.

Internet of Things-Based Ultrasound-Guided Erector Spinae Plane Block Combined with Edaravone Anesthesia in Thoracoscopic Lobectomy

This paper aimed to study the application value of Internet of Things (IoT) edge computing algorithm-based ultrasound-guided erector spinae plane block combined with edaravone anesthesia in thoracoscopic lobectomy. A total of 110 patients undergoing thoracoscopic resection were selected as subjects. The patients were anesthetized with erector spinae plane block combined with edaravone before surgery and underwent chest ultrasound scan. IoT edge computing algorithm was constructed and applied to ultrasound images of patients to enhance and denoise the images. It was found that, in different mixed noise mixtures (Gaussian noise 10% + speckle noise 90%; Gaussian noise 30% + speckle noise 70%), the edge computing algorithm can still maintain the edge information of the output image, showing better performance on edge information detection and denoising compared with the Prewitt and Canny operator. In addition, visual analog scale (VAS) scores decreased with postoperative time after edaravone anesthesia induction and erector spinae plane block lobectomy and reached the lowest level after five days. In short, erector spinae plane block combined with edaravone showed good sedative and analgesic effects on patients undergoing thoracoscopic lobectomy. Ultrasound images processed by IoT edge computing algorithm showed high accuracy in the identification of lung lesions, which was worth applying to clinical diagnosis.

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.

Erector spinae plane block for postoperative analgesia in spine surgery: a systematic review and meta-analysis

PURPOSE

Although in recent years some randomized controlled trails (RCTs) have explored the analgesic effect of erector spinae plane block (ESPB) in spine surgery, their results are controversial. Our study aimed to examine the analgesic effect of preoperative ESPB in spine surgery by a meta-analysis of RCTs.

METHODS

The articles of RCTs that compared preoperative ESPB with no block in terms of the analgesic effect in adult patients following spine surgery were eligible for inclusion. The primary outcome was the pain scores reported by Visual Analog Scale or Numerical Rating Scale of pain at different time intervals in 48 h after surgery. The secondary outcomes included postoperative opioid consumption, rescue analgesia requirement, opioid-related side effects and complications associated with ESPB.

RESULTS

Twelve studies involving 828 patients were eligible for our study. Compared with no block, ESPB had a significant effect on reducing postoperative pain scores at rest and at movement at different time intervals except at movement at 48 h. ESPB significantly decreased opioid consumption in 24 h after surgery (SMD - 1.834; 95%CI - 2.752, - 0.915; p < 0.001; I² = 89.0%), and reduced the incidence of rescue analgesia (RR 0.333; 95%CI 0.261, 0.425; p < 0.001; I² = 0%) and postoperative nausea and vomiting (RR 0.380; 95%CI 0.272, 0.530; p < 0.001; I² = 9.0%). Complications associated with ESPB were not reported in the included studies.

CONCLUSION

Our meta-analysis demonstrates that ESPB is effective in decreasing postoperative pain intensity and postoperative opioid consumption in spine surgery. Therefore, for the management of postoperative pain following spine surgery, preoperative ESPB is a good choice.

Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in "Enhanced Recovery after Cardiac Surgery (ERACS)" protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

Erector spinae block for postoperative pain management in lumbar disc hernia repair

PURPOSE

Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries.

METHODS

Fifty-four ASA I-II patients aged 18-65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery.

RESULTS

A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p < 0.05 for each timepoint). Total morphine consumption at 24 h after surgery decreased by 57% compared to that of the control group (11.3 ± 9.5 mg in the ESP group and 27 ± 16.7 mg in the control group). NRS scores were similar between the two groups.

CONCLUSION

This study showed that ESP block provided effective analgesia in patients who underwent lumbar disc herniation surgery.

CLINICAL TRIALS REGISTRY

NCT03744689.