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CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 487-489

Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Cervical and Thoracic Spine Surgeries — A Case Series


Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Date of Submission18-Jan-2020
Date of Decision12-Mar-2020
Date of Acceptance07-Jul-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Amit Goyal
Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314568

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 » Abstract 


Erector spinae plane (ESP) block is a recently introduced regional technique for pain management. However, its usefulness for perioperative analgesia in cervical and thoracic spine surgeries is underutilized. In this case series, we reviewed the case records of seven patients who received ultrasound-guided ESP block for perioperative analgesia for cervical and thoracic spine surgeries during a two-month period. We evaluated the performance of the ESP block with regards to intraoperative nociception and hemodynamics, postoperative pain, and need of rescue analgesia in these patients. The median age of our patients was 28 years (range 5–74 years) and the duration of surgery was 300 minutes (range 240–540 minutes). The surgical pleth index, a marker of intraoperative nociception, was below the threshold of 50 at most time-points during the surgery. Similarly, intraoperative hemodynamic parameters (HR and BP) were stable throughout the surgery. Postoperative pain control was good during the initial 48 after surgery with median NRS score of 2 at rest and 4 with movement. The ESP block results in good intraoperative and postoperative analgesia and also provides hemodynamic stability and opioid-sparing effect for cervical and thoracic spine surgeries.


Keywords: Perioperative analgesia, Erector spinae plane block, Spine surgery
Key Message: ESP block is feasible and effective for perioperative analgesia in cervical and thoracic spine surgeries without adverse effects. The benefits included intraoperative hemodynamic stability, good perioperative analgesia, and avoidance of opioids in the postoperative period.


How to cite this article:
Goyal A, Kalgudi P, Sriganesh K. Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Cervical and Thoracic Spine Surgeries — A Case Series. Neurol India 2021;69:487-9

How to cite this URL:
Goyal A, Kalgudi P, Sriganesh K. Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Cervical and Thoracic Spine Surgeries — A Case Series. Neurol India [serial online] 2021 [cited 2021 May 15];69:487-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/487/314568




One of the most feared aspects of surgery is pain. Pain after spine surgeries often lead to delayed mobilization, prolonged hospital stay, and poor functional outcome. Various analgesic modalities used for spine surgeries include systemic opioids and nonopioid drugs, epidural analgesia, and wound infiltration with local anesthetics (LA).[1],[2] Recently, erector spinae plane (ESP) block has been introduced to provide perioperative analgesia for spine surgeries; however, its use has been restricted to surgeries in the lumbar region. The aim of this case-series is to inform the effect of ESP block on intraoperative nociception and hemodynamics, postoperative pain, and consumption of rescue analgesia in cervical and thoracic spine surgeries.


 » Case Series Top


We reviewed the case records of seven patients who received ultrasound-guided ESP block for perioperative analgesia for cervical and thoracic spine surgeries during a two-month period. We collected data regarding

  1. intraoperative nociception as assessed by the Surgical Pleth Index (SPI),
  2. intraoperative hemodynamics—heart rate (HR) and blood pressure (BP),
  3. postoperative pain score as recorded using numerical rating scale (NRS), and
  4. any administration of rescue analgesia such as diclofenac, tramadol, or morphine, despite the routinely used paracetamol 10 mg/kg six hourly for first 48 hours.


NRS is a simple pain assessment tool where patients self-report pain severity on a 0 to 10 scale. Zero represents “no pain”, score 1 to 3 represents “mild”, 4 to 6 represents “moderate”, 7 to 9 represents “severe,” and 10 represents “worst possible pain”. The SPI and hemodynamic data were collected from our electronic anesthesia record system (GE Centricity) and other data (demographic, clinical, NRS, and ESP block details) were collected from surgical, nursing, and anesthesia records of these patients and analyzed after the ethical approval from the institutional ethics committee.

Following the administration of general anesthesia and after turning the patient prone for surgery, bilateral ESP block was performed in prone position under ultrasound guidance in all patients. The transverse process selected was at the mid-incision level for thoracic surgery, and at the lower level or just below the incision for cervical surgery. A 20G spinal needle was used to approach the transverse process and inject drug solution between tip of transverse process and erector spinae muscle (ESM), in caudal-to-cranial direction using in-line method [Figure 1]. Details about demographics, diagnosis, surgery, intraoperative systemic analgesia, and ESP block in these seven patients are shown in [Table 1]. Patients were aged between 5 and 74 years (median age 28 years) and weighed between 13 and 87 kg (median weight 68 kg). The median dose of morphine at the induction of anesthesia was 6.5 mg (range 2.5–9 mg) and the median duration of surgery was 300 minutes (range 240–540 minutes).
Figure 1: Line diagram showing the intraoperative heart rate (HR), mean arterial pressure (MAP), and Surgical Pleth Index (SPI) at different time-points during surgery

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Table 1: Demographic, clinical and erector spinae plane block details

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SPI values, collected every 30 minutes during the surgery were below 50 at most time points. Similarly, the intraoperative hemodynamic parameters (HR and BP) also remained stable throughout the surgery [Figure 2]. The maximum NRS scores reported by the first two patients at rest were 4 and 6 with movement in first 48 hours. Patients 3 and 5 reported a maximum NRS of 1 at rest and 3 with movement. Patient 4 reported a maximum NRS of 2 at rest and 4 with movement. Patient 6 and 7 reported the maximum NRS of 3 at rest and 5 with movement. The median NRS score in these patients at rest was 2 at 12, 24, 36 and 48 hours and 4 with movement at 12, 24, 36 hours and 3 at 48 hours after surgery. No rescue analgesia (including opioids) was required in any patient.
Figure 2: Ultrasonographic image showing the needle (arrows) approaching the D7 transverse process and the injection of local anesthetic (LA) drug solution under erector spinae muscle (ESM)

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 » Discussion Top


Previous reports have demonstrated the benefits of ESP block for lumbar spine surgery.[3],[4] A randomized controlled trial comparing ESP block with conventional analgesia for lumbar spine surgery also demonstrated reduced postoperative pain and rescue analgesic requirement with ESP block.[5] However, literature regarding the use of ESP block for cervical[6] and thoracic[7] spine surgeries is scant and hence this report.

ESP block is a fascial plane block where LA drug is injected in the fascial plane superficial to the transverse process and deeper to the ESM. It has shown to improve the quality and duration of analgesia in thoracoabdominal surgeries, and chronic pain conditions. The key advantage of ESP block is multilevel spread of LA in the fascial plane by single injection. The multi-level spread along with diffusion into paravertebral and intercostal space increases the extent of the dermatomal blockade by acting at close proximity of ventral and dorsal rami.[8],[9] In addition, the multi-level spread allows performing ESP block at a level distinct from the surgery site, thus avoiding surgical incision and wound dressing, especially at the end of surgery for postoperative analgesia.

Both single injection and continuous infusion (through catheter) techniques are described. Since the catheter technique has potential drawbacks such as failure, leak, infection, and higher cost, single injection technique is mostly used. Moreover, block can be repeated at the end of surgery to provide prolonged postoperative analgesia obviating the need for catheter placement as done in our patient number 5 when surgery was prolonged. The quality and duration of the block can be further improved by additives such as clonidine as done in all our patients. Earlier case series in lumbosacral surgeries demonstrated that alpha-2 agonists augment analgesia resulting in significant opioid sparing benefits.[10]

The results of our case-series demonstrate good analgesic efficacy (as demonstrated by SPI values), hemodynamic stability, and opioid-sparing effect of ESP block for cervical and thoracic spine surgeries. None of our patients required additional intraoperative opioid or postoperative rescue analgesics.

ESM consists of the spinalis, longissimus, and iliocostalis muscles which are further divided into three segments. The superior attachment of the cervicis segment of all the 3 muscles is between the C2-C6 vertebrae and the capitis segment of spinalis and longissimus is skull or mastoid process. In addition, ESM is covered by nuchal ligament in the cervical region, instead of thoracolumbar fascia. Because of these anatomical characteristics, we believe that the spread of LA was limited in the upper cervical region resulting in higher NRS scores (1-4 at rest and 1-6 with movement) in patients undergoing upper cervical surgeries as compared to thoracic surgeries (0-3 at rest and 0-5 with movement).

Minimization of opioids use in cervicothoracic spine surgeries is important to reduce the risk of adverse respiratory events in this high-risk population. No patient in this series developed postoperative respiratory problems or complications related to ESP block. Absence of significant postoperative pain also facilitated early (within 48 hours) mobilization in all our patients.

ESP block is feasible and effective for perioperative analgesia in cervical and thoracic spine surgeries without adverse effects. The benefits included intraoperative hemodynamic stability, good perioperative analgesia, avoidance of opioids, and early ambulation in the postoperative period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Singh A, Jindal P, Khurana G, Kumar R. Post-operative effectiveness of continuous wound infiltration, continuous epidural infusion and intravenous patient-controlled analgesia on post-operative pain management in patients undergoing spinal surgery. Indian J Anaesth 2017;61:562-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci 2015;22:930-8.  Back to cited text no. 2
    
3.
Singh S, Chaudhary NK. Bilateral ultrasound guided erector spinae plane block for postoperative pain management in lumbar spine surgery: A case series. J Neurosurg Anesthesiol 2019;31:354.  Back to cited text no. 3
    
4.
Ueshima H, Inagaki M, Toyone T, Otake H. Efficacy of the erector spinae plane block for lumbar spinal surgery: A retrospective study. Asian Spine J 2019;13:254-7.  Back to cited text no. 4
    
5.
Singh S, Choudhary NK, Lalin D, Verma VK. Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in lumbar spine surgery: A randomized control trial. J Neurosurg Anesthesiol 2019. doi: 10.1097/ANA.0000000000000603 [Epub ahead of print].  Back to cited text no. 5
    
6.
Goyal A, Kamath S, Kalgudi P, Krishnakumar M. Perioperative analgesia with erector spinae plane block for cervical spine instrumentation surgery. Saudi J Anaesth 2020;14:263-4.  Back to cited text no. 6
  [Full text]  
7.
Chin KJ, Dinsmore MJ, Lewis S, Chan V. Opioid-sparing multimodal analgesia with bilateral bi-level erector spinae plane blocks in scoliosis surgery: A case report of two patients. Eur Spine J 2019 Sep 3. doi: 10.1007/s00586-019-06133-8.[Epub ahead of print].  Back to cited text no. 7
    
8.
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 8
    
9.
Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth 2017;118:474-5.  Back to cited text no. 9
    
10.
Melvin JP, Schrot RJ, Chu GM, Chin KJ. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: A case series. Can J Anaesth 2018;65:1057-65.  Back to cited text no. 10
    


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