& AbstractIntroduction: Supplementary strategies, in combination with conventional analgesia, for pain control after lumbar fusion surgery remain limited. Case Description: Here, we describe a 79-year-old woman who experienced pain (10/10 on a numeric rating scale) on postoperative day 1 after undergoing L2 to S1 spine fusion. Erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, perineural catheters were placed bilaterally. Continuous infusion (5 mL/ h) of ropivacaine 0.2% per side was maintained for 48 hours. During this period, 2 boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. Discussion: Bilateral ESP catheterizations at T8, placed remotely from the surgical site, may be considered for patients undergoing extensive spinal fusion procedures, because they contribute to significant analgesic improvement, without significant motor block; the effect of the block remains mostly in the posterior rami of spinal nerves and in the posterior bony elements of the vertebrae. The risk for hematoma or bacterial colonization related to catheter placement at T8 level using epidural or ESP techniques is low; nevertheless, a delay in the diagnosis of postoperative epidural hematoma or abscess directly related to the surgical intervention is a potential concern in spine fusion surgery. However, the action of an ESP block is primarily in the posterior rami of the spinal nerves, which makes an eventual neuraxial compression less likely to be masked by an ESP block compared with an epidural block, because an ESP hematoma or infection will not directly impinge on the spinal cord. Lay Summary: A 79-year-old woman experienced excruciating pain on post-operative day 1 after undergoing L2 to S1 spine fusion. Bilateral continuous erector spinae plane (ESP) blocks were performed at T8 and, after a bolus of ropivacaine 0.2% (20 mL) per side, a continuous infusion (5 mL/hour) of ropivacaine 0.2% per side was maintained for 48 hours, which provided effective analgesia. During this period, two boluses (15 mL) per day of ropivacaine 0.2% were administered bilaterally to maintain optimal analgesia. ESP catheterizations at T8, placed remotely from surgical site, may be considered in extensive lumbar spinal fusion cases. &

Myasthenia gravis can interfere slightly with pregnancy and partum, although exacerbations of the disease occur frequently. Strict surveillance and therapeutic optimisation are crucial. In women with controlled disease, caesarean section should be carried out only if there are obstetric reasons. Locoregional anaesthesia is preferred, mainly epidural block. A good multidisciplinary cooperation, specific precautions and surveillance can certainly contribute to an improved outcome in myasthenia gravis patients during the peripartum period.

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We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateral-posterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. No complications were reported. The efficacy of the PSIP block may potentially depend on different mechanisms of action: (1) direct action in the fracture site by craniocaudal myofascial spread underneath the erector spinae muscle (ESM); (2) spread to deep layers through tissue disruption caused by trauma, to reach the proximal intercostal nerves; (3) further medial spread through deeper layers to the midline to block the posterior and ventral spinal nerves; (4) medial spread below the ESM, to reach the posterior spinal nerves (more reliably than rhomboid intercostal / sub-serratus [RISS] block); and (5) lateral spread in the sub-serratus (SS) plane to reach the lateral cutaneous branches of the intercostal nerves; while avoiding significant negative hemodynamic effects associated with techniques such as the paravertebral block (PVB), erector spinae plane (ESP) block or its variations, or thoracic epidural analgesia (TEA). A comparative comprehensive overview of the regional techniques described for posterior chest trauma is presented, including TEA, PVB, ESP block, retrolaminar block, mid-point to transverse process block, costotransverse foramen block, RISS, and serratus anterior plane (SAP) block. Lay Summary:We describe a new analgesic technique, parascapular sub-iliocostalis plane block (PSIP), for lateralposterior rib fractures as an alternative to other regional techniques in a high-risk patient who suffered a decompensation of her cardiorespiratory function after posterior chest trauma. We performed a continuous ultrasound-guided left PSIP block in the sub-iliocostalis plane next to the fourth rib to optimize analgesia and minimize complications. The patient had total pain relief with marked improvement in her cardiorespiratory condition. &

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