Combination of the T7 Unilateral Erector Spinae Plane Block and T10 Bilateral Retrolaminar Blocks in a Patient with Multiple Rib Fractures on the Right and T10–12 Vertebral Compression Fractures: A Case Report

Abstract

Multiple vertebral compression and rib fractures in elderly patients with pre-existing chronic obstructive pulmonary disease is a common scenario associated with significant morbidity and mortality. Severe pain prevents normal ventilation and leads to atelectasis, consolidation, and pneumonia. Subsequently, these patients frequently develop respiratory failure and require intubation and critical care. Therefore, adequate analgesia is often a life-saving intervention. Anesthetic management of a 78-year-old kyphotic patient with T6, T7, and T9 rib fractures on the right and T10–12 vertebral compression fractures sustained in an accidental fall is presented. She had inadequate pain control and was unable to take a deep breath or cough. Her respiratory status was deteriorating, with tachypnea and worsening hypoxia, necessitating bi-level positive airway pressure (BiPAP) support. Since thoracic epidural analgesia was contraindicated owing to compressive vertebral fractures and to the pending respiratory failure, we opted for a unilateral erector spinae plane (ESP) block at the T7 level and bilateral retrolaminar (RL) blocks at the T10 level. Following the procedure, the pain was immediately relieved and the patient was able to take deep breaths. Shortly thereafter, her respiratory status improved, with the respiratory rate coming back close to the baseline. The patient was subsequently weaned from BiPAP support and discharged from the intensive care unit. While the combination of ESP and RL blocks is not routinely used in patients with multiple rib and vertebral compression fractures, our report indicates that it may be an excellent alternative for analgesia in situations where thoracic epidural and/or paravertebral blocks are contraindicated and when timely intervention could be potentially life-saving.

Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review

“…Screening of abstracts resulted in 77 papers, following which 40 studies were excluded due to incorrect block or injury, surgical fixation, or for being presented in a conference abstract format. Of the 37 studies included, 10 were case reports, [18][19][20][21][22][23][24][25][26][27] 12 were case series, [28][29][30][31][32][33][34][35][36][37][38][39] 5 were cohort studies, 7,40-43 2 were randomized controlled trials (RCT), 44,45 1 was a prospective interventional study, 46 and 7 were letters to the editor. [47][48][49][50][51][52][53] The majority of studies were published after 2020, with 29% being published in 2022.…”

“…The main indication for ESB was as an analgesic intervention either for uncontrolled pain or as a preventative measure, with 9 studies reporting usage of the technique as a rescue measure for patients in respiratory failure. 18,[20][21][22]24,28,33,34,47 The majority of blocks were administered within the first 48 hours of presentation.…”

“…Twenty-eight studies reported objective changes in pain score post administration of ESB using various scoring scales including Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Defence and Veteran Pain (DVP) score, and a 4 point verbal score. 7,[18][19][20][21][22][23][24][25][27][28][29][30][31]33,34,[36][37][38][39]42,[44][45][46][47][48][49]53 Due to the heterogeneity of scales and time points used to evaluate pain, an average weighted percentage change in pain scores was calculated. The mean reduction in pain scores from pre-block baseline was approximately 40% within the first 24 hours.…”

“…Elawamy et al 45 in a comparative RCT demonstrated 6 cases of hypotension, 2 cases of bradycardia, and 3 vascular punctures in a cohort of 30 patients receiving thoracic paravertebral blocks (TPVB), with no complication demonstrated in the ESB cohort. Seven studies 19,20,25,33,35,40,43 included patients on prophylactic/therapeutic anticoagulation or had ESB administered in the setting of coagulopathy. Three papers, 38,44,45 including both RCTs, excluded this patient cohort.…”