Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series

Abstract

<jats:title>Abstract</jats:title><jats:sec id="j_j.sjpain.2017.08.013_s_008_w2aab2b8c65b1b7b1aab1c16b1Aa"><jats:title>Background and aims</jats:title><jats:p>Post thoracotomy pain syndrome (PTPS) remains a common complication of thoracic surgery with significant impact on patients’ quality of life. Management usually involves a mul¬tidisciplinary approach that includes oral and topical analgesics, performing appropriate interventional techniques, and coordinating additional care such as physiotherapy, psychotherapy and rehabilitation. A variety of interventional procedures have been described to treat PTPS that is inadequately managed with systemic or topical analgesics. Most of these procedures are technically complex and are associated with risks and complications due to the proximity of the targets to neuraxial structures and pleura. The ultrasound-guided erector spinae plane (ESP) block is a novel technique for thoracic analgesia that promises to be a relatively simple and safe alternative to more complex and invasive techniques of neural blockade. We have explored the application of the ESP block in the management of PTPS and report our preliminary experience to illustrate its therapeutic potential.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2017.08.013_s_009_w2aab2b8c65b1b7b1aab1c16b2Aa"><jats:title>Methods</jats:title><jats:p>The ESP block was performed in a pain clinic setting in a cohort of 7 patients with PTPS following thoracic surgery with lobectomy or pneumonectomy for lung cancer. The blocks were performed with ultrasound guidance by injecting 20–30mL of ropivacaine, with or without steroid, into a fascial plane between the deep surface of erector spinae muscle and the transverse processes of the thoracic vertebrae. This paraspinal tissue plane is distant from the pleura and the neuraxis, thus minimizing the risk of complications associated with injury to these structures. The patients were followed up by telephone one week after each block and reviewed in the clinic 4–6 weeks later to evaluate the analgesic response as well as the need for further injections and modification to the overall analgesic plan.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2017.08.013_s_010_w2aab2b8c65b1b7b1aab1c16b3Aa"><jats:title>Results</jats:title><jats:p>All the patients had excellent immediate pain relief following each ESP block, and 4 out of the 7 patients experienced prolonged analgesic benefit lasting 2 weeks or more. The ESP blocks were combined with optimization of multimodal analgesia, resulting in significant improvement in the pain experience in all patients. No complications related to the blocks were seen.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2017.08.013_s_011_w2aab2b8c65b1b7b1aab1c16b4Aa"><jats:title>Conclusion</jats:title><jats:p>The results observed in this case series indicate that the ESP block may be a valuable therapeutic option in the management of PTPS. Its immediate analgesic efficacy provides patients with temporary symptomatic relief while other aspects of chronic pain management are optimized, and it may also often confer prolonged analgesia.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2017.08.013_s_012_w2aab2b8c65b1b7b1aab1c16b5Aa"><jats:title>Implications</jats:title><jats:p>The relative simplicity and safety of the ESP block offer advantages over other interventional procedures for thoracic pain; there are few contraindications, the risk of serious complications (apart from local anesthetic systemic toxicity) is minimal, and it can be performed in an outpatient clinicsetting. This, combined with the immediate and profound analgesia that follows the block, makes it an attractive option in the management of intractable chronic thoracic pain. The ESP block may also be applied to management of acute pain management following thoracotomy or thoracic trauma (e.g. rib fractures), with similar analgesic benefits expected. Further studies to validate our observations are warranted.</jats:p></jats:sec>

Erector Spinae Plane Block Versus Retrolaminar Block

“…This was seen across 2 to 5 vertebral levels centered around the level of injection and provides a basis for the somatic and visceral analgesia that has been reported. [1][2][3][6][7][8][9][10][11][12][13] It also confirms the existence of anatomical pathways for anterior spread of local anesthetic. While the exact pathways have yet to be defined, they probably include the perforations in the intertransverse connective tissues through which the dorsal rami of spinal nerves and accompanying vessels emerge.…”

Erector spinae plane block for the management of chronic shoulder pain: a case report

“…11,12 The ESP block was originally described for management of thoracic pain with injection at the T5 transverse process. [4][5][6] Its therapeutic effect is attributed to the cranial-caudal spread of local anesthetic over multiple vertebral levels in the musculofascial plane deep to the erector spinae muscle, accompanied by diffusion anteriorly into the contiguous paravertebral and intercostal spaces, where the local anesthetic then acts on the ventral and dorsal rami of spinal nerves. The subsequent realization that the erector spinae muscle extends from the lumbar spine to cervical spine led to extrapolation of the ESP block for abdominal analgesia by injecting at the lower transverse processes (T7-T10) 7-9 and now, as described here, shoulder analgesia by injecting at the higher level of T2 or T3.…”

“…1 Multiple ultrasound (US)guided procedures have been described to treat chronic shoulder pain refractory to conservative management; these generally involve local anesthetic and steroid injections into the bursa, tendons, and joints around the shoulder. 2,3 The erector spinae plane (ESP) block is a relatively novel US-guided technique that was originally described in the management of thoracic pain when performed at the T5 vertebral level, [4][5][6] but has also been successfully applied to abdominal analgesia when performed at the lower levels of T8-10. [7][8][9] In this report, we extend this concept by describing the management of chronic shoulder pain with ESP blockade at the T2/T3 vertebral level, together with radiological evidence for the likely mechanism of action.…”

“…He described the intensity as 8/10 on a numerical rating scale (NRS), interfering with his sleep, and he was unable to abduct his shoulder beyond 90°. Based on our successful experience with the ESP block in chronic thoracic pain, 5 we proposed a left ESP block to alleviate his shoulder pain, to which the patient agreed after a discussion of potential risks and benefits.…”

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

“…Under ultrasound guidance, about 20 mL of local anesthetic are injected 3 cm beside the interspinous line at T5 level deep to the trapezius, rhomboid and erector spinae muscles. ESPB has been proposed for thoracic neuropathic pain, rib fractures and as rescue in thoracotomy after epidural failure (72)(73)(74). Currently, the lack of experience with this technique does not allow to define its role in the treatment of pain after VATS and hence its use is not yet recommended.…”