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 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 34  |  Issue : 3  |  Page : 202-205

Efficacy of ultrasound guided bilateral single shot erector spinae plane block for post-operative analgesia in patients undergoing lumbar spine surgery


1 Department of Anaesthesiology and Neurosurgery, Star Hospital, Hyderabad, Telangana, India
2 Department of Anaesthesiology, Virinchi Hospital, Hyderabad, Telangana, India

Date of Submission19-Sep-2019
Date of Decision03-Oct-2019
Date of Acceptance25-Apr-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Neha Kanojia
407 A Block, India Bulls Centrum, Kavadiguda, Lower Tank Bund, Hyderabad - 500 080, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_72_19

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  Abstract 


Severe postoperative pain following the lumbar spine surgery is a cause of significant morbidity, increased analgesic usage, and delayed discharge. With the present case series of 15 patients, we want to explore the efficacy of preincisional single-shot bilateral ultrasound-guided erector spinae plane block at L2 vertebrae level for postoperative analgesia in patients undergoing lumbar spine surgeries.

Keywords: Erector spinae plane block, lumbar spine surgery, postoperative analgesia, ultrasound guided


How to cite this article:
Kanojia N, Basvanapalli AR, Chagalakonda V, Sekhar B. Efficacy of ultrasound guided bilateral single shot erector spinae plane block for post-operative analgesia in patients undergoing lumbar spine surgery. Indian J Pain 2020;34:202-5

How to cite this URL:
Kanojia N, Basvanapalli AR, Chagalakonda V, Sekhar B. Efficacy of ultrasound guided bilateral single shot erector spinae plane block for post-operative analgesia in patients undergoing lumbar spine surgery. Indian J Pain [serial online] 2020 [cited 2021 Jan 25];34:202-5. Available from: https://www.indianjpain.org/text.asp?2020/34/3/202/305147




  Introduction Top


Lumbar spine surgery is associated with severe postoperative pain with marked analgesic usage and if poorly controlled can delay recovery and extend the length of hospital stay.[1] Opioids and nonsteroidal anti-inflammatory drugs remain the mainstay of therapy to combat immediate postoperative pain in these patients, but are associated with adverse effects.[2] Nowadays, regional anesthesia techniques such as epidural analgesia, paravertebral block, and quadratus lumborum block can play a significant role in multimodal analgesic regime and can reduce opioids and other analgesic dosages.[3]

Erector spinae plane (ESP) block is a regional anesthesia technique in which local anesthetic is injected deep to the erector spinae muscle and transverse process (TP) under ultrasound guidance.[4],[5] Numerous studies on the use of ESP block (78 case reports, 5 cadaveric studies, and 2 randomized controlled trials) have been reported in the recent years.[5] This block has been shown to provide good postoperative analgesia for thoracic, breast, and abdominal surgeries.[6],[7] Primarily, the anatomic location of the ESP block is thoracic level (89.9%), followed by lumbar (9.3%) and cervical (0.8%).[5] Evidence to date indicates that spread with 20 ml injectate extends 3–4 vertebral levels or more from the site of injection in a craniocaudal direction.[4],[6] Therefore, we hypothesized that if the block is performed at the level of L2 vertebrae, it could provide effective analgesia in patients undergoing lumbar spine surgery at or below L2 level. To demonstrate this, we are reporting a case series of 15 patients posted for lumbar spine surgery to evaluate the efficacy of single-shot bilateral ultrasound-guided ESP block for postoperative analgesia by measuring Numerical Rating Scale (NRS) pain scores at various time intervals post operatively, time to rescue analgesia, and any complications/adverse effects associated with the block.


  Case report Top


Fifteen American Society of Anesthesiology 1 and 2 patients were enrolled in the study after taking written and informed consent.

Demographic profile and surgical details are summarized in [Table 1].
Table 1: Demographic profile and surgical details

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Standard monitoring techniques were followed. General anesthesia was induced with propofol (2 mg/kg), atracurium (0.5 mg/kg), and fentanyl (1–2 ug/kg) to facilitate tracheal tube placement according to our institutional protocol. All blocks were performed in the prone position after the induction of general anesthesia. A low-frequency curvilinear probe (2–5 MHz, Sonosite Edge II, Bothell, WA, USA) covered in sterile drape was used to identify the L2 vertebrae by scanning from sacrum and subsequently moving the probe upward. The TP of L2 vertebrae was identified in longitudinal parasagittal orientation by sliding the probe 3.5–4 cm laterally from the midline. A 23 G quincke spinal needle with a 10 cm extension was inserted inplane from cephalocaudal direction to hit the tip of the TP. ESP block was performed by injecting 20 ml of 0.375% ropivacaine and 4 mg Dexamethasone[8],[9] at L2 level [Figure 1]. The spread of Local anaesthetic between the tip of the TP and erector spinae muscle was noted in the longitudinal scan [Figure 2]. The procedure was repeated on the other side also. After the surgeries, patients were extubated and shifted to postanesthesia care unit. Postoperatively, NRS score was monitored at regular intervals, and rescue analgesia was administered intravenously in the form of injection paracetamol 1 g when NRS score was more than 3 [Table 2]. Time to rescue analgesia was 6–8 h postoperatively. No adverse effects were noticed during the intraoperative and postoperative period.
Figure 1: Ultrasound image of needle trajectory with the tip in the plane between erector spinae muscle and transverse process

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Figure 2: LA spread in longitudinal view on ultrasound

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Table 2: Numerical Rating Score postoperatively

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  Discussion Top


Postspine surgery, 20%–40% patients report moderate-to-severe pain, which persists for at least initial 3–4 days.[1] Early ambulation to facilitate surgical outcome, adequate pain relief with patient safety are essential. ESP block which was introduced in 2016 has been shortly incorporated as a part of multimodal analgesia after thoracic surgeries, upper abdominal surgeries, renal surgeries, etc.[5],[6],[7] Erector spinae muscle, which is a group of three muscles, including iliocostalis, longissimus, and spinalis extends from sacrum and lumbar vertebrae up to C2 cervical vertebrae encased in an aponeurosis known as thoracolumbar fascia. This arrangement of erector muscle leads to extensive craniocaudal spread of the drug.[10] Because of the continuous plane between erector spinae muscle and TP along the vertebral column, currently ESP block has been extrapolated to the lumbar and cervical regions too.[10],[11] The posterior elements of the vertebral column are innervated by the branches of the dorsal rami of the spinal nerves, whereas the intervertebral discs and related ligaments are innervated by various branches of the ventral rami and the sympathetic nervous system.[12] The proposed mechanism of action is through the blockade of dorsal rami of the spinal nerves along with the sympathetic nerve fibers leading to effective management of visceral and somatic pain. Cadaveric and radiological studies suggest that local anesthetic injected in the ESP spreads both caudally and cranially covering several dermatomal levels at the level of injectate.[6],[10],[13] A recent study by Melvin et al. on the use of erector spinae blocks at lower thoracic levels for lumbar spine surgeries had lower NRS pain scores in the early postoperative period.[14] In our case series, mostly patients reported 0–2 NRS score in the immediate postoperative period (<2 h) and had low scores up to 6 h postoperatively. The efficacy of the block weaned off after 6–8 h requiring rescue analgesia. The block was relatively easy to perform as compared to epidural anesthesia or paravertebral block at the lumbar level under ultrasound guidance. As the needle insertion was away from the central neuraxis, it is expected to result in fewer complications such hematoma, nerve injuries, or motor blockade.[10] To prevent the surgical site infection, we avoided continuous catheter infusion which might have prolonged the analgesic benefit. Further clinical studies are warranted to show the effectiveness of ESP blocks.


  Conclusion Top


In summary, this case series demonstrates the successful use of single-shot bilateral ESP block for postoperative analgesia and can contribute enhance recovery after lumbar spine surgeries. This should provide impetus for further investigation into its utility in this context.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: A prospective cohort study comparing 179 surgical procedures. Anaesthesiology 2013;118:934-44.  Back to cited text no. 1
    
2.
Puvanesarajah V, Liauw JA, Lo S, Lina IA, Witham TF, Gottschalk A. Analgesic therapy for major spine surgery. Neurosug Rev 2015;38:407-18.  Back to cited text no. 2
    
3.
Carli F, Kehlet H, Baldini G, Steel A, McRae K, Slinger P, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 2011;36:63-72.  Back to cited text no. 3
    
4.
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. 4
    
5.
Tsui BC, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane block: A pooled review of 242 cases. J Clin Anesth 2018;53:29-34.  Back to cited text no. 5
    
6.
Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia 2017;72:452-60.  Back to cited text no. 6
    
7.
Chin KJ, Malhas L, Perlas A. The erector spinae pane block provides visceral abdominal analgesia in bariatric surgery: A report of 3 cases. Reg Anest Pain Med 2017:42:372-6.  Back to cited text no. 7
    
8.
Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B. Dexamethasone as an adjunct to peripheral nerve block. Cochrane Database Syst Rev 2017;11:cd011770.  Back to cited text no. 8
    
9.
Heesen M, Klimek M, Imberger G, Hoeks SE, Rossaint R, Straube S. Co-administration of dexamethasone with peripheral nerve block: Intravenous vs. perineural application: Systemic review, meta-analysis, meta-regression and trial sequential analysis. BJA 2018;120:212-27.  Back to cited text no. 9
    
10.
Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, et al. The erector spinae pane block: A narrative review. Korean J Anesthesiol 2019:72:209-20.  Back to cited text no. 10
    
11.
Tulgar S, Thomas DT, Suslu H. Ultrasound guided erector spinae plane block relieves lower cervical and inter scapular myofascial pain, a new indication. J Clin Anesth 2018;53:74.  Back to cited text no. 11
    
12.
Bogduk N. The innervation of the vertebral column. Aust J Physiother 1985;31:89-94.  Back to cited text no. 12
    
13.
Tulgar S, Senturk O. Ultrasound guided erector spinae palne block at L4 transverse process level provides effective post-operative analgesia for total hip arthroplasty. J Clin Anesth 2018;47:5-6.  Back to cited text no. 13
    
14.
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. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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