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 Table of Contents  
Year : 2021  |  Volume : 35  |  Issue : 3  |  Page : 256-257

Is bilateral erector spinae plane block a safe alternative to a difficult epidural?

1 Department of Anesthesiology andCritical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anesthesiology and Critical Care, Dr S.N Medical College, Jodhpur, Rajasthan, India

Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Rakesh Kumar
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_77_21

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How to cite this article:
Sharma L, Syal R, Kumar R, Kamal M. Is bilateral erector spinae plane block a safe alternative to a difficult epidural?. Indian J Pain 2021;35:256-7

How to cite this URL:
Sharma L, Syal R, Kumar R, Kamal M. Is bilateral erector spinae plane block a safe alternative to a difficult epidural?. Indian J Pain [serial online] 2021 [cited 2022 May 29];35:256-7. Available from: https://www.indianjpain.org/text.asp?2021/35/3/256/334106


Regional anesthesia is an integral component of perioperative pain management in frail geriatric patients. By reducing the central nervous system input of nociception from a surgical site, they not only decrease dose of systemically administered analgesic drugs but also their side effects that lead to enhance recovery. We hereby, describe our experience with a single shot bilateral erector spinae plane (ESP) block for acute postoperative pain in a geriatric patient posted for thoracic surgery.

An 80-year-old female patient, with an ulceroproliferative growth (8 cm × 7 cm) over a sternal area with an enlarged bilateral lymph node was scheduled for wide local excision and rotational flap reconstruction for anterior chest wall squamous cell carcinoma. She was a known case of hypertension, and coronary artery disease. She was very apprehensive and did not give consent for epidural insertion (Thoracic epidural analgesia [TEA]) in the awake state. In the operation theater, general anesthesia was given. The TE was attempted twice in the lateral position at the T4 level but was not successful. Then, we planned for ultrasound-guided bilateral single shot ESP block at T4 level [Figure 1]. A total of 15 ml of 0.5% ropivacaine and 2 mg dexamethasone was injected on each side. The intraoperative hemodynamics remained stable without any additional opioid requirement. Postoperatively, sensory assessment was done with the pinprick which revealed reduced sensation from C7 to T6 dermatome on left side and T1-T7 on the other side. Injection paracetamol 15 mg/kg, 8 hourly was advised for postoperative analgesia. Her visual analog score remained in the range of 1–2/10 on rest and 2–3/10 on movement.
Figure 1: Image of US guided erector spinae plane block: (a) Sagittal view T3T4 transverse process, and erector spinae muscle (b) needle placed just above the transverse process

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TEA is recommended as the gold standard regional anesthetic technique in acute postoperative pain management for surgery in the thoracic region. TEA can be technically challenging, especially in the upper thoracic level.[1] Anatomical irregularities in the elderly patients such as curvature or rotation of the spine, degenerative disc and joint changes, distortion, and compression of the epidural space increase this challenge many folds.

With the advent of ultrasound in regional anesthesia armamentarium, trends are shifting from central neuraxial block to the fascial plane blocks. ESP block is the most popular amongst these blocks, first described by Forero et al. The transverse processes of the thoracic vertebrae and the erector spinae muscles are the main target points in ESP block. LA injected in this plane diffuses anteriorly to ventral and dorsal rami of spinal nerves, as well as to the paravertebral and epidural space. While Sundararajan and Srinivasan[2] describe the role of ESP block as a sole anesthetic technique in poor cardiopulmonary reserve female. The bilateral ESP block has successfully been used in the cardiac,[3] and major open lower abdominal surgeries[4] as a promising alternative to TEA.

Our patient being a geriatric patient with multiple comorbidities was better suited for erector spinae plane block as it offers better hemodynamic stability,[4] and safety profile.

To summarize we believe ESP block can be a successful alternative to TEA due to its simplicity, ease of performance, and safety profile.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Romero A, Garcia JE, Joshi GP. The state of the art in preventing post-thoracotomy pain. Semin Thorac Cardiovasc Surg 2013;25:116-24.  Back to cited text no. 1
Sundararajan M, Srinivasan P. Erector spinae plane block as a sole anaesthetic technique for simple mastectomy in a cardiorespiratory crippled female. Indian J Anaesth 2020;64:77-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth 2018;21:323-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
Restrepo-Garces CE, Chin KJ, Suarez P, Diaz A. Bilateral continuous erector spinae plane block contributes to effective postoperative analgesia after major open abdominal surgery: A case report. A A Case Rep 2017;9:319-21.  Back to cited text no. 4


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