Rev Esp Anestesiol Reanim. 2019;66(8):443---446
Revista Española de Anestesiología y Reanimación www.elsevier.es/redar
The erector spinae plane block (ESPB) in the management of chronic thoracic pain. Correlation of pain/analgesia areas and long term effect of the treatment in three cases P. Kot Baixauli a,∗ , P. Rodriguez Gimillo a , J. Baldo Gosalvez b , J. De Andrés Ibá˜ nez c a
Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia. Avenida Tres Cruces, 2, 46014 Valencia, Espa˜ na b Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Universitario Doctor Peset, Av. de Gaspar Aguilar, 90, 46017 Valencia, Espa˜ na c Jefe de Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, na Avenida Tres Cruces, 2, 46014 Valencia, Espa˜ Received 12 February 2019; accepted 24 February 2019 Available online 5 August 2019
KEYWORDS Erector spinae plane block; Chronic pain; Thoracic pain; Regional anesthesia
Abstract The erector spinae plane block (ESPB) is a technique that is used both as perioperative analgesia and in the management of chronic pain. This has been described recently and is being a resource increasingly used for its easy implementation and low rate of complications. However, the correlation between pain and analgesia, as well as its long-term effect on chronic pain, should be studied. We present a series of 3 cases in which the effectiveness of the ESPB in patients with chronic chest pain was evaluated. The block was performed in all cases by depositing 20 ml of 0.2% Ropivacaine in the fascial plane of the erector spinae muscle. The pain was measured using a numerical scale prior to the block, at 30 minutes and a month. The areas were marked on the skin with different colours for comparison. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
Autor para correspondencia. E-mail address: pablo [email protected]
(P. Kot Baixauli).
https://doi.org/10.1016/j.redar.2019.02.010 0034-9356/© 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights 2341-1929 reserved.
PALABRAS CLAVE Bloqueo erector espinal; Dolor crónico; Dolor torácico; Anestesia regional
P. Kot Baixauli et al.
El bloqueo del plano del erector espinal en el manejo del dolor torácico crónico. Correlación de las áreas de dolor/analgesia y efecto a largo plazo del tratamiento en 3 casos Resumen El bloqueo del plano del erector espinal (ESPB, por sus siglas en inglés) es una técnica que se emplea tanto como analgesia perioperatoria como en el manejo del dolor crónico. Esta ha sido descrita recientemente y está siendo un recurso cada vez más utilizado por su fácil realización y su baja tasa de complicaciones. No obstante, la correlación entre dolor y analgesia, así como su efecto a largo plazo en el dolor crónico deben ser estudiados. Presentamos una serie de 3 casos en los que se evaluó la eﬁcacia del ESPB en pacientes con dolor torácico crónico. El bloqueo fue realizado en todos los casos depositando 20 ml de ropivacaína al 0,2% en el plano fascial del músculo rector espinal. El dolor fue medido mediante escala numérica previo al bloqueo, a los 30 min y al mes. Las áreas fueron marcadas en la piel con colores diferentes para su comparación. © 2019 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Fascial plane blockages are analgesic techniques used both in the perioperative period and in the management of chronic pain. Different types have been described and its use in clinical practice has been increased. One of the last techniques that has been described is the erector spinae plane block (ESPB). It was ﬁrst described by Forero et al. 1 for the treatment of chronic thoracic neuropathic pain as well as postoperative pain in thoracic surgery. The ESPB is performed by depositing the local anesthetic (LA) in the depth of the erector spinae muscle (ESM), between the fascia and the transverse process of the vertebra. LA is distributed in the cranio-caudally fascial plane one dermatome a median of each 3.4 ml of injected volume.2 In addition, it also diffuses anterior to the paravertebral and epidural spaces, and laterally to the intercostal space in several levels.3,4 The LA makes its effect on the ventral and dorsal ramus of the spinal nerve. In addition, the diffusion of LA to the paravertebral space provides both visceral and somatic analgesia. The main advantage offered by this technique include the ease of performing them, the analgesic efﬁcacy and the low risk of complications. Several studies have shown the efﬁcacy of ESPB in chronic thoracic pain.5---9 However, it has been found that the correlation between analgesia and skin sensitivity test does not always correlate well.10 But most importantly, the goal that the pain physician seeks is that the coverage of the blockade has a good correlation with the area that hurts the patient. We present a series of 3 cases in which ESPB was used to treat chronic chest pain. Areas of pain before the technique and analgesia after the technique were assessed, as well as the clinical evolution of the patients.
Procedure The written consent of the 3 patients was obtained, both for the realization of the technique and for the publication
TP 5 TP 4
Fig. 1 Ultrasound image in a parasagittal plane. The 3 muscle planes T (trapezius), MRI (rhomboid major) and ESM (erector spinae muscle) are observed. The asterisk marks the target of the needle to perform the blockade of the transverse process (TP) of the ﬁfth thoracic vertebra.
of the results. The performance of the blockade was carried out as follows in all cases. With the patient in a sitting position, the skin was disinfected with a 2% chlorhexidine solution. A high-frequency ultrasound linear probe was used in a transversal orientation to identify the spinous process. Once the level of vertebra was identiﬁed, the probe was moved 3 cm laterally until the transverse process was identiﬁed. The probe was rotated 90 degrees on the transverse process by placing it in a parasagittal plane. Three muscles were identiﬁed superﬁcial to the hyperechoic transverse process shadow: trapezius, rhomboid major, and erector spinae (Fig. 1). When the block was performed at the level of the seventh thoracic vertebra, only the trapezius and erector spinae muscles were visualized. The needle was inserted cranio-caudal in plane until contact with the transverse process. 20 ml of ropivacaine 0,2% was deposited between this process and the deep fascial plane of the ESM.
Bloqueo del plano erector espinal en el manejo del dolor torácico crónico
scapular territory. Despite treatment with Pregabalin and Oxycodone / Naloxone, she presented with severe pain with an NRS score of 9. The pain was predominantly dorsal, without radiating to the anterior chest wall. ESPB was performed at right T7 level with an 80% improvement in PACU after technique. Fig. 2b shows previous pain mapping and postblock analgesia. After one month, the improvement was 20-30% (NRS 6).
Case 3 A woman of 59 years ASA III of 62 kg of weight and 155 cm of height. She reported right thoracic neuropathic pain posthoracotomy due to transsegmental resection in the right upper lung lobe. The pain was localized in T4 territory irradiated towards breast and nipple. It also associated pain in the armpit. The patient presented poor response to pharmacological treatment with Gabapentin and 5% Lidocaine patches. She reported severe pain with an NRS score of 8. He did not show improvement with 8% Capsaicin patches either. An epidural block was performed at level T5-T6 with improvement of 20-30%. Subsequently, pulsed radiofrequency was performed for 3 minutes at the level of 4-6 right intercostal nerve with improvement of 60-70%. This allowed the patient to decrease the area of ??pain, but kept on the nipple and armpit. Subsequently, ESPB was performed at the right T5 level with improvement of 60% in PACU after technique. Fig. 2c shows previous pain mapping and post-block analgesia. One month later, she maintained an improvement of 20% (NRS 6).
Discussion Fig. 2 Images of the costal wall of the subjects of case 1 (a), case 2 (b) and case 3 (c). Mapping pain areas (red color) and anesthetic block (black color).
Case 1 A 55-year-old male ASA II of 104 kg of weight and 176 cm of height. He reported mechanical right back pain from fractures with wedging of the vertebral bodies T7, T8 and T9 grade 1. Despite treatment with Tramadol /Acetaminophen presented moderate to severe pain with a score on the numeric rating scale (NRS) of 7. An inﬁltration of the paravertebral musculature was performed with 100 IU of botulinum toxin without improvement. It was decided to perform ESPB at right T7 level with an improvement of 80% in PACU after technique. Fig. 2a shows previous pain mapping and post-block analgesia. The improvement allowed her to follow a rehabilitation program and a 50% improvement (NRS 3) per month. Likewise, an increase in the mobility of the spine was observed, so it could be discharged to continue the rehabilitation treatment.
Case 2 A 59-year-old ASA III woman of 79 kg in weight and 155 cm in height. She reported right thoracic neuropathic pain after surgical intervention of sebaceous cyst abseciﬁed in sub-
Regional anaesthesia and pain management have experienced advances in recent years with the appearance of fascial plane blockages. One of the last techniques described in the literature has been the ESPB. It is an easy technique to perform because the visualization of the target by ultrasound is very simple and reaching it with the needle is not difﬁcult. In addition, it is a technique with low risk of complications. Important structures (such as main vessels, pleura or medulla) whose injury can cause a serious complication are far from the target of blockage. All these characteristics, together with their effectiveness, have made the ESPB a therapy increasingly used. Although it was initially described as a technique in the treatment of chronic pain, most published studies describe its beneﬁt in the perioperative setting. In chronic pain we only have series of cases, and although it seems to be a technique that provides immediate signiﬁcant improvement, pain may recur over time. In the series of cases that we have described, the 3 patients showed an immediate relief of their pain. In addition, all of them had a good correlation between the areas of pain and analgesia, showing themselves as an adequate technique for their pain. However, only the patient in case 1 maintained a lasting beneﬁt. The main differences observed among the patients were the gender, the characteristics of the pain and the combination of the rehabilitation therapy (tabla 1). It is possible that the cause of long-term pain relief in patient 1 is due to the fact that mechanic pain responds
446 Tabla 1
P. Kot Baixauli et al. Evolution and correlation of pain after ESPB. Previous NRS
30 min NRS
1 month NRS
Patient 2 Patient 3
Combination with rehabilitation therapy Neuropathic pain Neuropathic pain
better to long-term ESPB, to the fact that performing multidisciplinary therapy is more effective, or a combination of both. Regional techniques like ESPB are a therapy that has shown good results in the treatment of acute pain,1,10 however it seems that pain recurs over time if used as monotherapy in chronic pain. In the treatment of chronic thoracic pain, Fusco et al. 5 performed a BPS in one patient, but the pain recurred at 45 days and had to undergo a paravertebral block (PVB). However, they observed that the duration of the ESPB was signiﬁcantly longer than that of the PVB. Ueshima et al. 6 had to repeat the ESPB 4 times in 2 weeks to maintain pain relief in the patient’s case. Ahiskalioglu et al. 7 chose to use a catheter with PCA for 24 hours, managing to maintain pain relief for 3 months. Forero et al.8 presented a series of 7 cases of posthoracotomy pain syndrome. 3 of the cases recurred in the short term (hours-days) and other 3 in the medium term (2-4 weeks). Only in one the relief was superior to 4 weeks after repeating the technique twice. Therefore, although there are very few cases described in this regard, they coincide with our results in that the performance of the ESPB in chronic pain has a good short-term response, but pain recurs if used in monotherapy. Despite being a series of cases, our experience indicates that one of the most important factors for the success of ESPB in the treatment of chronic chest pain is the multimodal approach. Although studies that increase the evidence on the use of ESPB in the treatment of chronic pain are necessary, we want to highlight the importance of interdisciplinary treatment in the management of chronic pain.
Conclusion The ESPB seems to be a very effective treatment in the management of chronic chest pain, with good correlation between the areas of pain and analgesia. However, this
technique must be part of a comprehensive therapeutic plan for long-term pain relief.
Bibliografía 1. 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. 2. De Cassai A, Tonetti T. Local anesthetic spread during erector spinae plane block. Journal of Clinical Anesthesia. 2018;48:60---1. 3. Adhikary S, Das, Bernard S, Lopez H, Chin KJ. Erector Spinae Plane Block Versus Retrolaminar Block. Reg Anesth Pain Med. 2018, http://dx.doi.org/10.1097/AAP. 0000000000000798. 4. Ueshima H, Hiroshi O. Spread of local anesthetic solution in the erector spinae plane block. J Clin Anesth. 2018. 5. Fusco P, Dicarlo S, Scimia P, Luciani A, Petrucci E, Marinangeli F. Could the new ultrasound-guided erector spinae plane block be a valid alternative to paravertebral block in chronic chest pain syndromes? Minerva Anestesiol. 2017, http://dx.doi.org/10.23736/S0375-9393.17.12109-7. 6. Ueshima H, Otake H. Erector spinae plane block for pain management of wide post-herpetic neuralgia. J Clin Anesth. 2018, http://dx.doi.org/10.1016/j.jclinane.2018.07.010. 7. Ahiskalioglu A, Alici HA, Ciftci B, Celik M, Karaca O. Continuous ultrasound guided erector spinae plane block for the management of chronic pain. Anaesthesia Critical Care and Pain Medicine. 2018. 8. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series. Scand J Pain. 2017, http://dx.doi.org/10.1016/j.sjpain.2017.08.013. 9. Mu˜ noz-Leyva F, Mendiola WE, Bonilla AJ, Cubillos J, Moreno DA, Chin KJ. In Reply to ‘‘Continuous Erector Spinae Plane (ESP) Block: Optimizing the Analgesia Technique. J Cardiothorac Vasc Anesth. 2018, http://dx.doi.org/10.1053/j.jvca.2018.03.034. 10. Luis-Navarro JC, Seda-Guzmán M, Luis-Moreno C, López-Romero JL. The erector spinae plane block in 4 cases of videonola Anestesiol y Reanim. assisted thoracic surgery. Rev Espa˜ 2018;65:204---8.