Mauricio Forero

The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain.

Abstract Thoracic neuropathic pain is a debilitating condition that is often poorly responsive to oral and topical pharmacotherapy. The benefit of interventional nerve block procedures is unclear due to a paucity of evidence and the invasiveness of the described techniques. In this report, we describe a novel interfascial plane block, the erector spinae plane (ESP) block, and its successful application in 2 cases of severe neuropathic pain (the first resulting from metastatic disease of the ribs, and the second from malunion of multiple rib fractures). In both cases, the ESP block also produced an extensive multidermatomal sensory block. Anatomical and radiological investigation in fresh cadavers indicates that its likely site of action is at the dorsal and ventral rami of the thoracic spinal nerves. The ESP block holds promise as a simple and safe technique for thoracic analgesia in both chronic neuropathic pain as well as acute postsurgical or posttraumatic pain.

The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair.

Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre‐operative bilateral ESP blocks with 20–30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24‐h opioid consumption was 18.7 mg (0.0–43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0–5.0) and 2.5 (0.0–3.0) on an 11‐point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2–L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra‐umbilical and infra‐umbilical dermatomes with a single‐level injection and its relative simplicity.

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

PurposeThe erector spinae plane (ESP) block has been described in the successful management of both thoracic and abdominal pain. Since the erector spinae muscle extends to the cervical spine, the ESP block may be potentially useful in painful conditions of the shoulder girdle.Clinical featuresWe performed a series of ESP blocks at the T2/T3 level in an elderly male patient with chronic shoulder pain. Immediate and profound analgesia with improved range of motion was consistently observed following the block. There was detectable sensory block in the congruent cervico-thoracic dermatomes with no motor block. Computed tomography imaging showed the spread of radiocontrast up to the C3 level in the vicinity of the neural foramina. Clinical analgesia generally outlasted the expected duration of conduction blockade and significantly contributed to overall improvement in the patient’s symptoms.ConclusionsThe ESP block may be a promising alternative to other interventional procedures in the management of chronic shoulder pain and deserves further study.RésuméObjectifLe bloc du plan des muscles érecteurs du rachis (ou bloc ESP, pour erector spinae plane) a été décrit dans des cas de prise en charge de la douleur thoracique et abdominale. Étant donné que les érecteurs du rachis s’étendent jusqu’à la colonne cervicale, le bloc ESP pourrait être utile en cas de conditions douloureuses au niveau de la ceinture scapulaire.Éléments cliniquesNous avons réalisé une série de blocs ESP au niveau T2/T3 chez un patient masculin âgé souffrant de douleur chronique à l’épaule. Une analgésie immédiate et profonde, accompagnée d’une amplitude articulaire améliorée, a été observée de manière constante après la réalisation du bloc. Un bloc sensoriel détectable dans les dermatomes cervico-thoraciques congruents a également été observée et ce, sans bloc moteur. Les images de tomodensitométrie ont montré la diffusion du produit de contraste radiologique jusqu’au niveau C3 à proximité des foramens intervertébraux. L’analgésie clinique a en général duré plus longtemps que la durée pharmacologique prévue du bloc et a considérablement contribué à l’amélioration globale des symptômes du patient.ConclusionUn bloc ESP pourrait constituer une alternative prometteuse aux autres procédures interventionnelles pour la prise en charge de la douleur chronique à l’épaule, et cette modalité mérite d’être étudiée de manière plus approfondie.

Successful Reversal of Hyperalgesia/Myoclonus Complex with Low-Dose Ketamine Infusion

Abstract:  We report the successful use of low‐dose ketamine infusion for treating a severe episode of painful myoclonus in the lower extremities, associated with opioid‐induced hyperalgesia (OIH), in a patient who was receiving long‐term, high dose intrathecal hydromorphone therapy. A low‐dose ketamine infusion immediately relieved the painful myoclonus. It also enabled a reduction in the intrathecal opioid dosage leading to a resolution of the acute symptoms attributed to OIH.

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

Abstract Background and aims 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. Methods 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. Results 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. Conclusion 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. Implications 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.

Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane

Post-operative pain after minimally invasive video-assisted thoracoscopic surgery (VATS) in adults is commonly managed with oral and parenteral opioids and invasive regional techniques such as thoracic epidural blockade. Emerging research has shown that the novel erector spinae plane (ESP) block, can be employed as a simple and safe alternative analgesic technique for acute post-surgical, post-traumatic and chronic neuropathic thoracic pain in adults. We illustrate this by presenting a paediatric case of VATS, in which an ESP block provided better analgesia, due to greater dermatomal coverage, as well as reduced side-effects when compared with a thoracic epidural that had previously been employed on the same patient for a similar procedure on the opposite side.

Reply to Dr Ueshima and Dr Murouchi.

To the Editor: We congratulate Dr Forero et al 1 on their article addressing the dermatomal effect of erector spinae plane block (ESPB). Their results show that the block may be effective with this easy maneuver. Moreover, the spread of the injectate was clearly shown with cadaveric dissection. However, it is important to note that current literature on retrolaminar block (RLB), or paravertebral block lamina technique, has already shown similar technique and analgesic effect for surgical patients. The ultrasound-guided technique of ESPB is almost identical to that of ultrasound-guided RLB shown in the previous article. Dr Forero and colleagues have demonstrated that superficial ESPB had no cutaneous sensory block and that deep injection into the interfascial plane between the transverse process and the erector spinae muscle resulted in complete sensory loss over the ipsilateral thorax. The pictures of the anatomical location of the needle tip placement under ultrasound guidance were identical to that of RLB. At this early stage of investigation regarding ESPB and RLB, it remains

Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study

M. Forero, MD, FIPP (&) Department of Anesthesia, McMaster University, Hamilton, ON, Canada e-mail: maoforeroman@hotmail.com Figure Magnetic resonance imaging with gadolinium contrast added to bupivacaine erector spinae plane block (30 mL total volume) injected at the left T10 level. A) Sagittal view at the level of the intervertebral foraminae showing transforaminal spread of the gadolinium from T5 to T12 of the left side (yellow arrows). B) Sagittal view of the spinal canal depicting epidural spread (red arrows) of the contrast from T5 to T12. C) Axial view at the T12 level demonstrating the spread of gadolinium from the erector spinae plane through paravertebral space (dashed white arrow) transiting the intervertebral foramina (yellow arrow) to spread circumferentially (red arrows) within the epidural space. Some venous uptake of gadolinium is also noted. Modified, with permission, from the original unpublished image in the Philip Peng Educational Series collection (Toronto, ON, Canada)

The efficacy of ultrasound-guided fascia iliaca block in hip surgery: a question of technique?

To the Editor: W e read with interest the work by Shariat et al. The attempt to increase our knowledge of analgesia for hip arthroplasty is commendable; however, we have noted some debatable statistics and questionable methodology, which may cast doubt on the conclusion and summary of this article. The study protocol describes visual analog scale scoring for pain assessment; however, the article refers solely to the numeric rating scale 11 (NRS-11) score. This could easily be a typographical error in the study protocol; if, however, it is not, then the substitution of NRS-11 (in the article) for visual analog scale (in the study protocol) is questionable. The interchangeability of these 2 scoring systems has been controversial in the past. Indeed, such interchangeability has been questioned specifically for postoperative orthopedic patients. The NRS-11 data in this article are presented as continuous (numerical) data, data that can be represented on a number line. Clearly, one patient’s NRS score of 8, say, is not twice as much pain as his NRS score of 4. Similarly, a patient’s perception of a score of 6, for example, is not the same as another patient’s score of 6. Is it therefore wise to consider NRS scores as a continuous variable? Finally, we noted that the authors wanted a “... mean NRS approximately 8–9 for the SB group” and pain intensity ranged up to 10 in each group (for up to 30 minutes postblock). Assuming a pain score of 10 is not an instantaneous event, to have a patient with a pain score of 10 up to 30 minutes after a hip arthroplasty seems a long timewithout giving supplemental analgesia (apart from the patient controlled analgesia morphine and fascia iliaca block), all in the name of a randomized control trial.

Long-term continuous erector spinae plane block for palliative pain control in a patient with pleural mesothelioma

To the Editor, Pleural mesothelioma is the most common type of asbestos-related cancer and has a median survival from presentation of nine to 12 months. The most common symptoms are dyspnea and chest pain. The pain arises from three sources: localized somatic pain from invasion of the chest wall, neuropathic pain from intercostal nerve or spinal canal invasion, and diffuse visceral pain from visceral pleura invasion. The erector spinae plane (ESP) block is a relatively new interfascial plane block originally described for thoracic neuropathic pain, but with an expanding number of reports in numerous other perioperative and pain settings. Thus far, however, no reports have outlined the use of the ESP block for the continuous delivery of local anesthetic in the management of pain from malignant mesothelioma in the outpatient setting. Herein, we present a 57-yr-old female with a four-month history of malignant pleural mesothelioma. The main issue was severe chest wall pain radiating to the right shoulder refractory to conventional analgesia that included highdose parenteral opioids (80 mg iv morphine per day). Thus, she was referred for an ESP block. An ultrasound-guided diagnostic block was performed with the patient in the sitting position using a linear probe (GE LOGIQ e, Wauwatosa, WI, USA) 3 cm lateral to the spinous process at the T3 level in the paramedian sagittal plane under sterile technique. A 100-mm 21G needle (Stimuplex A, Braun Melsungen AG, Germany) was inserted in plane from cephalad to caudal direction to the plane between the erector spinae muscle and the transverse process of T3. Using hydrodissection to ensure optimal spread, a total of 20 mL 0.5% bupivacaine was administrated in divided doses. Thirty minutes following the block, the patient reported a decrease in chest wall and shoulder pain from 6 to 2 (numerical rating scale [NRS]; 0 = no pain, 10 = worst possible pain). She did not demand any rescue analgesic for that night and was able to sleep well. Subsequently, an indwelling catheter was implanted targeting the T2 ESP level aiming to position the catheter tip at T3. After administration of 20 mL bupivacaine 0.5% using a single-shot needle (Figure A), an 18G 80-mm Tuohy needle (Braun, Melsungen AG) was introduced in the ESP followed by the insertion of a 20G catheter (Braun, Melsungen AG) 4 cm beyond the needle tip (Figure B, C). Intermittent boluses of 5 mL bupivacaine 0.5% were administered every eight hours for the first four days via the catheter. In addition, the intravenous parenteral dose of morphine was reduced from 80 mg day to 50 mg day without further need of rescue morphine. This regime allowed the patient to comfortably ambulate with a low resting pain score (NRS = 2/10). The pinprick test showed sensory block from T3 to T9 of the right hemithorax. An attempt was made to switch to continuous infusion using an elastomeric pump with a maximum rate of 5 mL hr over three days; a solution of up to 0.2% bupivacaine failed to reproduce the same analgesic effect. Therefore, intermittent bolus delivery was restored with 10 mL J. Ramos, MD Department of Anesthesia, Caja Petrolera de Salud, La Paz, Bolivia