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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 46-48

Exploring Potential of Ultrasound Guided Erector Spinae Plane (US-ESP) Block for Post-Operative Analgesia in Spine Surgeries: A Pilot Study

1 Assistant Professor, Dept. of Anesthesia, IGIMS, Patna, India
2 Senior Resident, Dept. of Anesthesia, IGIMS, Patna, India
3 Associate Professor, Dept. of Anesthesia, IGIMS, Patna, India
4 Professor, Dept. of Neuro Surgery, IGIMS, Patna, India

Date of Web Publication20-Nov-2020

Correspondence Address:
Nidhi Arun
Asst. Professor, Dept of Anesthesia, IGIMS, Patna
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Arun N, Kumar R, Kumar A, Jha K M. Exploring Potential of Ultrasound Guided Erector Spinae Plane (US-ESP) Block for Post-Operative Analgesia in Spine Surgeries: A Pilot Study. J Indira Gandhi Inst Med Sci 2019;5:46-8

How to cite this URL:
Arun N, Kumar R, Kumar A, Jha K M. Exploring Potential of Ultrasound Guided Erector Spinae Plane (US-ESP) Block for Post-Operative Analgesia in Spine Surgeries: A Pilot Study. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Dec 1];5:46-8. Available from: http://www.jigims.co.in/text.asp?2019/5/1/46/301077

  Introduction Top

US-ESP block is a quite newer block described by Forero et al in 2016.[1] ESP blocks ventral as well as dorsal rami of spinal nerves that innervates bony vertebrae and paraspinal muscles. Level and extent of block depends on level of injection and amount of local anaesthetic injected, as the erector spinae fascia extends from nuchal fascia cranially to sacrum caudally and the drug spreads unhindered over several levels in both directions.[2] We have explored the effectiveness of bilateral US-ESP block for post-operative analgesia after spine surgeries.

  Aims and Objectives: Top

Our primary aim was to evaluate effectiveness of bilateral US-ESP block for postoperative analgesia and opioid sparing effect in thoraco-lumbar spine surgeries. Secondary aim was to look for any side effects and patient satisfaction after ESP block.

  Material and Methods: Top

This study was conducted in our institute over period of three months from June to August 2018. This is an observational study where15 patients between age group 18 to 50 years of ASA-PS I and II, posted for spinal surgeries were selected. Exclusion criteria were patient refusal, ASA PS III or more, spine abnormalities, deranged coagulation profile and allergic to study drug i.e. bupivacaine and dexamethasaone. After taking institute ethical committee clearance, 15 patients between age group of 18 to 60 years of ASA PS I or II posted for routine thoraco/lumbar spine surgery, were randomly selected. Randomization was done using computer generated random number table. Informed written consent were taken for the procedure.

During PAC, all patients were educated about 11 points NRS for pain assessment, where 0 means no pain and 10 means maximum severe pain. Relevant medical and surgical history were documented, physical and airway examination done, investigations checked, premedication and order of NPO given one day before surgery.

In OT, basic monitoring was done. GA was given with propofol, morphine, Vecuronium, tracheal intubation, intermittent positive pressure ventilation with 02, N20 and sevoflurane. After positioning the patient in prone position, USG guided bilateral ESP block was given with 20 ml of 0.25% bupivacaine with 4 mg dexamethasone, one or two level above the proposed level of surgery. At the end of surgery, trachea was extubated and all patient were shifted to PACU. In post-operative period no other analgesic was given. Post-operatively all patients were followed for 24 hours. NRS, HR, Systolic and diastolic BP just after reaching in PACU and then at the interval of 2, 4, 8, 12 and 24 hours were recorded. We have decided to administer injection morphine (0.1mg/kg) as rescue analgesic when NRS will be found to be more than 4. Any side effects encountered were also recorded during the study duration. Patient satisfaction score was recorded as either YES or NO.

  Technique of US-ESP Block: Top

Patient placed in prone position. Back painted and draped. High frequency linear transducer was prepared by covering it with sterile camera cover. Materials required are 18/20 G spinal needle with 10 cm extension, 10 ml and 20 ml syringe, sterile water, 0.5% bupivacaine and dexamethasone.

First of all, anatomic landmark of spinous process of vertebra was identified at which level block was to be given. Then under full aseptic and antiseptic precautions, linear USG transducer was placed in longitudinal orientation 3 cm lateral to identified spinous process. Then trapezius, rhomboid major and erector spinae muscle were identified from the surface. Under USG guidance, 20 G spinal needle with 10 cm extension attached to it was passed in plane deep to erector spinae muscle. After confirming the right plane with hydro-dissection, drug was injected beneath erector spinae and above tip of spinous process.

  Results: Top

Parameters to be studied during study period of post-operative 24 hours were recorded and mean and standard deviation values calculated.
Table 1: Showing demographic parameters

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Table 2: Showing Mean heart rate, mean systolic BP, diastolic BP and numerical pain score are shown in the tabular form.

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We found that, only 2 out of 15 patients need rescue analgesia (13.3%) when NRS was found to be more than 4. One patient complained of pain at 4 hour and other at 8 hour post-operatively. After getting morphine as rescue analgesia, both patients were pain free. Only 1 out of 15 patients complained of PONV. No other adverse effects were recorded during the study period like, hyper/hypotension, brady/tachycardia, urinary retention, recent onset of muscle weakness and others. All patients were satisfied with post-operative pain management.

  Discussion: Top

ESP block is a quite newer block described by Forero et al in 2016, for thoracic neuropathic pain.[1] It is a myo-facial plane block where drug diffuses in paravertebral space. This block provides analgesia by blocking dorsal rami, ventral rami as well as rami communicans of spinal nerves. Vidal E, et al had done a cadaveric study to determine the mechanism of action of ESP block.[3] Four spinal columns of fresh corpses were used. A total of 9 USG-ESP blocks were performed in different regions of the specimens. Injections were performed with 20 ml of 0.01% of methylene blue to determine its distribution. The distribution of the dye was observed from the anterior side of the thorax, measuring the amount of intercostal spaces stained and the structures in which the stain was found were recorded. Dye was found in the paravertebral space, intercostal spaces, and in some cases in the prevertebral chain. The intensity of the dye was greater on the side of the injection, dorsal to the column, than that found in the ventral part. Based on the observation they had concluded that ESP has a mechanism of anaesthetic action similar to paravertebral blocks.

Level and extent of block depends on level of injection and amount of drug injected. ESP plane is larger than epidural space. Erector spinae fascia runs along the length of thoraco-lumbar spine from nuchal fascia cranially to sacrum caudally.[2] Thus providing extensive and unhindered spread of injected drug over several levels in both cranial and caudal direction. Chin KJ et al[4] had reported that ESP block given at level of T7, showed effective analgesia from C6 to T12. There is radiological evidence that injection of 20 ml of contrast at T7 in cadavers showed extension between C5 to T12. There are several advantages of ESP block over other blocks. It is easy to perform and safe. Under USG guidance target is transverse process, which is easily identifiable and is relatively distant from major vascular structure and pleura. As this is a paraspinal block, there is no hemodynamic fluctuations related to epidural analgesia. It provides extensive analgesia from a single puncture. ESP block can be given in different postural position i.e. sitting/prone/lateral decubitus. It is possible to perform block at metameric levels relatively distant from surgical zone. Catheter can be easily inserted for re-dosing and prolongation of anaesthesia. This novel block can be used for multiple indications from the neck down to the lumbar region. For example, to manage pain after breast surgery, after different open/laparoscopic abdominal surgeries, after renal transplant, to improve analgesia in open heart surgery, as part of multimodal anaesthetic regimen for posterior spinal fusion surgery, for acute herpes zoster pain management. Continuous ESP block has been used for pain management in extensive burn. It may aid weaning from mechanical ventilation in patients with multiple rib fracture. Since 2016, various authors had published case reports and case series on benefits of ESPB. Hironobu Uahima et al[5] had published their clinical experience of USG guided ESP block for thoracic vertebrae surgery. Melvin JP et al[6] has reported the role of low thoracic erector spinae plane block for peri-operative analgesia in lumbo-sacral spine surgery. Swati Singh et al[7] has concluded that ESP block an effective block for post-operative analgesia in modified radical mastectomy. Juan Carlos Luis Navarro et al[8] and Niraj G et al[9] has exploited the benefit of ESP block in various open abdominal surgeries. Tulgar Serkam et al[8] had used ESP block for different laparoscopic surgeries. Daniele Bonvicini et al[10] have used bilateral USG guided ESP block in breast cancer and reconstruction surgery. First review providing a pooled review of ESP block characteristics was done by Tsui BCH et al[12] to examine pooled clinical data from published literature to gain an understanding of ESP block characteristics. PubMed search was conducted to gather all ESP block related publications in English. Inclusion criteria included reports on ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. It was concluded that ESP block appears to be a safe and effective option for multiple type of thoracic, abdominal and extremity surgery.

  Conclusion: Top

Based on our observations and results, we conclude that bilateral ESP block is effective and opioid sparing technique for post-operative analgesia after spinal surgery.

  References Top

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. 1
Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia: Anatomy, function and clinical considerations. J Anat. 2012;221:507-36.  Back to cited text no. 2
Vidal E, Giménez H, Forero M, Fajardo M. Erector spinae plane block: A cadaver study to determine its mechanism of action. Rev Esp Anaestesiol Reanim. 2018 Nov;65(9):514-19.  Back to cited text no. 3
Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral ESP block in patients having ventral hernia repair. Anaesthesia 2017;72:452-60.  Back to cited text no. 4
Hironobu U, Hiroshi O. Clinical experiences of ultrasound guided erector spinae plane block for thoracic vertebra surgery. Journal of clinical anaesthesia 38(2017)137.  Back to cited text no. 5
Melvin JP et al. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Can J Anaesth. 2018Sep;65(9):1057-1065.  Back to cited text no. 6
Singh S, Chowdhary NK. Erector spinae plane block an effective block for post operative analgesia in modified radical mastectomy. Indian J Anaesth 2018;62:148-150.  Back to cited text no. 7
[PUBMED]  [Full text]  
Luis-Navarro JC, Seda-Guzman, Luis-Moreno C, Chin KJ. Erector spinae plane block in abdominal surgery: Case series. Indian J Anaesth 2018;62:549-54.  Back to cited text no. 8
[PUBMED]  [Full text]  
Niraj G et al. Continuous erector spinae plane block (ESP) analgesia in different open abdominal surgical procedures: A case series. J Anesth Surg 2018;5(1):57-60.  Back to cited text no. 9
Tulgar S, Kapali MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasound guided erector spinae plane block for post-operative analgesia in laparoscopic cholecystectomy: A pros prospective, randomized, controlled clinical trial. J Clin Anesth. 2018Sep;49:101- 106.  Back to cited text no. 10
Bonvicini D, Giacomazzi A, Pizzirani E. Use of the ultrasound guided erector spinae plain block in breast surgery. Minerva Anestiol 2017;83:1111-2.  Back to cited text no. 11
Tsui BCH et al. The ESP block: A pooled review of 242 cases. Journal of clinical anaesthesia, October 2018 ;53:29-34  Back to cited text no. 12


  [Table 1], [Table 2]


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