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Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 395-396

Modified erector spinae block for modified radical mastectomy: A novel technique


Department of Anaesthesia, AIIMS, Patna, Bihar, India

Correspondence Address:
Dr. Chandni Sinha
Department of Anaesthesia, 112, Block 2, Type 4, AIIMS Residential Complex, Khagaul, Patna - 801 505, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_266_19

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Date of Web Publication5-Sep-2019
 


How to cite this article:
Kumar A, Sinha C, Kumar A, Kumari P. Modified erector spinae block for modified radical mastectomy: A novel technique. Saudi J Anaesth 2019;13:395-6

How to cite this URL:
Kumar A, Sinha C, Kumar A, Kumari P. Modified erector spinae block for modified radical mastectomy: A novel technique. Saudi J Anaesth [serial online] 2019 [cited 2019 Nov 21];13:395-6. Available from: http://www.saudija.org/text.asp?2019/13/4/395/265995



Sir,

Erector spinae plane (ESP) block is a myofascial plane block employed as a simple and safe alternative analgesic technique to provide sensory block at multi-dermatomal levels across the posterior, lateral, and anterior chest wall. It can be used for acute post-surgical, post-traumatic, and chronic neuropathic thoracic pain. The extent of analgesia provided by ESP block depends upon the volume of drug, site of injection, approach of block, and pattern of spread within the myofascial plane.

Forero et al.[1] injected 20 mL of 0.5% ropivacaine deep to erector spinae muscle and reported a sensory loss from T3 to T9 over the entire posterolateral aspect of the left hemithorax, extending anteriorly to the midclavicular line. There was no blockade of intercostobrachial nerve leading to the sparing of axilla. On injecting drug superficial to erector spinae muscles, the axilla and medial aspect of the upper arm were also anesthetized.

We in our patients have been injecting the local anesthetic both superficial and deep to the erector spinae muscles for modified radical mastectomy (MRM) as shown in [Figure 1]. Written consent has been taken from patient. Structure identified during the ultrasound scan includes trapezius muscle, rhomboid major muscle, erector spinae muscle (ESM), and transverse process. A total volume of local anesthetic 40 ml 0.2% ropivacaine (20 ml superficial and 20 ml deep to erector spinae muscle) was used at the level of T5 transverse process. Thereafter, the sensory blockade has been adequate: T2-T8 (posteriorly) and upto the midclavicular line (anteriorly). The axilla has been blocked in these patients.
Figure 1: Sonoanatomy of drug spread above and below erector spinae muscle

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The proposed mechanism of ESP block as described by Forero et al.[1] was due to blockade of dorsal and ventral rami of the thoracic spinal nerves by local anesthetic. CT imaging further suggested the rami were involved at a proximal location close to the intervertebral foramina. This evidence was supported by the cadaveric data when the dye was injected deep to erector spinae muscle. However, when the dye was injected superficial to erector spinae in the cadavers, the ventral rami was spared.

According to Chin KJ, et al.[2] who achieved excellent analgesic effects in bariatric surgery, the effect was because of the diffusion of local anesthesia into the paravertebral space. The drug acted at both the dorsal and ventral rami of the thoracic spinal nerves. Ivanusic J, et al.[3] injected the dye mixture deep to erector spinae in cadavers. There was no spread to the paravertebral space, the proposed mechanism may be due to blockade of lateral cutaneous branches of the intercostals nerves near the angle of the ribs. Ivanusic J, et al. did not study injecting the dye superficial to erector spinae below the rhomboid major muscle.

To ensure adequate blockade of intercostobrachial nerve, we recommend local anesthetic injection both superficial and deep to erector spinae muscle for MRM. This should be validated by further cadaveric studies of ultrasound-guided ESP block by injecting the dye deep and superficial to ESM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Forero M, Adhikari 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
    
2.
Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: A Report of 3 cases. Reg Anesth Pain Med 2017;42:372-6.  Back to cited text no. 2
    
3.
Ivanusic J, Konishi Y, Barrington MJ. A Cadaveric study investigating the mechanism of action of erector spinaeblockade. Reg Anesth Pain Med 2018;43:567-71.  Back to cited text no. 3
    


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