Year : 2020 | Volume
| Issue : 4 | Page : 535-537
Bilateral high thoracic continuous erector spinae plane blocks for postoperative analgesia in a posterior cervical fusion
Sandeep Diwan1, Won Uk Koh2, Ki Jinn Chin3, Abhijit Nair4
1 Department of Anesthesia, Sancheti Hospital, Pune, Maharashtra, India
2 Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
3 Department of Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada
4 Department of Anesthesia, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Dr. Abhijit Nair
Department of Anesthesia, Basavatarakam Indo.American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
Source of Support: None, Conflict of Interest: None
|Date of Submission||10-Oct-2019|
|Date of Decision||13-Apr-2020|
|Date of Acceptance||20-Apr-2020|
|Date of Web Publication||24-Sep-2020|
Posterior decompression and instrumentation of the cervical spine are associated with severe postoperative pain due to extensive soft tissue and muscle dissection during the surgery. In this case series, we describe bilateral continuous cervical erector spinae plane block (CESPB) placed at T1-2 through the thoracic erector spinae plane. A series of 4 patients underwent posterior cervical decompression and stabilization for various surgical indications. The CESPB block provides intense analgesia with low requirements of anesthetic drugs in the perioperative period and opioid-free analgesia in the postoperative period. The spread of local anesthetic was studied by performing CT contrast studies after obtaining informed consent.
Keywords: Acute pain; cervical spine fusion; erector spinae plane block; regional anesthesia; ultrasound
|How to cite this article:|
Diwan S, Koh WU, Chin KJ, Nair A. Bilateral high thoracic continuous erector spinae plane blocks for postoperative analgesia in a posterior cervical fusion. Saudi J Anaesth 2020;14:535-7
|How to cite this URL:|
Diwan S, Koh WU, Chin KJ, Nair A. Bilateral high thoracic continuous erector spinae plane blocks for postoperative analgesia in a posterior cervical fusion. Saudi J Anaesth [serial online] 2020 [cited 2021 Jun 25];14:535-7. Available from: https://www.saudija.org/text.asp?2020/14/4/535/296021
Posterior decompression and instrumentation of the cervical spine is associated with severe postoperative neck pain, which is a result of the extensive soft tissue and muscle dissection during the surgery. Inadequate pain control can delay recovery during the postoperative period and prolong hospital stay. The erector spinae plane block (ESPB) was first described in 2016 for managing chronic thoracic neuropathic pain in a cancer patient. It continued to evolve as a block for the management of postoperative pain in various thoracic, abdominal, and lower limb surgeries among adults and pediatric patients as it is easy to perform and provided good quality analgesia. The ESPB has been used in lumbar and thoracic spine surgeries to provide effective perioperative analgesia. Through its action on the dorsal rami, the ESPB provides extensive analgesia in the postoperative period. In this case series, we describe the use of cervical ESPB (CESPB) in four patients undergoing posterior cervical spine decompression and fusion to provide postoperative analgesia. Written informed consent was obtained from all patients in this case series.
The basic demographic details and the level of operation are summarized [Table 1]. The four patients described in this case series underwent posterior cervical decompression with posterior laminectomy, pedicle instrument fixation, and interbody fusion. After induction of general anesthesia, the patient was positioned prone and the patient received bilateral ESP blocks at T1 (cases 1 and 2) or T3 (cases 3 and 4) with 20 mL of 0.2% ropivacaine with a mixture of 25 mcg of dexmedetomidine. After skin disinfection under the guidance of high-frequency linear probe (M-Turbo, Sonosite, Bothel, USA) bilateral ESP catheters were placed at the same level and inserted until the tip of the catheters were positioned 2 levels below the lowest level of decompression. The catheter was subcutaneously tunneled laterally away from the surgical incision site [Figure 1]a. The same procedure was repeated on the opposite side. A continuous infusion of 0.1% ropivacaine at an infusion rate of 5 mL/h was commenced in the post-anesthesia care unit (PACU) through the ESP catheters for the next 48 h. No additional opioid was given during the operation after the initial dose of intravenous 1.5 μg/kg fentanyl at the start of anesthesia in every patient. All patients were hemodynamically stable throughout the operation. Neurologic examination in the immediate postoperative period was normal in all patients, with full motor strength and intact sensation in the four extremities. Every patient received a standard regimen of 1 g of intravenous paracetamol every 8 h and 75 mg of diclofenac every 12 h for the next 48 h. Intravenous fentanyl was prescribed as needed for the management of additional breakthrough pain during the postoperative period.
|Figure 1: (a) Bilateral subcutaneously tunneled ESP catheters. (b) Coronal image depicting a bilateral spread of contrast in the paravertebral area (red arrow). (c) Axial plane depicting the bilateral spread of the contrast in the cervical erector spinae plane which also includes the dorsal rami (blue arrow). (d) Sagittal image depicting the catheter insertion at T2-3 and contrast spread below erector spinae muscle and in the paravertebral space|
Click here to view
The Numeric Rating Scale (NRS) pain score of the patients from the immediate postoperative time (0 h) to 48 h after the operation are summarized in [Table 2]. Initial pain scores reported at the arrival to PACU ranged from 2–3/10. The follow-up pain scores ranged from 2–3/10 (2 h), 2/10 (4 h), 1–2/10 (8 h), 1/10 (12 h), and 1/10 (24 h), respectively. Only one patient (Case 1) received one rescue dose of 50 mg of tramadol at 2 h after operation and 50 μg of fentanyl at 4 h after the operation. The other three patients did not receive any additional doses of fentanyl during the postoperative period. The CESPB catheters were removed at 48 h postoperatively and the patients were discharged without complications.
|Table 2: Numeric Rating Scale (NRS) pain scores at the postoperative period of 48 hours|
Click here to view
Computed tomographic (CT) contrast imaging studies
After receiving informed consent from all the patients, CT contrast imaging studies were performed 24 h after the surgery to investigate the spread of injectate after CESPB axial, sagittal, and coronal planes. A solution containing 3 mL of omnipaque (300 mg iodine/mL) with 17 mL of 0.9% saline was injected into each CESPB catheter. The resulting CT images [Figure 1]b, [Figure 1]c, [Figure 1]d were interpreted by a consultant radiologist. The results of contrast dye spread injected through the bilateral CESP catheters are described in [Table 3]. Every patient demonstrated paravertebral spread and to the dorsal ramus in the coronal plane with no spread to the ventral ramus.
| Discussion|| |
ESPB in cadavers has established that it provides an effective blockade of dorsal rami of spinal nerves. The multifidus cervical plane block is a related technique that has been described for perioperative analgesia in cervical spine surgery. However, two theoretical complications can exist with the abovementioned approach; the needle can transgress the intrathecal space or it may perforate the artery accompanying the dorsal rami. Extensive posterior cervical exploration and instrumentation is a cause for severe pain in the postoperative period. The postoperative pain relief must be aimed at multimodal analgesia (MMA) with opioid-sparing strategies.
To our knowledge, the continuous cervical erector spinae for cervical spine surgery is not described. The catheters and infusions were placed in sterile conditions. Rapid recovery, tolerance of endotracheal tube for the first 24 h, and no intravenous fentanyl requirements in the postoperative period were the chief highlights in our case series. Contrast studies revealed no encroachment of LA in the surgical field. An infusion of 0.1% ropivacaine at 5 mL/h provided good pain relief with IV paracetamol 1 g 8 hourly.
In contrast to the single injection multifidus cervicis plane block and the cervical interfascial plane block reported for cervical spine surgery, bilateral continuous catheters introduced at T1 provided uninterrupted delivery of LA for postoperative pain relief. Bilateral single injections of long-acting local anesthetic agents in the thoracocervical ESP for dorsal spine surgery would provide intraoperative analgesia extending for a few hours in the postoperative period.
This novel approach warrants further prospective study and comparison with single-injection techniques to establish the role of CESPB for dorsal spine surgery.
| Conclusion|| |
To conclude, bilateral continuous CESPB is an easy modality of managing perioperative pain by providing opioid-free or opioid-sparing analgesia thus promoting early recovery. We recommend incorporating CESPB in the MMA regimen for all patients undergoing cervical to dorsal spine surgery.
We acknowledge the contributions made by Late Dr. Ketan Khurjekar, Ex-Chief, Department of Spine Surgery at Sancheti Hospital, Pune, Maharashtra and Dr. Pramod Bhilare, Department of Spine Surgery at Sancheti Hospital, Pune, Maharashtra, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: A prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013;118:934-44.
Chin KJ, Lewis S. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae plane (ESP) blocks in a multimodal anesthetic regimen. Spine (Phila Pa 1976) 2019;44:E379-83.
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.
De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: A systematic qualitative review. Minerva Anestesiol 2019;85:308-19.
Ueshima H, Inagaki M, Toyone T, Otake H. Efficacy of the erector spinae plane block for lumbar spinal surgery: A retrospective study. Asian Spine J 2019;13:254-7.
Ivanusic J, Konishi Y, Barrington MJ; A Cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med 2018;43:567-71.
Nielsen MV, Moriggl B, Hoermann R, Nielsen TD, Bendtsen TF, Børglum J. Are single-injection erector spinae plane block and multiple-injection costotransverse block equivalent to thoracic paravertebral block? Acta Anaesthesiol Scand 2019;63:1231-8.
Ohgoshi Y, Izawa H, Kori S, Matsukawa M. Multifidus cervicis plane block is effective for cervical spine surgery. Can J Anaesth 2017;64:329-30.
[Table 1], [Table 2], [Table 3]