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Year : 2023  |  Volume : 17  |  Issue : 1  |  Page : 141-143

Continuous erector spinae plane block for analgesia following cervical rib resection

1 Department of Anaesthesiology, Government Medical College, Pali, Rajasthan, India
2 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence Address:
Sadik Mohammed
Department of Anaesthesiology and Critical Care, AIIMS Phase II, Basani Industrial Area, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.sja_546_22

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Date of Submission25-Jul-2022
Date of Acceptance26-Jul-2022
Date of Web Publication02-Jan-2023

How to cite this article:
Bhararia S, Mohammed S, Kewalramani R, Patel S. Continuous erector spinae plane block for analgesia following cervical rib resection. Saudi J Anaesth 2023;17:141-3

How to cite this URL:
Bhararia S, Mohammed S, Kewalramani R, Patel S. Continuous erector spinae plane block for analgesia following cervical rib resection. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:141-3. Available from:

Although most cases of thoracic outlet syndrome (TOS) are being managed conservatively, around 35% of patients may require decompression surgery (rib resection) which is associated with intense postoperative pain, leading to high postoperative narcotic use and prolonged hospital stay.[1] We describe the use of ultrasound (US)-guided continuous erector spinae plane (ESP) block at T1 level for prolonged postoperative analgesia after cervical rib resection for TOS.

A 26-years-old female patient was admitted with complaints of neck pain and numbness in the left upper arm more than the right arm at rest for the past one year. Radiological imaging revealed the presence of bilateral cervical rib. The diagnosis of neurogenic TOS without vascular involvement was made. As conservative measures failed, she was posted for unilateral (left) cervical rib excision through a transaxillary approach. After induction of general anesthesia, US-guided ESP block at T1 level on the left side was performed with 20 mL, 0.375% ropivacaine [Figure 1]a,[Figure 1]b,[Figure 1]c. A catheter was placed 4 cm beyond the needle tip for continuous drug delivery in the perioperative period [Figure 1]d. Ropivacaine 0.2% at 5 mL/hr was started and continued for 48 hours in the postoperative period. To prevent breakthrough pain, intravenous (IV) paracetamol 1 gm every 6 hours was advised and pain was assessed using visual analogue scale (VAS) every 2 hours in the postoperative period. Rescue analgesia with IV diclofenac aqueous 75 mg on patient demand or on recording of VAS score ≥4 was planned. The median VAS score at rest and during movement was 2 and 3, respectively throughout the observation period without requirement of rescue analgesia. After 48 hours, the ESP catheter was removed and patient was discharged home with oral paracetamol.
Figure 1: (a) Patient position and marking of lower cervical and upper thoracic spinous process, (b) sonoanatomy of the erector spinae plane block at T1 level, (c) needle in situ with confirmation of correct position evidenced by hydro dissection, (d) catheter in situ with subcutaneous tunneling

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First described in 1956, TOS includes a group of disorders resulting from compression of the nerves and vascular structures as they exit the thoracic outlet, a compact region between the first rib, clavicle, and scalenus muscle.[2] Treatment modalities available for this include conservative management, injection technique, or surgical decompression using supraclavicular, infraclavicular, or transaxillary approach. As most of these patients are on long-term potent analgesics at home before the operation, the analgesic requirement in the perioperative period is high. A number of regional analgesia techniques, including brachial plexus block with and without superficial cervical plexus block, single shot and continuous paravertebral block at T1 level, single shot ESP block etc., have been described to address the postoperative pain.[3],[4] The ESP block, first described for thoracic neuropathic pain, has rapidly gained popularity in view of relative safety. The use of continuous ESP block has been described to improve pulmonary function and provide analgesia in patients with multiple rib fracture.[5] To the best of our knowledge, the use of continuous ESP block has not been described for rib resection. The placement of ESP block at T1 level in our case adequately controls the postoperative pain, and continuous catheter technique prolonged the analgesia during the hospital stay. As the source of pain after transaxillary approach for cervical rib resection is lower cervical and upper thoracic segment, we suggest using continuous ESP block at T1 level for postoperative analgesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.


We would like to acknowledge the digital artwork support provided by Mr Satyanarayan Tripathi (Anaesthesia Technician, AIIMS, Jodhpur).

Financial support and sponsorship

Support was provided solely from institutional and/or departmental sources.

Conflicts of interest

There are no conflicts of interest.

  References Top

Morel J, Pirvu A, Elie A, Gallet N, Magne JL, Spear R. Functional results of cervical rib resection for thoracic outlet syndrome: Impact on professional activity. Ann Vasc Surg 2019;56:233-9.  Back to cited text no. 1
Peet RM, Henriksen JD, Anderson TP, Martin GM. Thoracic-outlet syndrome: Evaluation of a therapeutic exercise program. Proc Staff Meet Mayo Clin 1956;31:281-7.  Back to cited text no. 2
Kalava A, Pribish A. Paravertebral catheter for postoperative pain management after first rib resection for venous thoracic outlet syndrome: A case report. A A Pract 2018;11:1-3.  Back to cited text no. 3
Guffey R, Abuirqeba AA, Wolfson M, Fingerman ME, Liu Q, Ohman JW, et al. Erector spinae plane block versus continuous perineural local anesthetic infusion for postoperative pain control after supraclavicular decompression for neurogenic thoracic outlet syndrome: A matched case-control comparison. Ann Vasc Surg 2021;77:236-42.  Back to cited text no. 4
Syal R, Mohammed S, Kumar R, Jain N, Bhatia P. Continuous erector spinae plane block for analgesia and better pulmonary functions in patients with multiple rib fractures: A prospective descriptive study. Braz J Anesthesiol 2021:S0104-0014(21)00361-4. doi: 10.1016/j.bjane. 2021.09.010.  Back to cited text no. 5


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