Vipin Kumar Goel1, Hetal Kumar Vadera2, Tuhin Mistry3
- Consultant, Department of Anaesthesiology, Ganga Medical Centre Hospitals Pvt Ltd, Coimbatore, (India)
- Consultant Anaesthesiologist, Sterling Hospital, Rajkot, Gujarat, (India)
- Senior Resident, Onco Anaesthesiology Pain and Palliative Care, Dr B. R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, (India)
Correspondence: Dr Tuhin Mistry
dr.tuhin2014@gmail.com; Mobile: 918240823526
Citation: Goel VK, Vadera HK, Mistry T. Landmark guided erector spinae plane block as a part of multimodal analgesia in thoracolumbar spine surgeries. Anaesth pain & intensive care 2019;23(4):404-405.
DOI: 10.35975/apic.v23i4.1180
Dear Editor,
Conventionally, ultrasound guided erector spinae plane block (ESB) has been used for postoperative pain management in lumbosacral spine surgeries.
[1] We want to share our experience with landmark guided erector spinae plane block (LESB) in this set of surgeries.
We have performed LESB as described by Vadera et al.
[2] in four ASA status 1, male patients aged 25 to 40 y, scheduled for surgical decompression and instrumentation (Table 1). Written informed consent was obtained from all patients during pre-anesthesia check-up. LESB was performed in prone position except in second patient in which it was done in lateral decubitus. The block was performed before or after induction, intraoperatively after the closure of muscle layer with the help of surgeon and after completion of surgery but before extubation. Inj ropivacaine 0.2% 20 ml was injected on each side after negative aspiration for blood or air. All patients received standard general anesthesia and there were no significant intraoperative hemodynamic changes or any other adverse events. Intraoperatively, each patient received 1 gm paracetamol, 8 mg dexamethasone and 30 mg ketorolac intravenously as a part of multimodal analgesia. After skin closure, patients were extubated and shifted to post anesthesia care unit (PACU) for observation. Pain score was recorded using numeric rating scale (NRS). In PACU, our patients received paracetamol 1 gm 6 hourly, ketorolac 30 mg 8 hourly, and pregabalin 75 mg at night as per hospital protocol. Intravenous fentanyl 0.5-1 µg/kg was used as rescue analgesic if required. All four patients reported NRS score ≤ 5 at rest in first 24 h (Table 1) and two patients required rescue analgesia after 18 h following surgery.
The postoperative pain is a nightmare for the patients after spine surgeries especially after instrumentation and fusion surgeries. So, adequate pain relief helps in early mobilization and decrease in morbidity and hospital stay. Ultrasound guided ESB has shown to reduce postoperative opioid requirement and improves patient satisfaction in lumbar spine surgery patients.
[3] But unfortunately not all anesthesiologists have access to ultrasound machines in the operating rooms. LESB is a simple technique which can be used to provide effective and reliable analgesia in absence of ultrasound. Further investigations and randomized controlled trials are required.
Table 1: Postoperative pain score and opioid consumption:
| Pt |
Surgery |
Time of ESPB |
Duration of surgery (min) |
Numeric Rating Scale |
Fentanyl Consumption |
| Post Extubation |
6 h |
12 |
18 |
24 |
| 1 |
T8-T9 spondylodiscitis-
Instrumented stabilization and decompression |
Post-induction |
130 |
0 |
1 |
2 |
3 |
4 |
Nil |
| 2 |
L4-L5 decompression |
Pre-induction |
90 |
0 |
1 |
2 |
3 |
4 |
Nil |
| 3 |
T12 burst fracture with normal neurology - decompression and instrumented stabilization |
Before skin closure |
120 |
0 |
1 |
2 |
3 |
4 |
20 mcg |
| 4 |
T10-T12 Instrumented stabilization and decompression |
Post- surgery |
150 |
0 |
1 |
3 |
3 |
5 |
30 mcg |
Declaration of patient consent:
Appropriate patient consent was obtained from all patients to be reported in the journal.
Conflicts of interest: There is no conflict of interest.
REFERENCES
- Melvin JP, Schrot RJ, Chu GM, Chin KJ. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Can J Anaesth. 2018;65(9):1057-65. [PubMed] DOI: 10.1007/s12630-018-1145-8.
- Vadera HK, Mistry T. Erector spinae plane block: Anatomical landmark-guided technique. Saudi J Anaesth 2019;13:268-9 [PubMed] [Free Full Text] DOI:4103/sja.SJA_780_18
- Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth. 2018;53:29-34. [PubMed] DOI: 10.1016/j.jclinane.2018.09.036