The erector spinae plane block for effective analgesia after lung lobectomy: Three cases report

Abstract

Rationale: The thoracic epidural block and thoracic paravertebral block are widely used techniques for multimodal analgesia after thoracic surgery. However, they have several adverse effects, and are not technically easy. Recently, the erector spinae plane block (ESPB), an injected local anesthetic deep to the erector spinae muscle, is a relatively simple and safe technique.

Patient concerns: Three patients were scheduled for video assisted thoracoscopic lobectomy with mediastinal lymph node dissection. All the patients denied any past medical history to be noted.

Diagnoses: They were diagnosed with primary adenocarcinoma requiring lobectomy of lung.

Interventions: The continuous ESPB was performed at the level of the T5 transverse process. The patient was received the multimodal analgesia consisted of oral celecoxib 200 mg twice daily, intravenous patient-controlled analgesia (Fentanyl 700 mcg, ketorolac 180 mg, total volume 100 ml), and local anesthetic (0.375% ropivacaine 30 ml with epinephrine 1:200000) injection via indwelling catheter every 12 hours for 5 days. Additionally, we injected a mixture of ropivacaine and contrast through the indwelling catheter for verifying effect of ESPB and performed Computed tomography 30 minutes later.

Outcomes: The pain score was maintained below 3 points for postoperative 5 days, and no additional rescue analgesics were administered during this period. In the computed tomography, the contrast spread laterally from T2-T12 deep to the erector spinae muscle. On coronal view, the contrast spread to the costotransverse ligament connecting the rib and the transverse process. In the 3D reconstruction, the contrast spread from T6-T10 to the costotransverse foramen.

Lessons: Our contrast imaging data provides valuable information about mechanism of ESPB from a living patient, and our report shows that ESPB can be a good option as a multimodal analgesia after lung lobectomy.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Figure 1

Ultrasound guided erector spinae plane block. Tuohy needle was inserted in a cephalad-to-caudal direction, toward the 3 muscles and the transverse process of T5. After contacting the transverse process, the needle was advanced forward. After confirming that the needle was deep to the erector spinae muscle, we injected the local anesthetic. Then, a 19-gauge epidural catheter was inserted using real time ultrasound guidance. Arrow head = catheter, arrow = needle, ESM = erector spinae muscle, TP = transverse process.

Figure 2

Computed tomography scan and 3-dimensional reconstruction. (A) The contrast spread extensively in the cephalocaudal direction between the C4 and L1 vertebrae. (B) Arrow head indicate that the contrast spread to the costotransverse foramen at level of T6-T10. (C) Contrast spread to the thoracic paravertebral space (thick arrow). (D) On the coronal section, the contrast spread to the costotransverse ligament (arrows), which connects the rib and the transverse process.

Figure 3

Schematic diagram. Local anesthetic, which is injected deep to the erector spinae muscle, spreads to the thoracic paravertebral and intercostal space through the fenestrations in the costotransverse ligament and costotransverse foramen. Image adapted and used with permission from Journal of Korean Medical Science.[9] ESM = erector spinae muscle, TM = trapezius muscle, TP = transverse process.