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The erector spinae plane block provides equal analgesia compared to paravertebral block for bilateral mastectomy: A case report
Paravertebral blocks (PVB) have been the regional technique of choice for breast surgery. Recently, newer fascial plane blocks such as the Pecs I and II blocks have been used with and without PVB in an attempt to optimize analgesia for breast surgery. However, there are few studies that have compared the efficacy of PVB against Pecs blocks and the results of these studies appear to be conflicting. The erector spinae plane (ESP) block is a novel fascial plane block first described to treat thoracic neuropathic pain.1 Here, we describe a case report in which we compared PVB directly to ESP block in a single patient having bilateral mastectomy.
A 48-year-old female (weight 74.8kg, height 160cm) with a history of hypertension and breast cancer was scheduled for bilateral mastectomy. Pre-operatively a right PVB was performed using two injections of 0.25% ropivacaine with 20cc given at the T3 level and 20cc at the T5 level. Next, a left ESP block was performed at the T5 level and 30cc of 0.25% ropivacaine was injected in the plane between erector spinae and transverse process as described by Forero et al. The patient then underwent general anesthesia with an LMA maintained via sevoflurane. She received a total of 200mcg fentanyl, 0.2mg dilaudid, and 1000mg IV acetaminophen prior to the PACU. In the PACU, the patient reported 3/10 dull aching chest pain bilaterally that required no additional narcotic and resolved prior to discharge. The patient had decreased sensation to cold bilaterally from approximately T2-T8 and did not notice any discernable difference in cold or pain sensation on either side. Upon follow up with the patient the next day, she reported the local anesthetic had worn off at approximately 22 hours after placement and until that point she had 0/10 pain not requiring any additional opioid.
This case provides preliminary support of the ESP block as non-inferior to PVB. The ESP block seems to have several potential advantages over PVB. The ESP block appears safer than PVB since the transverse process is the anatomical structure deep to the injection site versus PVB where the lung is immediately deep to the injection site. ESP block requires only one injection to obtain similar coverage as PVB. Additionally, PVB can be technically challenging especially in patients with a larger body habitus due to the depth required to reach the paravertebral space. However, the ESP block requires less depth to reach the transverse process and has been used recently in morbidly obese patients undergoing bariatric surgery with promising results.2 Although single injection ultrasound-guided PVB has been reported to cover almost the same dermatomal spread as multiple injection PVB, the axilla appears to have inadequate coverage when compared to multiple injections.3 Thus, future studies should compare the efficacy of single injection PVB vs ESP block including comparison of dermatomal spread, perioperative opioid usage, complications, and amount of time taken to perform each block.
1. 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; 41:621-627
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; 42:372-376
3. Uppal V, Sondekoppam RV, Sodhi P, Johnston D, Ganapathy S. Single-injection versus multiple-injection technique of ultrasound-guided paravertebral blocks: A randomized controlled study comparing dermatomal spread. Reg Anesth Pain Med. 2017; 42:575-581
Ultrasound image prior to ESP block showing trapezius (T), rhomboid major (R), and erector spinae (ES) muscles superficial to transverse processes (TP) and pleura deep to TP.
Ultrasound image showing hyperechoic needle (yellow) and hypoechoic local anesthesia (LA) spread between erector spinae (ES) and transverse process (TP). Trapezius (T) and rhomboid major (R) muscle layers also seen.