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A novel approach to a chronic pain patient with rib fractures: erector spinae plane catheter vs. thoracic epidural.
Angeline Nguyen, MD, Amanda Hu, MD and Rakhi Dayal, MD
Rib fractures are common and associated with significant pulmonary morbidity (1). Epidural analgesia is a common modality of treatment, but has limitations when contraindications such as anticoagulation or cervical spine to avoid respiratory depression while trying to also account for the patient’s baseline injuries exist. Acute posttraumatic one-sided rib fractures in a chronic pain patient raises an interesting conundrum- opioid sparing techniques pain.
We present a case of a 69 year old male with past medical history of insulin dependent diabetes mellitus, hypertension, chronic pain patient (on morphine IR 45mg po q8hr as needed at baseline) who presents with rib fractures status post auto versus pedestrian. His chronic pain was from back pain and an amputation pain. Baseline pain score at home 7/10) The admission X- ray demonstrated left sided rib fractures 3-9 with small pulmonary contusions and lacerations. Pain was poorly controlled (patient’s pain score 10/10) with hydromorphone patient controlled analgesia (PCA). The patients best effort with incentive spirometer (IS) was 500 ml, saturation was 92% on 5L O2 nasal cannula (NC). Epidural was recommended, however the patient was highly reluctant to proceed because he had a presumed epidural infection a year ago. He had also received a therapeutic dose of lovenox that morning, limiting the possibility of a neuraxial procedure at that time. We decided to proceed with an ultrasound guided left sided erector spinae nerve catheter.
The patient had excellent pain relief immediately after the initial bolus was given for the errector spinae block. Patient’s pain score went down from a 10/10 to 4 /10. His saturation increased to 100% on 2L O2 on NC. On IS his effort was improved and he was able to pull 1250ml. Subsequently, that evening, he had a chest tube placed for hemothorax leading to increasing pain (pain score reported as 8/10). The decision was made to remove the erector spinae nerve catheter. Patient counseled and consented to proceed with a thoracic epidural for improved analgesia. Catheter was successfully placed at T7/8. However, the next day, the patient was still complaining of uncontrolled pain in his left chest with movement (pain was still noted to be 8 out of 10). The patient was switched to local only epidural and restarted on a hydromorphone PCA with his home dose of morphine IR. At this time, the patients pain score was marginally better at 7 out of 10. The epidural was removed 4 days later due to catheter migration and infusion discomfort. After the chest tube was removed and the hydromorphone PCA was discontinued, the patient ended up at his baseline pain score of 7 out of 10 with the addition of MS contin for long-acting opioid analgesia and his home dose of morphine IR.
The erector spinae plane block is a novel technique and is an interfascial plane block which is technically easier to perform than a neuraxial or nerve plexus block and has fewer side effects such as spinal cord damage, nerve damage or pneumothorax (2). The erector spinae muscle is composed of three muscles: spinalis, longissimus thoracis and iliocostalis. Local anesthetic is placed deep to the erector spinae muscle where spread is closer to the dorsal and ventral rami, extending along the thoracolumbar spine and extending coverage over the hemi-thorax across multiple dermatomes (3).
The block worked extremely well initially – with relief of neuropathic pain and cutaneous block of the posterior, lateral and anterior chest wall. We assumed that the worsening of the pain later was because of the placement of the chest tube. Hence, we offered epidural analgesia since it is the gold standard for management of pain associated with rib fractures. However, our situation was complicated by an acute onset pain in a chronic pain patient. The patients pain was possibly also affected by central pain mechanisms precluding the alleviating effects of both the erector spinae plane block and the thoracic epidural. The patient’s analgesia was short-lived with the erector spinae block due to the maintenance of central sensitization seen in chronic pain patients; which is why he also did not have significant pain relief with more invasive procedures like the thoracic epidural. Despite the patient’s short duration of pain relief with both the erector spinae plane block and the thoracic epidural, he had remarkably improved incentive spirometry (2000cc) and was discharged without any pulmonary complications.
While the erector spinae plane block is simple and relatively safe with no major structures at risk for needle injury (less risk of nerve damage or pneumothorax), further investigation should be done to assess the degree of analgesia and determine the extent of cutaneous block that can be achieved. Studying the different sites of injection for the erector spinae plane block and the varying quantity of local anesthetic that can be used to provide significant analgesia will be an advancement in regional anesthetic techniques and help manage chest wall pain and alleviate any associated pulmonary morbidity. It is definitely a useful tool for clinicians in situations when an epidural catheter can not be placed.