51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

•Postoperative analgesia following lumbar spine surgery represents a significant challenge in perioperative management due to the invasive nature of the surgery and the prevalence of chronic preoperative opioid use among patients.

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•Erector Spinae Plane (ESP) block was introduced in 2016 by Forero et al.1.

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•Initially intended for thoracic neuropathic pain, the ESP block is an interfascial plane block where local anesthetics is deposited between the erector spinae muscle and the transverse process2

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•Despite varied patterns of the drug spread, ESPB has been showing promising results due to consistent involvement of dorsal rami that supply pain generators of spine surgery.

Case Report:

This is an 80-year-old woman presenting with refractory lower back and left hip pain with impaired functional mobility and worsening bladder incontinence.

An MRI and clinical exam revealed a combination of upper lumbar spinal stenosis, facet arthropathy, and interspinous synovitis superimposed upon loss of lumbosacral lordosis from her prior surgeries.

The patient was scheduled for a two-staged anterolateral lumbosacral L4-S1interbody fusion, followed by a posterior thoracolumbar-to-pelvis decompression and fusion.

A unilateral upper lumbar ESP block was planned after first stage of the surgery series as part of postoperative multimodal analgesia regimen.

Under ultrasound guidance using a high-frequency linear probe, the block needle contacted the visualized osseous structure and was withdrawn slightly to target the fascial plane. Aspiration was negative for CSF or blood. 20 mL of 0.25% Bupivacaine was injected and separation of the erector spinae muscle from the underlying osseous structures was visualized on ultrasound. No significant alteration in motor evoked potentials (MEPs) were noted during the surgery and the patient remained hemodynamically stable upon emergence.

However, in the Post-Anesthesia Care Unit (PACU), the patient reported significant weakness in the bilateral lower extremities without paresthesia. An emergency lumbar spine MRI demonstrated no clear etiology for the paraplegia.

Bilateral lower extremity strength improved under observation in the PACU and returned to baseline within three hours of emergence and block performance.

Disucssion:

•Similar complications with transient paraplegia following ESP blocks have been identified in prior case reports 3–5.

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•Drug distribution during an ESPB crosses multiple anatomical planes (craniocaudal, anteroposterior, and lateral-to-medial).

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•This broad spread can involve the paravertebral space, neural foramina, and the ipsilateral epidural space and sympathetic chain.

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•The likely etiology of the bilateral weakness following unilateral ESPB includes accidental intrathecal injections versus inadvertent spread into epidural space consistent with the motor deficits in lower extremities.

Suggested Lumbar ESP technical changes to decrease the risk of epidural spread:

•Use of curvilinear probe to improve visualization of lumbar ESP block landmarks,

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•Consider performing a low thoracic ESP block instead of lumbar ESP with cephalocaudal needle orientation due to easier anatomical identification

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•Decrease pressure with local anesthetic injection

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•Consider performing ESPB prior to spine surgical procedure to minimize risk of spread through disrupted anatomical planes

51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Transient Paraplegia Following Lumbar Erector Spinae Plane Block After Anterolateral Lumbosacral Interbody Fusion: A Case Report

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