Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracic surgery: a study protocol for a prospective randomized open label non-inferiority trial

Abstract

Background Thoracic epidural analgesia is considered the gold standard for pain relief in video-assisted thoracoscopic surgery. This neuraxial technique blocks pain sensation by injecting a local anesthetic agent in the epidural space near the spinal cord to block spinal nerve roots. Recently, the erector spinae plane block has been introduced as a practical alternative to the thoracic epidural. This interfascial regional anesthesia technique interrupts pain sensation by injecting a local anesthetic agent in between the muscular layers of the thoracic wall. Several case series and three RCTs described it as an effective pain management technique in video-assisted thoracoscopic surgery (Scimia et al., Reg Anesth Pain Med 42:537, 2017; Adhikary et al., Indian J Anaesth 62:75–8, 2018; Kim, A randomized controlled trial comparing continuous erector spinae plane block with thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery, n.d.; Yao et al., J Clin Anesth 63:109783, 2020; Ciftci et al., J Cardiothorac Vasc Anesth 34:444–9, 2020). The objective of this study is to test the hypothesis that a continuous erector spinae plane block incorporated into an opioid-based systemic multimodal analgesia regimen is non-inferior in terms of the quality of postoperative recovery compared to continuous thoracic epidural local anesthetic-opioid analgesia in patients undergoing elective unilateral video-assisted thoracoscopic surgery. Methods This is a prospective randomized open label non-inferiority trial. A total of 90 adult patients undergoing video-assisted thoracoscopic surgery will be randomized 1:1 to receive pain treatment with either (1) continuous erector spinae plane block plus intravenous patient-controlled analgesia with piritramide (study group) or (2) continuous thoracic epidural analgesia with a local anesthetic-opioid infusate (control group). All patients will receive additional systemic multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs. The primary endpoint is the quality of recovery as measured by the Quality of Recovery-15 score. Secondary endpoints are postoperative pain as Numerical Rating Score scores, length of hospital stay, failure of analgesic technique, postoperative morphine-equivalent consumption, itching, nausea and vomiting, total operative time, complications related to surgery, perioperative hypotension, complications related to pain treatment, duration of bladder catheterization, and time of first assisted mobilization > 20 m and of mobilization to sitting in a chair. Discussion This randomized controlled trial aims to confirm whether continuous erector spinae plane block plus patient-controlled opioid analgesia can equal the analgesic effect of a thoracic epidural local anesthetic-opioid infusion in patients undergoing video-assisted thoracoscopic surgery. Trial registration Netherlands Trial Register NL6433. Registered on 1 March 2018. This trial was prospectively registered.

Ultrasound-guided continuous erector spinae plane block vs continuous thoracic epidural analgesia for the management of acute and chronic postthoracotomy pain: a randomized, controlled,double-blind trial

“…39 For a long time, TEA was considered the gold standard for thoracotomy pain. 27,42,44 Yet, TEA problems like a technical failure are high (30%), sympathectomy-associated hemodynamic liability, opioid-induced nausea, vomiting, pruritis, urinary retention, and respiratory depression, besides risks of epidural hematoma or abscesses. 35 Furthermore, this study protocol mandates extending postoperative pain control to 5 to 6 days for managing postoperative dorsal root ganglia (DRG) hyperexcitability and neuroplasticity.…”

Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching

“…Commonly, it requires the placement of the Foley catheter and may prolong the patients' LOS in the hospital due to the difficulty in transition from epidural analgesia ( 19 , 20 ). Meanwhile, cryoanalgesia requires an additional port for placement, which may prolong the operation time and may cause nerve injury, leading to neuropathic pain ( 21 ).…”