Single continuous erector spinae plane block for multiple rib, clavicle, and scapula fractures

Abstract

The aim of this study is to describe the ability of a continuous erector spinae plane (ESP) block to provide analgesia in an extended territory (brachial plexus and thoracic nerves) with a single catheter. A continuous ESP block at T4 was performed in a 74-year-old man, two days after trauma involving clavicle, scapula, and multiple posterior rib fractures (first to ninth). The technique was maintained for 12 days and provided effective analgesia not only to the thoracic region but also the scapula and clavicle area (C5–T12 dermatomes). Concomitant respiratory insufficiency was ameliorated, which helped to avoid mechanical ventilation and intensive care unit admission. Moreover, this analgesia technique promoted patient's ambulation. ESP block, as an alternative to a thoracic epidural, is a more straightforward and safer procedure than paravertebral block (PVB). To obtain an extensive dermatome block using PVB, more than one paravertebral catheter would be necessary. Extensive cephalad–caudad spread of the PVB is primarily related to analgesia due to the concomitant epidural spread. PVB frequently causes bilateral block and may produce significant motor or sympathetic block. Additionally, proximal extension of the block under the erector spinae muscle fascia can provide a significant extension of the block to the cervical region, which allows brachial plexus block (cervical plexus block was not observed clinically). This is a unique feature of ESP block, as there is no communication between adjacent paravertebral levels in the cervical region that could allow the same pattern of analgesia using PVB.

Erector Spinae Plane Block as an Analgesic Intervention in Acute Rib Fractures: A Scoping Review

“…Screening of abstracts resulted in 77 papers, following which 40 studies were excluded due to incorrect block or injury, surgical fixation, or for being presented in a conference abstract format. Of the 37 studies included, 10 were case reports, [18][19][20][21][22][23][24][25][26][27] 12 were case series, [28][29][30][31][32][33][34][35][36][37][38][39] 5 were cohort studies, 7,40-43 2 were randomized controlled trials (RCT), 44,45 1 was a prospective interventional study, 46 and 7 were letters to the editor. [47][48][49][50][51][52][53] The majority of studies were published after 2020, with 29% being published in 2022.…”

“…The main indication for ESB was as an analgesic intervention either for uncontrolled pain or as a preventative measure, with 9 studies reporting usage of the technique as a rescue measure for patients in respiratory failure. 18,[20][21][22]24,28,33,34,47 The majority of blocks were administered within the first 48 hours of presentation.…”

“…Twenty-eight studies reported objective changes in pain score post administration of ESB using various scoring scales including Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Defence and Veteran Pain (DVP) score, and a 4 point verbal score. 7,[18][19][20][21][22][23][24][25][27][28][29][30][31]33,34,[36][37][38][39]42,[44][45][46][47][48][49]53 Due to the heterogeneity of scales and time points used to evaluate pain, an average weighted percentage change in pain scores was calculated. The mean reduction in pain scores from pre-block baseline was approximately 40% within the first 24 hours.…”

Novel continuous sub-splenius plane block for analgesia of the shoulder region and for upper rib fractures: a comprehensive technical report

“…The high thoracic erector spinae plane (ESP) block has shown effectiveness for rib fractures analgesia and, performed at T2-T3, for shoulder painful conditions or surgery. [2][3][4] In the high thoracic ESP block the local anesthetic (LA) spreads cranially within the prevertebral compartment up to C4 and distally in the ESP, as demonstrated by magnetic resonance imaging (MRI) and cadaveric studies. [2,3] Forero et al [2] performed ESP block at the T2 level in a patient with chronic shoulder pain and reported effective pain treatment with the spread of LA over the C3-C7 region in MRI.…”

“…The high thoracic erector spinae plane (ESP) block is effective for rib fracture analgesia and is performed at T2–T3 for painful shoulder conditions or during surgery [ 2 – 4 ]. With the high thoracic ESP block, the LA spreads cranially within the prevertebral compartment up to C4 and distally in the ESP, as demonstrated by magnetic resonance imaging (MRI) and cadaveric studies [ 2 , 3 ].…”