The Erector Spinae Plane Block Provides Visceral Abdominal Analgesia in Bariatric Surgery

Abstract

Postoperative pain after bariatric surgery can be significant and yet difficult to manage. These patients frequently have associated obstructive sleep apnea and are at risk of respiratory depression with opioid analgesia. Abdominal wall blocks such as the subcostal transversus abdominis plane block are not of significant benefit, probably in part because they provide only somatic analgesia. The ultrasound-guided erector spinae plane (ESP) block is a recently described regional anesthetic technique for providing thoracic analgesia when performed at the level of the T5 transverse process. Local anesthetic injected into the fascial plane deep to the erector spinae muscle spreads in a craniocaudal fashion over several levels. Local anesthetic also penetrates anteriorly through the intertransverse connective tissue and enters the thoracic paravertebral space where it can potentially block not only the ventral and dorsal rami of spinal nerves but also the rami communicantes that transmit sympathetic fibers. Coupled with the fact that the erector spinae muscle and ESP extend down to the lumbar spine, this suggests that the ESP block could result in both visceral and somatic abdominal analgesia if the injection were performed at a lower thoracic level. We describe a series of 3 cases that illustrate the efficacy of bilateral ESP blocks performed at the level of the T7 transverse process for relieving visceral abdominal pain following bariatric surgery. Further investigation is recommended to establish the potential of the ESP block as an analgesic modality in abdominal surgery.

Erector Spinae Plane Block Versus Retrolaminar Block

“…This was seen across 2 to 5 vertebral levels centered around the level of injection and provides a basis for the somatic and visceral analgesia that has been reported. [1][2][3][6][7][8][9][10][11][12][13] It also confirms the existence of anatomical pathways for anterior spread of local anesthetic. While the exact pathways have yet to be defined, they probably include the perforations in the intertransverse connective tissues through which the dorsal rami of spinal nerves and accompanying vessels emerge.…”

“…Cadaveric and clinical evidence suggests that the local anesthetic may penetrate anteriorly through the intertransverse connective tissues into the paravertebral space where it acts on the ventral rami of spinal nerves 1,2 ; local anesthetic may also reach and block the rami communicantes and sympathetic chain to produce visceral analgesia. 3 It has been suggested 4,5 that the ESP block is identical to another paraspinal regional anesthesia technique, the retrolaminar block, 6,7 which also involves injection into the musculofascial plane between the paraspinal muscles and underlying vertebrae.…”

Erector Spinae Plane Block for Surgery of the Posterior Thoracic Wall in a Pediatric Patient

“…3,5 Peripheral nerve blocks are associated with a lower rate of complications compared with neuraxial blocks. 1,6,7 We believe that the relatively superficial nature of the ESP block, with the needle tip distant from the pleura and neuraxis, offers a superior risk profile compared with thoracic epidural or paravertebral analgesia, although it must be noted that there is insufficient published evidence for any definitive conclusions on safety.…”

Erector Spinae Plane Blocks Provide Analgesia for Breast and Axillary Surgery

“…5,6 There have been no reports of ESPB for axillary analgesia. We report the use of ESPB for 3 patients undergoing breast and/or axillary surgery.…”