Erector Spinae Plane Block for Providing Labor Analgesia in a Rural Health Care Setting in India: A Case Series.

The practice of labor analgesia is highly variable in India. Parturients are often prescribed mild opioids (tramadol and pethidine). Erector spinae plane blocks can provide widespread analgesia covering multiple dermatomes. After a process evaluation to introduce safe and effective labor analgesia mandated due to poor efficacy of the standard care, erector spinae plane analgesia was offered to nulliparous parturients. The procedure was performed under ultrasound guidance at the lumbar L4 level in 10 patients. Outcomes included pain scores. There was a major reduction in labor pain. Erector spinae plane blocks can be part of a sustainable and effective labor analgesia service.

Intermediate Cervical Plexus Block in the Management of Refractory Somatosensory Tinnitus Following Whiplash: Prospective Series in 30 Patients.

OBJECTIVE: Whiplash-associated disorder comprises of a constellation of persistent symptoms after neck trauma. Tinnitus that develops postwhiplash is termed somatosensory tinnitus. The objective is to assess the role of intermediate cervical plexus block (iCPB) in patients with somatosensory tinnitus secondary to whiplash. METHODS: Prospective service evaluation in adults with whiplash-associated disorder and concomitant somatosensory tinnitus. Patients underwent specialist otorhinolaryngology review before pain clinic referral. Patients were offered ultrasound-guided iCPB with steroids. Intensity of tinnitus was recorded on a numerical rating scale at baseline, 3 and 6 months posttreatment. Brief Pain Inventory Short Form and Hospital Anxiety Depression Scale questionnaires were also completed. RESULTS: Over a 36-month period, 32 patients with refractory somatosensory tinnitus following whiplash were offered iCPB(s). Two patients refused because of needle phobia. iCPB(s) was performed in 30 patients as an outpatient procedure. One patient (1/30, 3.3%) was lost to follow-up. Twenty-three patients (23/30, 77%) reported clinically significant reduction in intensity of tinnitus at 3 months postprocedure. Nineteen patients (19/30, 63%) reported ongoing benefit at 6-month follow-up. Six patients failed to report any benefit (6/30, 20%). CONCLUSION: The cervical plexus could play a significant role in the development of somatosensory tinnitus after whiplash. iCPB may have a role in the management of somatosensory tinnitus in this cohort.

The incidence of post cholecystectomy pain (PCP) syndrome at 12 months following laparoscopic cholecystectomy: a prospective evaluation in 200 patients.

OBJECTIVES: Post cholecystectomy pain syndrome can cause significant distress, impairs quality of life and exacerbations often result in emergency visits. Poorly controlled postoperative pain is a recognized cause of persistent postsurgical pain. Abdominal myofascial pain syndrome is an underdiagnosed cause of persistent pain in this cohort. The objective was to estimate the incidence of poorly controlled postoperative pain in the first 48 h after surgery and the likelihood of developing persistent pain at 12 months. METHODS: The patients undergoing laparoscopic cholecystectomy at a tertiary unit were consented for participation in a prospective service evaluation. A telephone review was performed at three, six and twelve months after surgery. Incidence of poorly controlled pain in the first 48 h after surgery was assessed. Patients with persistent pain were referred to the pain clinic. RESULTS: Over a six-month period, 200 patients were assessed. Eleven patients were excluded (5.5 %). Twelve patients were lost to follow-up (6.6 %, 12/189). Patient satisfaction with acute postoperative pain management was low in 40 % (76/189). Poorly controlled postoperative pain was reported by 36 % (68/189) of patients. Incidence of persistent pain was 29 % (54/189) at 12 months post-surgery. Over half of patients with persistent pain (63 %, 34/54) reported poorly controlled postoperative pain. A somatic source was diagnosed in 54 % (29/54) with post cholecystectomy pain syndrome. CONCLUSIONS: Poorly controlled postoperative pain was reported by a third of patients. Persistent pain was present in 29 % at twelve months post-surgery. Abdominal myofascial pain syndrome should be considered as a differential diagnosis in post cholecystectomy pain syndrome.

Effectiveness of Intermediate Cervical Plexus Block in Whiplash-Associated Disorder: A Prospective Observational Trial in Fifty Patients.

BACKGROUND: Whiplash trauma can result in a range of symptoms, including chronic neck pain, headache, facial pain, upper back pain, and tinnitus, which comprises whiplash-associated disorder (WAD). Intermediate cervical plexus block (iCPB) is a novel intervention that targets the upper cervical nerves and anecdotal reports suggest benefits in WAD. OBJECTIVES: We hypothesized that the cervical plexus may have a role in the pathogenesis of WAD and blocking the cervical plexus may provide analgesia. STUDY DESIGN: Prospective observational trial. SETTING: Tertiary pain medicine unit at a university teaching hospital. METHODS: Adult patients who presented with refractory chronic neck pain following whiplash were included in a prospective observational trial. The pragmatic trial studied the effectiveness of 2 sequential cervical plexus blocks (iCPB with local anesthetic [iCPB-LA] and iCPB with steroid and LA mixture [iCPB-Steroid]) in refractory chronic neck pain following whiplash. Patients who reported < 50% relief at 12 weeks after iCPB-LA were offered iCPB-Steroid. Primary outcome was "neck pain at its worst in the last 24 hours" at 12 weeks. Secondary outcomes included change in neck disability index, employment status, and mood. RESULTS: After excluding cervical zygapophyseal joint dysfunction, 50 patients underwent the iCPB-LA between June 2020 and August 2022. Five patients reported > 50% relief (durable relief) at 12 weeks and 3 patients were lost to follow-up. Forty-two patients received iCPB-Steroid. iCPB-Steroid was associated with significant reduction in neck pain, neck disability, and improvement in mood at 12 weeks when compared to the block with LA. In addition, iCPB-Steroid was associated with significant reduction in neck pain and disability at 24 weeks. Due to functional improvement, 34 patients (34/50, 78%) were able to maintain employment. LIMITATIONS: This is an open-label, observational, single-center study in a limited cohort under a single physician. Cervical facet joint dysfunction was ruled out clinically and radiologically. CONCLUSIONS: Cervical plexus may play a central role in the pathogenesis of WAD. iCPB could potentially be a treatment option in this cohort.

Interventional pathway in the management of refractory chronic flank pain: Prospective series in 45 patients.

BACKGROUND: Chronic flank pain can pose a therapeutic challenge. Current management centres on visceral pathology affecting the renal system. Acute exacerbations can be severe, requiring emergency admission. Patients usually have well-established visceral pathology including polycystic kidney disease, Fowler's syndrome, and renal calculi disease that often cause recurrent urinary tract infections. However, in many cases, despite negative investigations including imaging, biochemistry and urine analysis, flank pain persists. Abdominal myofascial pain syndrome is a poorly recognized pathology in this cohort. The report describes the underlying pathophysiology and a novel interventional management pathway for patients presenting with refractory flank pain secondary to abdominal myofascial pain syndrome. METHODS: Adult patients with refractory chronic flank pain at a tertiary renal unit were included as a part of an on-going prospective longitudinal audit. Patients refractory to standard management were offered the interventional pathway. The pathway included two interventions: quadratus lumborum block with steroid and pulsed radio frequency treatment. Patients completed brief pain inventory and hospital anxiety and depression scale questionnaires at baseline, 3 and 6 months postprocedure. Outcomes collected included ability to maintain employment, change in opioid consumption at 6 months and impact on emergency hospital admissions at 12 months after initiation of the pathway. RESULTS: Forty-five patients were referred to the pain medicine clinic over a seven-year period between 2014 and 2021. All patients were offered the interventions. Four patients refused due to needle phobia. Forty-one patients received transmuscular quadratus lumborum plane block with steroids. Twenty-seven patients (27/41, 66%) reported durable benefit at 6 months and six patients (6/41, 15%) had clinically significant relief at 3 months. Fifteen patients received pulsed radiofrequency to quadratus lumborum plane and 11 patients (73%) reported > 50% analgesia at 6 months. Treatment failure rate was 10% (4/41). Opioid consumption at 6 months and emergency admission at 12 months were reduced post intervention. CONCLUSION: Abdominal myofascial pain syndrome is a poorly recognized cause of chronic flank pain syndrome. The interventional management pathway could be an effective solution in this cohort.

Interventional pathway in the management of refractory post cholecystectomy pain (PCP) syndrome: a 6-year prospective audit in 60 patients.

OBJECTIVES: Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome. METHODS: The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits. RESULTS: Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced. CONCLUSIONS: Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.

Management and outcomes of persistent headache after accidental dural puncture in the obstetric population: A 9-year prospective audit.

OBJECTIVE: To assess the effectiveness and safety of a novel management pathway in the obstetric population presenting to a pain medicine clinic with persistent headache after accidental dural puncture (PHADP). BACKGROUND: Accidental dural puncture (ADP) can result in headaches that persist for months to years. These headaches can be a therapeutic challenge, often cause severe disability, and management pathway remains obscure. METHODS: Obstetric patients with PHADP referred to a pain medicine physician were prospectively followed up in a longitudinal audit of a novel management pathway. ADP reports dated from 2008 until 2019. Initial management included brain imaging and pharmacological agents. Patients who failed to respond were offered greater occipital nerve (GON) block with depot methylprednisolone followed by pulsed radiofrequency (PRF) treatment. A headache diary was completed for 4 weeks prior to commencing treatment and maintained for 24 weeks following an intervention. Data collected included use of epidural blood patch to manage postdural puncture headache, past history of headache, severity of headache, duration of persistent headache, low back pain, and employment status. RESULTS: Over the 9-year period, a cohort of 54 obstetric patients with PHADP with a 16-gauge Tuohy needle were reviewed in the pain clinic. Forty patients presented with chronic daily headache (40/54, 74%). Brain imaging did not reveal any sign of intracranial hypotension in 50 patients (50/54, 93%). Mean follow-up period was 5.7 years. Two patients were lost to follow-up (2/54, 4%). Pharmacological management was effective in 17 patients (17/52, 33%). Medical management failed to improve symptoms in 35 patients (35/52, 67%), and they were offered GON block. Fourteen (14/35, 40%) patients refused the intervention. Nerve block was performed in 21 patients and produced durable benefit lasting 24 weeks in 18 patients (18/21, 86%). Three patients underwent PRF treatment to GONs and all three (100%) reported durable benefit. At final follow-up, mean monthly headache frequency was 5.9 for the medical management group, 8.6 for the refused nerve block group, and 4.1 in patients who received GON treatment (p < 0.001). CONCLUSION: ADP can cause chronic headaches that persist beyond 3 years. Interventions targeting the GONs appear to have a role in the management of PHADP.

Intermediate cervical plexus block in the management of treatment resistant chronic cluster headache following whiplash trauma in three patients: a case series.

OBJECTIVES: Cluster headaches are an intensely painful and debilitating headache disorder. Conventional management includes abortive and preventative agents. A fifth of patients with chronic cluster headaches can be refractory to conventional treatment. Cluster headache can develop following whiplash trauma to the head and neck. CASE PRESENTATION: Three patients were referred to a tertiary pain medicine unit in a university teaching hospital with treatment-resistant chronic cluster headache. They were treated with a novel intervention namely, ultrasound-guided intermediate cervical plexus block with depot methylprednisolone. Patient one reported chronic cluster headache for three years. Patient two reported episodic cluster headache that appeared to be evolving into chronic cluster headache. Patient three reported bilateral cluster headache following a motor vehicle accident. Intermediate cervical plexus block provided significant and durable relief in three patients with treatment resistant chronic cluster headache. CONCLUSIONS: The novel intervention may have played a role in aborting and preventing chronic cluster headaches.

Intermediate Cervical Plexus Block for Refractory Bilateral Facial Pain From a Whiplash Injury in 3 Patients: A Case Report.

Bilateral facial pain is associated with temporomandibular joint dysfunction and rarely, trigeminal neuralgia. In the absence of clinical and radiological signs, a diagnosis of persistent idiopathic facial pain is often made. Standard management of persistent idiopathic facial pain includes pharmacotherapy and psychotherapy with variable therapeutic efficacy. Whiplash can result in persistent facial pain although its clinical presentation and management are poorly defined. This report includes 3 patients with refractory bilateral facial pain. A detailed review of history revealed whiplash before the onset of the symptoms. The authors present a novel intervention, an intermediate cervical plexus block that produced durable analgesia.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study.

OBJECTIVES: Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy. METHODS: We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening. RESULTS: Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes. CONCLUSIONS: ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Risk of infection within 4 weeks of corticosteroid injection (CSI) in the management of chronic pain during a pandemic: a cohort study in 216 patients.

OBJECTIVES: Targeted corticosteroid injections (CSI) are one of the treatments that can provide pain relief and thereby, enhance quality of life in patients with chronic pain. Corticosteroids (CS) are known to impair immune response. The objective was to evaluate the risk of developing post-procedural infection within 4 weeks of receiving depot CSI for chronic pain as part of on going quality improvement project. We hypothesised that interventional treatment with depot steroids will not cause a significant increase in clinical infection in the first 4 weeks. METHODS: Telephone follow-up was performed as a part of prospective longitudinal audit in a cohort of patients who received interventional treatment for chronic pain at a multidisciplinary pain medicine centre based at a university teaching hospital. Patients who received interventional treatment in the management of chronic pain under a single physician between October 2019 and December 2020 were followed up over telephone as part of on going longitudinal audits. Data was collected on any infection within 4 and 12 weeks of receiving the intervention. Outcomes collected included type of intervention, dose of depot steroids and pain relief obtained at 12 weeks following intervention. RESULTS: Over a 15 month period, 261 patients received pain interventions with depot CS. There was no loss to follow-up. Nine patients reported an infection within 4 weeks of receiving depot steroids (9/261, 3.4%). None of the patients tested positive for Covid-19. Eight patients (8/261, 3%) reported an infection between 5 and 12 weeks following the corticosteroid intervention. Although none of the patients tested positive for Covid-19, two patients presented with clinical and radiological features suggestive of Covid-19. Durable analgesia was reported by 51% (133/261) and clinically significant analgesia by 30% (78/261) at 12 weeks following the intervention. Failure rate was 19% (50/261). CONCLUSIONS: Pain medicine interventions with depot steroids do not appear to overtly increase the risk for Covid-19 infection in the midst of a pandemic.

Persistent headache and low back pain after accidental dural puncture in the obstetric population: a prospective, observational, multicentre cohort study.

Accidental dural puncture following epidural insertion can cause a post-dural headache that is defined by the International Headache Society as self-limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed-up at six-monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0-56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11-8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long-term morbidity including persistent headache in parturients. This challenges the current definition of post-dural puncture headache as a self-limiting condition and raises possible clinical, financial and medicolegal consequences.

Leiomyosarcoma of the small intestine presenting as abdominal myofascial pain syndrome (AMPS): case report.

OBJECTIVE: To highlight an extremely unusual presentation of an aggressive, rare small bowel malignancy presenting as abdominal myofascial pain syndrome. CASE PRESENTATION: The report is presented from a tertiary pain medicine unit at a university teaching hospital. A female patient presenting with chronic abdominal pain was initially diagnosed as abdominal myofascial pain syndrome. The report details the possible facilitation of the diagnosis of a rare, highly aggressive small bowel tumour by interventional treatment for abdominal myofascial pain syndrome. CONCLUSION: This case highlights a rare and aggressive malignancy of the small intestine presenting clinically as abdominal myofascial pain syndrome.

Opioid Reduction and Long-Term Outcomes in Abdominal Myofascial Pain Syndrome (AMPS): A 6-Year Longitudinal Prospective Audit of 207 Patients.

BACKGROUND: Abdominal myofascial pain syndrome is an important cause of refractory chronic abdominal pain. It causes severe functional impairment resulting in significant patient distress and substantial health care costs, and it can be a challenge to treat. Opioid consumption is a recognized challenge in this cohort. STUDY DESIGN: We conducted a prospective longitudinal audit over a 6-year period. SETTING: The study was conducted at a tertiary pain medicine clinic in a university teaching hospital. METHODS: Over a 6-year period, 234 patients diagnosed with chronic abdominal pain secondary to abdominal myofascial pain syndrome were included in a structured management pathway. Long-term outcomes were prospectively audited at a tertiary-care university hospital. Patients who completed a minimum of 12 months in the pathway were included. The main outcome was reduction in opioid consumption. Treatment outcomes included treatment failure, number of patients with clinically significant pain relief, durable pain relief, and long-term pain relief. Other outcomes included patient satisfaction and success in maintaining gainful employment. RESULTS: Two hundred seven patients completed a minimum of 12 months of follow-up. Seventy-eight percent (162 of 207) were on opioids at presentation. There was significant reduction in opioid consumption at >= 12 months' follow-up. Among patients who underwent interventional management, clinically significant relief was reported in 31 patients (31 of 180, 17%), durable relief in 71 patients (71 of 180, 40%) and long-term relief lasting 12 months in 23 patients (23 of 180, 13%). Twenty-six patients (26 of 180, 15%) reported cure from symptoms. The treatment failure rate was 15%. LIMITATIONS: This was an open-label study that took place at a single center. CONCLUSION: The authors present the first prospective practice-based evidence report on the long-term outcomes in patients diagnosed with abdominal myofascial pain syndrome. There was significant reduction in opioid consumption at 12 months and over two-thirds of patients reported significant durable relief on long-term follow-up. The authors present their recommendation for managing this complex group of patients.

Interventional Management of Refractory Trigeminal Neuropathic Pain: A Prospective Audit of a Novel Management Pathway in 70 Patients.

BACKGROUND: Trigeminal neuropathic pain (TNP) can present as a constant, unremitting unilateral facial pain. Current management is based on expert recommendation that includes pharmacologic agents and psychological therapy. However, treatment success with pharmacologic management is poor. We adopted a novel strategy that proved to be effective in providing durable relief. OBJECTIVES: Prospectively audit a novel strategy in the management of refractory TNP. STUDY DESIGN: The authors present a prospective audit of a novel structured management pathway in the treatment of refractory TNP. SETTING: Multidisciplinary facial pain clinic at a University Teaching Hospital. METHODS: Over a 4-year period, 70 patients with unilateral TNP were prospectively audited at a tertiary care university hospital. Initial treatment was based on pharmacologic therapy while the patient awaited psychological therapy. Patients who failed to respond were offered a novel set of interventions that included ultrasound-guided trigeminal nerve block with depot steroids. RESULTS: Patient satisfaction with the novel pathway was high. Only 13 patients (13/70, 18%) responded to standard treatment. Of the 57 patients who were offered the novel intervention, 50 patients consented to undergo the intervention. Forty-two patients (42/50, 84%) reported clinically significant pain relief at 3 months, and 27 patients (27/50, 54%) reported on-going durable relief at 6 months. Treatment failure with the novel intervention was 16%. Out of 54 patients in the employable age, 45 patients (45/54, 83%) were able to maintain gainful employment. LIMITATIONS: Open-label, nonrandomized observational design. CONCLUSIONS: Standard treatment of TNP is ineffective. The novel set of interventions based on empirical evidence may have a role in managing patients with refractory TNP.

Intermediate Cervical Plexus Block: A Novel Intervention in the Management of Refractory Chronic Neck and Upper Back Pain Following Whiplash Injury: A Case Report.

Chronic neck and upper back pain occurs in 40%-60% of patients that suffer whiplash injury. Increasing evidence points to a dysfunction of the cervical and thoracic muscles as the predominant cause of persistent pain in this cohort. Response to standard management including physiotherapy, psychotherapy, medications, and acupuncture are often inadequate. As a result, there is significant functional impairment leading to excessive health care costs. The authors present a novel treatment, intermediate cervical plexus block with depot steroids, in 3 patients presenting with refractory chronic neck and upper back pain from whiplash injury that produced durable analgesia and enabled return to employment.

Erector spinae plane and intra thecal opioid (ESPITO) analgesia in radical nephrectomy utilising a rooftop incision: novel alternative to thoracic epidural analgesia and systemic morphine: a case series.

Background Open radical nephrectomy and inferior vena cava exploration through a roof top incision involves significant peri-operative morbidity including severe postoperative pain. Although thoracic epidural analgesia provides excellent pain relief, recent trends suggest search for effective alternatives. Systemic morphine is often used as an alternative analgesic technique. However, it does not provide dynamic analgesia and can often impede recovery in patients undergoing major surgery on the abdomen. The authors present the first report of a novel analgesic regimen in this cohort with good outcomes. Methods Five patients undergoing open radical nephrectomy and inferior vena cava exploration received erector spinae plane infusion and intra thecal opioid analgesia at a tertiary care university teaching hospital. Outcomes included dynamic analgesia, length of hospital stay and complications Results Five adult patients undergoing major upper abdominal surgery, who refused thoracic epidural analgesia, received erector spinae plane infusion and intrathecal opioid analgesia. Patients reported effective dynamic analgesia, minimal use of rescue analgesia, early ambulation and enhanced recovery. Conclusion The novel regimen that avoids both epidural analgesia and systemic morphine can be an option in enabling enhanced recovery in this cohort.

Continuous Erector Spinae Plane and Intrathecal Opioid Analgesia: Novel Regimen Avoiding Thoracic Epidural Analgesia and Systemic Morphine in Open Radical Cystectomy: A Case Series.

There has been a significant shift away from epidural analgesia after radical cystectomy within an enhanced recovery program. Alternative techniques reported including continuous erector spinae plane analgesia require supplemental systemic morphine. A new analgesic regimen is described that avoids both thoracic epidural analgesia and systemic morphine. Three adult patients undergoing open radical cystectomy, who refused thoracic epidural analgesia, were offered continuous erector spinae plane and intrathecal opioid analgesia. Median length of hospital stay was reduced by a third. The novel analgesic regimen may have the potential to enhance recovery after open radical cystectomy.