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

BACKGROUND AND OBJECTIVES: The evolving surgical techniques in thoracoscopic surgery necessitate the exploration of anesthesiological techniques. This study aimed to investigate whether incorporating a continuous erector spinae plane (ESP) block into a multimodal analgesia regimen is non-inferior to continuous thoracic epidural analgesia (TEA) in terms of quality of postoperative recovery for patients undergoing elective unilateral video-assisted thoracoscopic surgery. METHODS: We conducted a multicenter, prospective, randomized, open-label non-inferiority trial between July 2020 and December 2022. Ninety patients were randomly assigned to receive either continuous ESP block or TEA. The primary outcome parameter was the Quality of Recovery-15 (QoR-15) score, measured before surgery as a baseline and on postoperative days 0, 1, and 2. Secondary outcome parameters included pain scores, length of hospital stay, morphine consumption, nausea and vomiting, itching, speed of mobilization, and urinary catheterization. RESULTS: Analysis of the primary outcome showed a mean QoR-15 difference between the groups ESP block versus TEA of 1 (95% CI -9 to -12, p=0.79) on day 0, -1 (95% CI -11 to -8, p=0.81) on day 1 and -2 (95% CI -14 to -11, p=0.79) on day 2. CONCLUSIONS: The continuous ESP block is non-inferior to TEA in video-assisted thoracoscopic surgery. TRIAL REGISTRATION NUMBER: Dutch Trial Register (NL6433).

Erector spinae plane block improves postoperative recovery after laminectomy and discectomy surgery: a retrospective cohort study.

BACKGROUND: There is still room for improvement of pain management after spinal surgery. The goal of this study was to evaluate adding the erector spinae block to the standard analgesia regimen. Our hypothesis was that the erector spinae plane block will decrease length of hospital stay, reduce opioid need and improve numeric rating scale pain scores. METHODS: This was a single center retrospective cohort study. We included 418 patients undergoing laminectomy or discectomy from January 2019 until December 2021. The erector spinae plane block was introduced in 2016 by Forero and colleagues and added to our clinical practice in October 2020. Patients who did not receive an erector spinae plane block prior to its implementation in October 2020 were used as control group. The primary outcome measure was functional recovery, measured by length of hospital stay. Secondary outcome measures were perioperative opioid consumption, need for patient-controlled analgesia and numeric rating scale pain scores. Postoperative data collection time points were: at the PACU and after 3, 6, 12 and 24 h postoperatively. RESULTS: There was a significant shorter length of hospital stay in patients undergoing single level laminectomy (with erector spinae plane block 29 h (IQR 27-51), without block 53 h (IQR 51-55), p < .001), multiple level laminectomy (with erector spinae plane block 49 h (IQR 31-54), without block 54 h (IQR 52-75), p < .001) and discectomy (with erector spinae plane block 27 h (IQR 25-30), without block 29 h (IQR 28-49), p = .04). CONCLUSIONS: Erector spinae plane block reduces length of stay after laminectomy surgery.

Deep posterior gluteal compartment block for regional anaesthesia of the posterior hip: a proof-of-concept pilot study.

Background: Various regional anaesthesia approaches to branches of the anterior lumbar plexus have been proved effective in providing analgesia in hip surgery. However, some patients still experience significant residual posterior hip pain attributed to the posterior nerve supply of the hip. This not only suggests that anterior approaches may not always provide sufficient pain relief, but also that the blocking of major nerves supplying the posterior pericapsular region is needed. Methods: We present an ultrasound-guided technique to block all major nerves supplying the posterior capsule of the hip joint. The optimal target area was determined by ultrasound imaging, cross-sectional digitised anatomy, and cadaver research, and was found in the deep gluteal compartment. Furthermore, this posterior pericapsular deep-gluteal block was evaluated in two patients. Results: The spread of dye in the cadaver was observed deep to the gluteus maximus and in between the quadratus femoris and piriformis muscles, and conformed to the presumed location during the ultrasound procedure. It included all major supplying nerves to the posterior hip capsule, that is the superior gluteal nerve, nerve to quadratus femoris and sciatic nerve. In both patients where this posterior pericapsular deep-gluteal block was applied the pain was substantially reduced (numeric rating scale: 4 to 1 and 7 to 1). Conclusion: We present a successful ultrasound-guided technique targeting the deep gluteal compartment to block all major nerves supplying the hip joint's posterior capsule. This posterior pericapsular deep-gluteal block can be applied as an additional block in hip surgery, with also a possible role in chronic hip pathology.

Serum concentrations of local anesthetics after unilateral interpectoral-pectoserratus plane block in breast cancer surgery: a pharmacokinetic study.

INTRODUCTION: The ultrasound-guided interpectoral-pectoserratus plane block is a fascial plane block for superficial surgery of the anterolateral chest wall. This technique involves injecting a relatively large volume of local anesthetics (typically 30 mL of 0.25%-0.50%, ie, 75-150 mg ropivacaine) underneath the major and minor pectoral muscles of the anterior thoracic wall. There is a potential risk of toxic serum concentrations of local anesthetics due to systemic absorption. METHODS: 22 patients scheduled for elective unilateral breast cancer surgery were included in this study. All surgery was performed with general anesthesia and an ultrasound-guided interpectoral-pectoserratus plane block with 2.5 mg/kg ropivacaine. Ten venous blood samples were collected at 0 (two samples) 10, 20, 30, 45, 60, 90 and 120 min and at 4 hours after performing the block. Free and total ropivacaine levels were measured at each time point. Albumin and alpha-1-acid-glycoprotein were measured to monitor shifts between the free and bound fraction of ropivacaine. RESULTS: Samples of 20 patients were analyzed. The mean dose of ropivacaine was 172.8 (22.5) mg. In 50% of the patients, the potentially toxic threshold of 0.15 µg/mL free ropivacaine concentration was exceeded. Mean peak serum concentration occurred at 20 min postinjection. CONCLUSIONS: This pharmacokinetic study demonstrated that a 2.5 mg/kg ropivacaine interpectoral-pectoserratus plane block may result in exceeding the threshold for local anesthetic systemic toxicity.

Interpectoral-pectoserratus plane (PECS II) block in patients undergoing trans-axillary thoracic outlet decompression surgery; A prospective double-blind, randomized, placebo-controlled clinical trial.

STUDY OBJECTIVE: To investigate if an interpectoral-pectoserratus plane (PECS II) block decreases postoperative pain, postoperative nausea and vomiting and improves quality of recovery in patients with neurogenic thoracic outlet syndrome (NTOS) undergoing trans-axillary thoracic outlet decompression surgery. DESIGN: A prospective single center double blinded randomized placebo-controlled trial. SETTING: Perioperative period; operating room, post anesthesia care unit (PACU) and hospital ward. PATIENTS: Seventy patients with NTOS, undergoing trans-axillary thoracic outlet decompression surgery. INTERVENTIONS: Patients were randomized to an interventional arm, receiving the block with 40 ml ropivacaine 0.5% (concentration was adjusted if the patient's weight was <66 kg), and a placebo group, receiving a sham block with 40 ml NaCl 0.9%. The interpectoral-pectoserratus plane block was performed ultrasound guided; the first injection below the pectoral minor muscle and the second below the pectoral major muscle. The hospitals' pharmacist prepared the study medication and was the only person able to see the randomization result. The study was blinded for patients, researchers and medical personnel. MEASUREMENTS: Primary outcome parameters were postoperative pain, measured by numeric rating scale on the PACU (start and end) and on the ward on postoperative day (POD) 0 and 1, and postoperative morphine consumption, measured on the PACU and on the ward during the first 24 h. Secondary outcome parameters were postoperative nausea and vomiting, and quality of recovery. MAIN RESULTS: There was no statistically significant difference in NRS on the PACU at the start (ropivacaine 4.9 ± 3.2 vs placebo 6.2 ± 3.0, p = .07), at the end (ropivacaine 4.0 ± 1.7 vs placebo 3.9 ± 1.7, p = .77), on the ward on POD 0 (ropivacaine 4.6 ± 2.0 vs placebo 4.6 ± 2.0, p = 1.00) or POD 1 (ropivacaine 3.9 ± 1.8 vs placebo 3.6 ± 2.0, p = .53). There was no difference in postoperative morphine consumption at the PACU (ropivacaine 11.0 mg ± 6.5 vs placebo 10.8 mg ± 4.8, p = .91) or on the ward (ropivacaine 11.6 mg ± 8.5 vs placebo 9.6 mg ± 9.4, p = .39). CONCLUSIONS: The interpectoral-pectoserratus plane block is not effective for postoperative analgesia in patients with NTOS undergoing trans-axillary thoracic outlet decompression surgery.

Anatomical basis of fascial plane blocks.

Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.

Evaluation of adding the Erector spinae plane block to standard anesthetic care in patients undergoing posterior lumbar interbody fusion surgery.

Postoperative analgesia in patients undergoing spinal fusion surgery is challenging due to the invasiveness of the surgical procedure and the frequent use of opioids preoperatively by many patients. Recently, the erector spinae plane (ESP) block has been introduced in our clinical practice as part of a multimodal pain strategy after posterior lumbar interbody fusion surgery. This is a retrospective case-control study evaluating the analgesic efficacy of the ESP block when added to our standard analgesic regimen for posterior lumbar interbody fusion surgery. Twenty patients who received an erector spinae plane block were compared with 20 controls. The primary endpoint was postoperative pain, measured by the numeric rating scale. Secondary outcome measures were opioid use, postoperative nausea and vomiting, and length of stay. Postoperative pain scores in the PACU were lower in patients who received an erector spinae plane block (p = 0.041). Opioid consumption during surgery and in the PACU was not significantly different. Need for patient-controlled analgesia postoperatively was significantly lower in the group receiving an ESP block (p = 0.010). Length of stay in hospital was reduced from 3.23 days (IQR 1.1) in the control group to 2.74 days (IQR 1.6) in the study group (p = 0.012). Adding an erector spinae plane block to the analgesic regimen for posterior lumbar interbody fusion surgery seemed to reduce postoperative pain and length of hospital stay.

Pectoral Nerve Block Type II as the Sole Anesthetic for Removal of a Large Axillary Tumor: A Case Report.

The pectoral nerve block type II (Pecs II block) combined with general anesthesia provides analgesia during breast and axillary surgery. This report describes the first use of the Pecs II block as the sole anesthetic for axillary surgery. A patient needed resection of axillary masses. She was not only very reluctant to have general anesthesia but also considered high risk because of multiple comorbidities. An ultrasound-guided Pecs II block was performed. Both masses were resected without additional sedation or analgesia. This case report suggests that, in selected cases, the Pecs II block can be used as the sole anesthetic for axillary surgery.

Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression.

BACKGROUND: Postoperative analgesia in patients undergoing transaxillary thoracic outlet decompression (TATOD) is challenging because of the invasive surgery, the complex innervation of the axillary region, and the preoperative use of opioids by many patients. Commonly, postoperative pain is managed with additional opioids that introduce well-known sideeffects. To investigate the analgesic efficacy of 2 novel regional anesthesia techniques, we performed a retrospective study comparing the combined pectoral block type 1 and erector spinae block (PECS 1 + ESB) and the pectoral block type 2 (PECS 2) and systemic intravenous opioids regimen (no block) in patients undergoing TATOD. MATERIALS AND METHODS: We performed 10 PECS 1 + ESB and 10 PECS 2 blocks in patients undergoing TATOD. Twenty patients were randomly selected as controls. The primary endpoint was pain. Secondary endpoints were opioid use, nausea, and vomiting. RESULTS: Postoperative maximal numeric rating scale scores on recovery were significantly lower in patients receiving either a PECS 1 + ESB or a PECS 2 block compared with controls without block (no block: median 6.00, interquartile range [IQR] 3.00; PECS 1 + ESB: median 4.50, IQR 4.00; PECS 2: median 4.00, IQR 5.00; P = 0.031). Postoperative intravenous morphine consumption was 43% lower in the PECS 1 + ESB group and 56% lower in the PECS 2 group compared with the group with no block (oral morphine equivalents; no block: mean 16.05 ± SD 6.79 mg; PECS 1 + ESB mean 9.05 ± SD 6.24 mg; PECS 2: mean 7.00 ± SD 6.16; P = 0.03 and P = 0.003, respectively). There was no statistical difference in both nausea and vomitus (no block 45% nausea and 30% vomitus, PECS 1 + ESB 40% nausea and 20% vomitus, PECS 2 10% nausea and 0% vomitus, P = 0.17 and P = 0.14, respectively). CONCLUSIONS: There was a significant reduction in postoperative pain and opioid consumption for patients treated with either the PECS 1 + ESB block or PECS 2.

The pecs anesthetic blockade: A correlation between magnetic resonance imaging, ultrasound imaging, reconstructed cross-sectional anatomy and cross-sectional histology.

The interfascial thoracic wall blockades Pecs I and Pecs II are increasingly applied in breast and axillary surgery. Despite the clear anatomical demarcations depicted at their introduction, the clinical outcome is more variable than would be expected based upon the described anatomy. In order to elucidate factors that explain this variability, we evaluated the spread of each injection-medial Pecs I, lateral Pecs I, the deep injection of the Pecs II-separately. A correlation of in vivo landmarks and ultrasound images with ex vivo ultrasound, reconstructed anatomical planes, histology and magnetic resonance imaging. The medial Pecs I, similar to the sagittal infraclavicular block positioning with needle position medial to the pectoral branch of the thoracoacromial artery, reaches the medial and lateral pectoral nerves. The lateral Pecs I, below the lateral third of the clavicle at the level of the third rib with needle position lateral to the pectoral branch of the thoracoacromial artery, additionally spreads to the axilla and reaches the intercostobrachial nerve. The deep Pecs II injection spreads to the lateral cutaneous part of the III-VI intercostal nerves and reaches the long thoracic nerve. The variability of the Pecs anesthetic blockades is driven by the selected Pecs I approach as only the lateral approach stains the intercostobrachial nerve. The pectoral branch of the thoracoacromial artery can serve as the landmark to differentiate the needle position of the medial and lateral Pecs I block. Clin. Anat. 32:421-429, 2019. © 2019 Wiley Periodicals, Inc.

Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II.

STUDY OBJECTIVE: The aim of this clinical trial was to test the hypothesis whether adding the pectoral nerves (Pecs) block type II to the anesthetic procedure reduces opioid consumption during and after breast surgery. DESIGN: A prospective randomized double blind placebo-controlled study. SETTING: A secondary hospital. PATIENTS: 140 breast cancer stage 1-3 patients undergoing mastectomy or tumorectomy with sentinel node or axillary node dissection. INTERVENTIONS: Patients were randomized to receive either a Pecs block with levobupivacaine 0.25% (n=70) or placebo block with saline (n=70). MEASUREMENTS: The pain levels were evaluated by Numeric Rating Scale (NRS) pain scores at 15-minute intervals during the post anesthesia care unit stay time (PACU), at 2-hour intervals for the first 24h on the ward and at 4-hour intervals for the next 24h. Intraoperative and postoperative opioid consumption were recorded during the full stay. Patient satisfaction was evaluated upon discharge using a 10-point scale. MAIN RESULTS: Intraoperative sufentanil requirements were comparable for the Pecs and placebo group (8.0±3.5µg and 7.8±3.0µg, P=0.730). Patients in the Pecs group experienced significantly less pain than patients in the control group (P=0.048) during their PACU stay. Furthermore, patients in the Pecs group required significant less postoperative opioids (9.16±10.15mg and 14.97±14.38mg morphine equivalent, P=0.037) and required significant fewer postsurgical opioid administration interventions than patients in the control group (P=0.045). Both patient-groups were very satisfied about their management (9.6±0.6 and 9.1±1.8 on a 10-point scale, P=0.211). CONCLUSIONS: The Pecs block reduces postsurgical opioid consumption during the PACU stay time for patients undergoing breast surgery.