|Year : 2020 | Volume
| Issue : 1 | Page : 124-130
Analgesic efficacy of erector spinae block in comparison to thoracic epidural anesthesia in patients undergoing transthoracic esophageal surgical procedure
Hoda Shokri, Amr A Kasem
Department of Anesthesiology, Ain Shams University, Cairo, Egypt
|Date of Submission||08-Apr-2019|
|Date of Acceptance||29-Dec-2019|
|Date of Web Publication||16-Apr-2020|
MD, PhD Hoda Shokri
Department of Anesthesiology, Ain Shams University, 11772 Cairo
Source of Support: None, Conflict of Interest: None
Background The ultrasound-guided erector spinae plane block is a new regional anesthetic technique providing long-lasting excellent analgesia in addition to hemodynamic stability and minimal rescue analgesic request.
Materials and methods Following ethics committee approval, a total of 80 patients aged 36–65 years, American Society of Anesthesiologists physical status I and II undergoing elective transthoracic esophageal surgical procedures were enrolled in this prospective study. The patients were randomized into epidural group: patients who received thoracic epidural anesthesia with injection of 15 ml of bupivacaine 0.25% combined with general anesthesia, followed by 7 ml/h of 0.125% bupivacaine and bilateral erector spinae block group, which were performed with an injection of a total of 15 ml of bupivacaine 0.25% on either side combined with general anesthesia and then 7 ml/h of 0.125% bupivacaine was injected in each catheter 2 h for 24 h postoperatively. The primary end point included postoperative minor complications (hypotension, vomiting, urinary retention) and major complications (mortality). Secondary end points included the extubation time, hospital stay length, pain scores at 4, 8, 12, 18, and 24 h postoperatively, rescue analgesic consumption and patient satisfaction scores.
Results Pain scores and the total dose of rescue analgesic were comparable in the two groups. The length of hospital stay was significantly longer in the epidural group compared with the erector group. Satisfaction scores were significantly higher in the erector group compared with the epidural group. There was no significant difference between the study groups regarding time to perform the block, time to extubation, and incidence of postoperative complications except for hypotension which was significantly higher in the epidural group.
Conclusion Erector spinae plane block has an outstanding beneficial effect in reducing pain and providing better satisfaction scores with less incidence of complications compared with thoracic epidural anesthesia.
Keywords: bupivacaine, erector spinae, esophageal surgeries, thoracic epidural, visual analog scale
|How to cite this article:|
Shokri H, Kasem AA. Analgesic efficacy of erector spinae block in comparison to thoracic epidural anesthesia in patients undergoing transthoracic esophageal surgical procedure. Res Opin Anesth Intensive Care 2020;7:124-30
|How to cite this URL:|
Shokri H, Kasem AA. Analgesic efficacy of erector spinae block in comparison to thoracic epidural anesthesia in patients undergoing transthoracic esophageal surgical procedure. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Jul 7];7:124-30. Available from: http://www.roaic.eg.net/text.asp?2020/7/1/124/282589
| Introduction|| |
The transthoracic esophageal procedures are performed using combined laparotomy and right thoracotomy . Transthoracic esophageal procedure is a major surgery resulting in multiple morbidities including the respiratory and circulatory systems .
Patients experienced torturing post-thoracotomy pain which delays the recovery and increase the incidence of postoperative adverse events such as chest infection and lung collapse . Eventually, postoperative pain management following thoracotomy hinders these complications and prevents chronic pain development. Moreover, it promotes smooth recovery together with minimal surgical morbidities and shorter hospitalization. A multimodal analgesia is widely applicable using a combination of regional anesthetic blockade, nonopioid and opioid medications and nerve blockade .
Pain management following esophageal surgery is modulated according to the surgical approach to the esophagus particularly thoracotomy incision, which is considered one of the most painful surgical incisions . For this reason, local anesthetic techniques for postoperative pain control is considered the cornerstone in improving the outcomes after transthoracic esophageal surgeries . One of the most reliable techniques is the ultrasound-guided erector spinae plane (ESP) because of its simplicity and safety.
ESP block is a novel technique that provides thoracic analgesia . It is relatively safer than thoracic epidural or paravertebral block due to the fact that the site of injection is away from the neural and vascular structures as well as the pleura .
The block provides effective and immediate analgesia which makes it an attractive choice especially for chronic thoracic pain management and acute pain management following thoracotomy .
The ultrasound-guided ESP block is a regional anesthetic technique that can be performed at the level of the T5 transverse process and may be at a lower level. Local anesthetic is introduced into the fascial plane deep into the erector spinae muscle which spreads in a cranio-caudal manner within several levels . Local anesthetic flows anteriorly through the intertransverse connective tissue and enters the thoracic paravertebral space and successfully block the ventral and dorsal rami of spinal nerves and also the rami communicantes that carry sympathetic fibers. Amazingly, the ESP block results in both visceral and somatic abdominal analgesia due to extension of erector muscle to the lumbar spine .
In contrast, epidural anesthesia has been assumed to increase the cost and complications of thoracic surgery . Epidural management plan involves the site of incision(s), the effect of incisional pain on respiratory function, and the epidural-induced sympathectomy effect on hemodynamics .
Unfortunately, not all patients are proper candidates for thoracic epidural anesthesia; so lumbar epidural analgesia can be used as a substitute for pain management after thoracoabdominal esophageal procedures .
This study was established to compare the efficacy of TEA and ultrasound-guided bilateral ESP block, both combined with general anesthesia (GA) in terms of pain scores, the incidence of complications, and the length of hospital stay in adults undergoing elective esophageal surgeries.
| Materials and methods|| |
Following Ethics Committee approval of Ain Shams University FMASU R 192018, Clinical trial.gov.: NCT03504371. Eighty patients aged from 36 to 65 years, the American Society of Anesthesiologists physical status I and II posted for elective transthoracic esophageal surgical procedures were enrolled in this prospective, randomized, parallel group study.
This study was carried out in Ain Shams University Hospital from February 2018 till April 2019. Patients suffering from cardiac dysfunction, hepatic or renal impairment, electrolyte disturbances, neuromuscular disorder, immune disease, endocrinological disorders, allergy to LA, unable to communicate with the investigators or hospital staff, obesity (BMI >40 kg/m2), contraindications for TEA and emergency surgery were not eligible to participate in the study. The patients were declined from the study if prolonged postoperative mechanical ventilation with sedatives or another surgery was required during the study.
Preanesthetic evaluation and routine investigations were carried out on the night of surgery and patients were fasting for 6–8 h and written informed consent was signed by every patient.
An intravenous cannula was secured and midazolam 0.05 mg/kg intravenously was given to all patients before transfer to the operating room, where standard monitoring devices and invasive blood pressure monitoring equipment were placed using local anesthesia. The patients were randomized using a concealed envelope method into two groups. Randomization was done using random allocation software 2.0 and the allocation of patients to either group was done by a clinician not involved in the study. There were two groups of patients: TEA group and erector group. In TEA group, patients received TEA where an epidural catheter was placed at the T7-8 interspace after proper sterilization and 15 ml of bupivacaine 0.25% was given. Patients of both groups received a standard general anesthetic protocol in the form of intravenous fentanyl (2 µg/kg), propofol (2 mg/kg), and atracurium (0.5 mg/kg). Anesthesia was maintained using oxygen 50% in air 50%, isoflurane, and supplements of atracurium 0.1 mg/kg. Volume-controlled ventilation (tidal volume: 10 ml/kg) was adjusted to maintain an end-tidal carbon dioxide of between 35 and 40 mmHg. A left-sided, double-lumen tube (Batch number: USA0604-2005; male: #37; female: #35) was inserted and confirmed by bronchofiberoscopy. Anesthesia was maintained with isoflurane at 1.2 minimal alveolar concentration and then central venous catheter was inserted in the left internal jugular vein; warm intravenous fluids were administered according to the fluid chart. Red blood cells were transfused according to maximum allowable blood loss and hypothermia was prevented using a warming mattress. In the TEA group, an additional 7 ml epidural doses of bupivacaine 0.125% was administered every 1 h for 24 h postoperatively. In the erector group, patients received bilateral ESP blocks which were performed as follows: The patient was put in the lateral position and a high-frequency linear ultrasound transducer (GE LOGIQe, Wauwatosa, Wisconsin, USA) was placed longitudinally 3 cm lateral to the T5 spinous process. Three muscles were seen as follows: trapezius, rhomboid major, and erector spinae as shown in [Figure 1]. An 8 cm 22 G block needle (EchoStim; Benlan Inc., Oakville, Canada) was inserted in a cephalocaudal direction until its tip lay in the plane between rhomboid major and erector spinae muscles. A 20 G catheter under direct vision was placed 3 cm beyond the needle tip in the ESP and was subcutaneously fixed. Then, 15 ml of 0.25% bupivacaine was injected, this was repeated on the other side. A measure of 7 ml/h of 0.125% bupivacaine was injected in each catheter 2 h for 24 h postoperatively. TEA and bilateral erector spinae block were performed by the same anesthesiologist. Heart rate, arterial blood pressure, central venous pressure, oxygen saturation, and total blood loss were monitored intraoperatively. The heart rate and arterial blood pressure were maintained within 20% of the preoperative values. At the end of the procedure, anesthesia was discontinued and neuromuscular blockade was antagonized with intravenous 0.05 mg/kg neostigmine, and atropine intravenous (0.03 mg/kg) at appropriate doses. Patients were extubated, then patients will be transported postoperatively to the ICU.
|Figure 1 Ultrasound image of the erector spinae plane block with transducer placed longitudinally in line with the tip of thoracic transverse process. ES, Erector spinae muscle; Rm, Romboid muscle; Tm, Trapezious muscle; TV, Thoracic vertebrare.|
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Study end points
The primary end point of this study included postoperative minor complications (hypotension, vomiting, urinary retention) and major complications (15-day postoperative mortality). Hypotension was defined as fall of systolic BP below 20% of the baseline or mean arterial pressure below 65 mmHg. It was treated with phenylephrine 50 µg and intravenous fluids while significant bradycardia was defined as a heart rate of less than 60/min with hypotension (as stated above) or less than 45/min with any blood pressure. It was treated with atropine 0.5 mg.
The secondary end points included the extubation time, the length of hospital stay, and visual analog scale (VAS) scores at 4, 8, 12, 18, and 24 h postoperatively; postoperative rescue analgesic consumption and patient satisfaction scores were determined. The patients were asked to answer a questionnaire with 10 questions to assess their satisfaction scores before being discharged from the hospital (0=most unsatisfactory, 10=most satisfactory). The patients before induction were instructed how to use the VAS which is a 10 cm scale where 0=no pain and 10=the worst imaginable pain), Additional fentanyl doses (50 µg) were used as rescue analgesia if VAS greater than 5.
Sample size calculation
The software used for statistics and data science (Stata program) (Stata Corp LLC, Texas, USA) revealed that 80 patients, 40 per arm after considering a10% dropout were recruited, setting alpha error at 5% and power at 80%. These calculations were based on a previous study by Richardson and colleagues that compared minor complications as hypotension; it was absent in the PVB group compared with 14.28% in the thoracic epidural group. The collected data were coded, tabulated, and statistically analyzed using the Statistical Package for the Social Sciences software, version 17.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were carried out for numerical parametric data and presented as mean±SD, whereas categorical data were presented as number and percentage. Variables such as demographic data and comorbidities were compared using the χ2-test. A P value less than 0.05 was considered significant.
| Results|| |
80 patients were assessed for eligibility and enrolled in this study without any case violating the protocol as shown in consort flow diagram ([Figure 2]). They were randomized and their data were analyzed.
Demographic data, American Society of Anesthesiologists and surgical data were comparable between the study groups ([Table 1]).
There was no significant difference between the study groups regarding the incidence of vomiting, urinary retention and 15-day mortality ([Table 2]).
The number of patients who had hypotension was statistically higher in the epidural group compared with erector group ([Table 2]).
The time of performance of each technique and the extubation time were comparable between the study groups ([Table 3]).
|Table 3 Comparison of hospital stay length, time of performance of each technique, satisfaction scores, total dose of postoperative opioids, and extubation time between the study groups|
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The length of hospital stay was significantly longer in epidural group compared with erector group ([Table 3]).
Satisfaction scores were significantly higher in erector group compared with epidural group ([Table 3]).
Total postoperative fentanyl consumption was significantly higher in epidural group compared with erector group ([Table 3]).
There was no significant difference between the study groups regarding VAS scores at 8 and 12 h postoperatively ([Table 4]).
|Table 4 Comparison of visual analog scale scores between the study groups|
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VAS scores were significantly higher in epidural group compared with erector group at 16, 18 and 24 h postoperatively ([Table 4]).
| Discussion|| |
The ESP block is a feasible option for postoperative pain control as it is simple to perform and a relatively noninvasive technique providing thoracic analgesia in both acute postsurgical and post-traumatic pain .
The results of this prospective study showed that erector spinae block usage was associated with a shorter length of hospital stay, better satisfaction scores, lower VASs, and less postoperative opioid consumption with less incidence of complications.
Forero et al.  underwent either ESP block or thoracic epidural anesthesia in a group of patients posted for thoracic surgery (lobectomy or pneumonectomy). In contrast to our findings, they reported that there was no significant difference between the study groups regarding pain scores. However, excellent analgesia was maintained for 48 h postextubation and no complications were encountered.
Another study by Chin et al.  in which they performed bilateral ESP block to provide visceral analgesia in three patients scheduled for bariatric surgery. The block was undertaken at the level of the T7 transverse process, they stated that both ventral and dorsal rami of the spinal nerves were blocked achieving effective somatic and visceral abdominal analgesia.
Tulgar et al.  studied the analgesic effects of ESP block used for patients aged 85 years with uncontrolled hypertension undergoing left-sided total hip arthroplasty. They reported that the patient was pain free for 18 h at rest and on joint movement, so the authors concluded that ESB is as effective as epidural anesthesia without any significant complications.
A study by Hamilton et al.  was done on a 50-year-old patient suffering from multiple unilateral right-sided rib fractures at the level of T6–T9 area, who has received e ESP block for pain relief. Two minutes after performing the regional block, pain scores were dramatically reduced to 0/10 at rest and 1/10 on cough enhancing patient mobility and early home discharge.
Tulgar et al.  performed ESP block in patients undergoing multiple laparoscopic abdominal surgical procedures. The patients encountered two types of pain: visceral pain resulting from peritoneal irritation and parietal pain which was caused by skin incision. Bilateral ESP block was found to be an effective analgesic method for both upper and lower abdominal surgical procedures; in addition, it is easy to perform and is a safer technique.
A study by Nagaraja et al.  compared the benefits of using either continuous TEA and bilateral erector spinae block in patients undergoing cardiac surgery and they found that VAS scores at rest and on cough were significantly lower in erector spinae group at 24, 36, and 48 h postoperatively. Both ICU stay length and postoperative complications were comparable between the study groups.
Eldemerdash and Abdelazeem  compared the efficacy of ESB with paravertebral block or serratus anterior plane block in patients undergoing breast surgery under general anesthesia. They found that pain scores in the erector group was significantly lower particularly at 4, 6, 12, 24 h postoperatively. The total rescue morphine dose was significantly lower in the erector group and minimal duration of analgesia was lower in the erector group (416±68 min) compared with the other groups.
The results of these previous studies agreed with our results and supported our findings, so we would like to emphasize the fact that these outcomes encourage researchers to undertake more studies with bigger sample sizes, which would definitely add more to the scientific value of the outcomes of this study.
This study was subjected to some limitations such as lack of blinding and therefore it opens the channel for observer bias and the sample size is relatively small. Further studies are needed to confirm these findings.
| Conclusion|| |
ESP block has a brilliant beneficial effect in reducing pain and providing better satisfaction scores with less incidence of complications compared with thoracic epidural anesthesia.
Human and animal rights
No animals were used in this research. All human research procedures followed were in accordance with standards of the committee responsible for experimentation (institutional and national) and with the Helsinki Declaration of 1975.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]