Intermittent Erector Spinae Plane Block as a Part of Multimodal Analgesia After Open Nephrectomy
The erector spinae plane block (ESPB) has gained attention in recent years as an effective regional anesthesia technique for postoperative pain management. Initially described for thoracic and breast surgeries, its application has expanded to various surgical procedures. This case report highlights the successful use of intermittent ESPB as part of a multimodal analgesia strategy following open nephrectomy, a procedure associated with significant postoperative pain.
Background and Clinical Context
Open nephrectomy is a major surgical procedure often performed for conditions such as renal cell carcinoma. The surgery involves a large flank incision, which can lead to considerable postoperative pain. Effective pain management is crucial not only for patient comfort but also for facilitating early mobilization and recovery. Traditional pain management strategies often rely on systemic opioids, which can have undesirable side effects such as respiratory depression, nausea, and sedation. Multimodal analgesia, which combines different classes of analgesics and regional anesthesia techniques, has emerged as a preferred approach to minimize opioid use and enhance recovery.
The ESPB is a relatively new regional anesthesia technique that involves injecting local anesthetic into the plane between the erector spinae muscle and the transverse process of the vertebrae. This block has been shown to provide effective analgesia for various thoracic and abdominal surgeries by targeting the dorsal and ventral rami of the spinal nerves. However, its use in open nephrectomy has been scarcely reported, with only one documented case in a pediatric patient.
Case Presentation
A 69-year-old female patient (height: 155 cm, weight: 54 kg) underwent a left open nephrectomy for renal cell carcinoma. The surgery was performed through a 15-cm flank incision under general anesthesia. Postoperatively, an ESPB was performed at the T7 level to manage pain. The block was administered using 20 mL of 0.375% ropivacaine with epinephrine (1:200,000) to prevent systemic toxicity, following the protocol of Daejeon St. Mary’s Hospital. A catheter was then inserted for intermittent administration of the local anesthetic.
Pain Management Protocol
The patient’s postoperative pain was managed using a multimodal approach, which included the following components:
- Intermittent ESPB Catheter Injections: Every 8 hours, 20 mL of 0.375% ropivacaine with epinephrine (1:200,000) was administered through the catheter for two days.
- Oral Analgesics: The patient received 80 mg of oral zaltoprofen twice daily.
- Intravenous Patient-Controlled Analgesia (PCA): A PCA pump was used to deliver fentanyl at a basal rate of 1 mL/h with a bolus dose of 2 mL as needed.
Outcomes and Patient Response
In the recovery room, the patient reported a resting visual analogue scale (VAS) score of 2 and a dynamic VAS score (during coughing and deep breathing) of 3. A pinprick test revealed complete sensory loss in the T2–T8 dermatome area and decreased sensation in the T9–T10 dermatome compared to the contralateral side. Throughout the postoperative period, the patient’s resting and dynamic (ambulation) VAS scores remained between 1 and 2, and she did not require additional analgesics. The patient reported no discomfort during ambulation and expressed high satisfaction with the pain management strategy. She was discharged without any complications.
Mechanism of Analgesia
The effective analgesia provided by the ESPB in this case can be attributed to several mechanisms. First, the block likely resulted in the blockade of multiple dorsal and ventral rami, which are responsible for transmitting somatic pain from the surgical incision. The sensory blockade observed in the T2–T10 dermatomes suggests that the block effectively covered the incision site, providing sufficient analgesia even if sympathetic fibers were not blocked. Second, the ESPB may have induced a differential blockade, preferentially affecting unmyelinated C fibers, which transmit nociceptive signals, while sparing larger A-delta and A-gamma fibers, which mediate other types of pain. This differential blockade could explain the clinically evident analgesia despite the limited range of sensory loss detected by the pinprick test.
Discussion
The use of ESPB in open nephrectomy represents a novel application of this regional anesthesia technique. The successful pain management in this case demonstrates the potential of ESPB as part of a multimodal analgesia strategy for major abdominal surgeries. The intermittent administration of local anesthetic through the catheter allowed for sustained pain relief over two days, reducing the need for systemic opioids and minimizing their associated side effects.
The mechanisms underlying the effectiveness of ESPB in this case are still not fully understood. It is possible that the block’s analgesic effects are mediated by a combination of dorsal and ventral ramus blockade, sympathetic fiber blockade, and differential blockade of nociceptive fibers. Further research is needed to elucidate these mechanisms and to determine the optimal dosing and timing of ESPB for different surgical procedures.
Conclusion
This case report highlights the successful use of intermittent ESPB as part of a multimodal analgesia strategy following open nephrectomy. The patient experienced effective pain control with minimal opioid use, facilitating a smooth recovery and early discharge. The findings suggest that ESPB can be a valuable component of postoperative pain management for major abdominal surgeries, particularly in cases where traditional opioid-based analgesia may be less desirable. Further studies are warranted to explore the broader applications of ESPB and to refine its use in clinical practice.
doi.org/10.1097/CM9.0000000000000269
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