Erector Spinae Plane Fascial Block in Multiple Rib Fractures (Case Report)

The aim of the study: to improve the efficacy of erector spinae plane (ESP) fascial block for pain management in patients with multiple rib fractures.
Materials and methods. We observed 4 patients with multiple rib fractures who were treated with ESP fascial block with subsequent prolonged administration of local anesthetic for pain relief. To evaluate the efficacy of the ESP block, the visual analogue scale (VAS) for pain intensity, cough performance index and forced vital capacity (FVC), as well as a modified 3-item scale were used. The distribution of local anesthetic (10% lidocaine solution) and contrast (iohexol solution, 350 mg iodine/ml) media was analyzed by computed tomography and correlated with the data on reduced pain perception according to the thoracic vertebrae (Th) levels.
Results. After the ESP block in patients with multiple rib fractures, we found a decrease in VAS pain intensity at rest by 3-4 points and on coughing by 3-6 points, an increase in cough performance by 1 point and in the modified 3-item scale by 1-3 points. The distribution of the local anesthetic solution was registered mainly in the cranial-caudal and anterior direction to the intertransversal space without significant leakage in lateral and medial directions. In all 4 cases the local anesthetic and contrast media spread from the catheter tip cranially several levels of thoracic vertebrae farther than in caudal direction.
Conclusion. ESP block in patients with multiple rib fractures is a reasonably effective method of pain relief. Catheterization of the fascial plane of erector spinae muscle should be performed at the level of vertebra corresponding to the underlying fractured rib. The data obtained may serve as a basis for further studies with more patients included.

1. Forero M., Adhikary S.D., Lopez H., Tsui C., Chin K.J. The Erector Spi-nae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016; 41 (5): 621-627. DOI: 10.1097/AAP.0000000000000451. PMID: 27501016.

2. MariaB.L., AlvaroG.C., JoseM.L., EnriqueD.S., CarlosL.C., FranciscoP.S. Erector Spinae Block. A narrative review. Central Eur J Clin Res. 2018; 1 (1): 28-39. DOI: 10.2478/cejcr-2018-0005. PMID:30292068.

3. Tulgar S., Selvi O., Ozer Z. Clinical experience of ultrasound guided single and bi-level erector spinae plane block for postoperative analgesia in patients undergoing thoracotomy. Journal of Clinical Anesthesia 2018; 50: 22-23. DOI: 10.1016/j.jclinane.2018.06.034. PMID: 29940470.

4. Chin K.J., Adhikary S.D., Sarwani N., Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017; 72: 452-460. DOI: 10.1111/anae.13814. PMID: 28188621.

5. Chung K., Kim E.D. Continuous erector spinae plane block at the lower lumbar level in a lower extremity complex regional pain syndrome patient. J Clin Anesth 2018; 48: 30-31. DOI:10.1016/j.jclinane.2018.04.012. PMID: 29727760.

6. Hamilton D.L., Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017; 118 (3): 474-475. DOI: 10.1093/bja/aex013. PMID: 28203765.

7. Venkatesan T., Hillen E., Sanjib A. An update on regional analgesia for rib fractures. Curr Opin Anaesthesiol. 2018. 31 (5): 601-607. DOI: 10.1097/ACO.0000000000000637. PMID: 30020155.

8. Forero M., Rajarathinam M., Adhikary S., Chin K.J. Continuous Erector Spinae Plane Block for Rescue Analgesia in Thoracotomy After Epidural Failure: A Case Report. A A case reports. 2017;8 (10): 254-256 PMID:28252539. DOI: 10.1213/XAA.0000000000000478.

9. Adhikary S.D, Bernard S., Lopez H., Chin K.J. Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Regional Anesthesia and Pain Medicine. 2018; 43: 756-762. DOI: 10.1097/AAP.0000000000000798. PMID: 29794943.

10. Ivanusic J., Konishi Y., Barrington M.J. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018; 43: 567-571. DOI: 10.1097/AAP.0000000000000789. PMID: 29746445.

11. Tulgar S., Balaban O. Spread of local anesthetic in erector spine plane block at thoracic and lumbar levels. Reg Anesth Pain Med. 2019; 44: 134-135. DOI: 10.1136/rapm-2018-000027. PMID: 30640667.

12. Forero M., Rajarathinam M., Adhikary S.D., Chin K.J. Erector spinae plane block for the management of chronic shoulder pain: a case report. Can J Anesth. 2018; 65: 288-293. DOI: 10.1007/s12630-017-1010-1. PMID:29134518.

13. Schwartzmann A., Peng P., Maciel M.A., Forero M. Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study. Can J Anaesth. 2018; 65 (10): 1165-1166. DOI: 10.1007/s12630-018-1187-y. PMID: 30076575.

14. Luftig J., Mantuani D., HerringA.A., Dixon B., ClattenburgE., Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018; 36 (8): 1391-1396. DOI: 10.1016/j.ajem.2017.12.060. PMID: 29301653.

15. Adhikary S.D., Liu W.M., Fuller W.M., Cruz-Eng H., Chin K.J. The effect of erector spinae plane block on respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study. Anaesthesia. 2019; 74: 585-93. DOI: 10.1111/anae.14579. PMID: 30740657.

16. Witt C.E., Bulger E.M. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surgery & Acute Care Open 2017; 2 (1): e000064. DOI: 10.1136/tsaco-2016-000064. PMID: 29766081.

17. Todd S.R., McNally M.M., Holcomb J.B., Kozar R.A., Kao L.S., Gonzalez E.A., Cocanour C.S., Vercruysse G.A., Lygas M.H., Brasseaux B.K., Moore A.F. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006; 192: 806-811. DOI: 10.1016/j.amjsurg.2006.08.048. PMID: 17161098.

18. Martin T.J., Eltorai A.S., Dunn R., Varone A., Joyce M.F., Kheirbek T., Adams C., Eltorai A.E. Clinical management of rib fractures and methods for prevention of pulmonary complications: A review. Injury. 2019. 50 (6): 1159-1165. DOI.org/10.1016/j.injury.2019.04.020. PMID: 31047683.