Unilateral erector spinae plane block for managing acute pain arising from multiple unilateral injuries: A case report.

Sir,

A 25-year-old male who sustained high-velocity injury after a road traffic accident was brought to emergency room in a hypotensive state with blood pressure of 80/60 mmHg, Glasgow Coma Scale of 15/15, oxygen saturation (SpO2) of 91% and respiratory rate of 32–34/min. He had severe right lower chest, right abdominal and right pelvic pain. After resuscitation (1000 ml of balanced salt solution, oxygen with face mask), he was transferred for computed tomography (CT) scan of thorax and abdomen after an infusion of 1 gm IV paracetamol.

On arrival in intensive care unit (ICU), his pain score on visual analogue scale (VAS) was 7/10, which was addressed with IV fentanyl 50 μg followed by an infusion of 30 μg/hr. As pain did not relieve for next 2 h, the pain team was consulted.

The patient was conscious, haemodynamically stable with VAS of 8/10. CT Scan revealed fractures of right ribs (6–10), T12-L1 vertebral body (mild posterior displacement with thecal sac indentation), right transverse process, i.e. TP (L1-L5), right sacroiliac disruption and right first sacral vertebra [Figure 1a]. TP fractures are usually associated with intrabdominal injuries, but there were none in this case.[1] Sensations of touch and cold were preserved below the umbilicus. Quadriceps and ankle movements were weak. There was no surgical intervention planned by the spine and orthopaedic team. We decided to administer a continuous ESPB under ultrasound (US) guidance after counselling the relative and the patient and after obtaining an informed consent.

Figure 1

(a) CT scan with volume rendering technique (VRT) depicting the spread from T7 caudally. The fractures in the posterolateral Aribs, transverse processes and sacroiliac joint are visualised. (Yellow circle—Fracture ribs; Blue circle—Fracture transverse process; Green circle—Disruption of Sacroiliac joint; Black hollow arrows—ESP Contrast spread). (b) Transverse scan showing paravertebral spread of injected contrast (blue arrows showing the spread). (c) Coronal scan showing spread of contrast posterior to costotransverse foramen from ESP

In ICU, IV ketamine 20 mg with 1 mg midazolam was administered and patient was turned lateral with affected side up in the presence of the spine surgeon. Under strict asepsis, a high-frequency linear transducer (6–13 MHz, Sonosite M-Turbo, Sonosite Inc.) was placed in lower thoracic area by counting the ribs from 12th cephalad in the right parasagittal plane. The 4th rib was identified and the transducer was shifted medially towards costotransverse junction. After skin infiltration with 4 ml of 2% lidocaine, an 18G Tuohy needle was advanced with the transducer in the parasagittal plane. With the tip identified above the 5th TP and below erector spinae muscle (ESM), hydrodissection was performed to confirm the needle in fascial plane. On confirmation, 30 ml of 0.375% ropivacaine with 50 μg clonidine was injected in ESP. A 20 G catheter was inserted to a distance of 10 cm from the skin and was tunnelled subcutaneously. An infusion of 0.1% ropivacaine at 8 ml/h was initiated subsequently. The patient continued to receive 1 g paracetamol 8 hourly and IV fentanyl (25 μg) was prescribed as rescue analgesic if VAS was more than 4. The VAS decreased from 8/10 to 2/10 at the 16th minute. For 72 h, the VAS was constant in the range of 2–3/10 without the requirements of IV fentanyl.

Spine surgeon planned for a repeat CT scan after 72 h of admission. We planned a CT contrast study at the same time using radio-opaque contrast (3 ml Omnipaque—300 mg iodine/ml diluted in 27 ml of 0.9% saline) which was injected through ESP catheter. An informed consent was obtained for the scan. Scan revealed a wide linear unilateral spread across the ESP in the thoracolumbar area. A paravertebral spread was observed in the axial scan at T9, T10 and T11, which could be corelated with coronal and sagittal images [Figure 1b and c]. On 4th day, the catheter was removed.

Pain due to fractured ribs is relayed in thoracic area, from vertebral body and TP in thoracolumbar region and the sacroiliac joint and first sacral body pain has its origin from upper sacral plexus. Forero et al. described ESPB for treating chronic neuropathic thoracic pain followed by Hamilton et al. who used ESPB for managing excruciating pain due fracture ribs successfully.[23] Klesius et al. utilised bilateral ESPB with catheters at T5 level for surgical repair of L1 burst fracture with T11-L3 posterior spinal instrumentation.[4] Cadaveric studies mention that placement of LA close to costotransverse junction blocks dorsal and ventral rami of thoracic spinal nerves.[5] Thoracolumbar fascia extends across the whole of the posterior thorax and abdomen and is continuous with nuchal fascia in neck.

To conclude, unilateral ESPB may be considered for managing pain arising from multiple sources.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.