Exploring the efficacy of ultrasound-guided lumbar erector spinae plane block for perioperative analgesia in percutaneous nephrolithotomy: Report of two cases

Samarjit Dey; Omer Mohammed Mujahid; Suresh Nagalikar; Prateek Arora

doi:10.4103/ijpn.ijpn_53_21

CASE SERIES

Year : 2022 | Volume : 36 | Issue : 1 | Page : 43-45

Exploring the efficacy of ultrasound-guided lumbar erector spinae plane block for perioperative analgesia in percutaneous nephrolithotomy: Report of two cases

Samarjit Dey, Omer Mohammed Mujahid, Suresh Nagalikar, Prateek Arora
Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Submission	16-Jun-2021
Date of Decision	31-Oct-2021
Date of Acceptance	20-Dec-2021
Date of Web Publication	25-Apr-2022

Correspondence Address:
Dr. Samarjit Dey
Department of Anaesthesiology, Pain and Critical Care, All India Institute of Medical Sciences, GE Road, Raipur - 492 099, Chhattisgarh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ijpn.ijpn_53_21

Abstract

Erector spinae plane block (ESPB) is used to a great extent for perioperative analgesia. The ease of administering it, safety and the perioperative analgesia achieved make it a good addition to anesthetic plans. The reduction in opioid usage with the usage of regional analgesia techniques may aid in enhanced recovery; in addition, regional analgesia with this block provides excellent analgesia and better postoperative outcome as seen here in two cases who underwent percutaneous nephrolithotomy (PCNL). Single-shot ESPB was performed in two cases undergoing PCNL. We achieved stable hemodynamics throughout the procedure and a mean NRS of 1.8 for a duration of 18 h postsurgery in both cases, with faster mobilization and early discharge of the patients.

Keywords: Analgesia, erector spinae plane block, percutaneous nephrolithotomy

How to cite this article:
Dey S, Mujahid OM, Nagalikar S, Arora P. Exploring the efficacy of ultrasound-guided lumbar erector spinae plane block for perioperative analgesia in percutaneous nephrolithotomy: Report of two cases. Indian J Pain 2022;36:43-5

How to cite this URL:
Dey S, Mujahid OM, Nagalikar S, Arora P. Exploring the efficacy of ultrasound-guided lumbar erector spinae plane block for perioperative analgesia in percutaneous nephrolithotomy: Report of two cases. Indian J Pain [serial online] 2022 [cited 2023 Mar 31];36:43-5. Available from: https://www.indianjpain.org/text.asp?2022/36/1/43/343827

Introduction

Pain after percutaneous nephrolithotomy (PCNL) has both somatic and visceral components. Somatic pain from the incision site is mediated by the T10–T11 dermatomes. The visceral pain is due to dilatation of the renal capsule and the parenchymal tract and the ureteral pain which is mediated by T10–L1 spinal nerves and the T10–L2 spinal nerves, respectively.^[1] Erector spinae plane block (ESPB) has been described for the management of thoracic neuropathic pain and also been used extensively for thoracic and abdominal surgeries as part of perioperative analgesia.^[2],[3] Here, we present to you two cases of PCNL where perioperative analgesia was successfully managed by single-shot ESPB.

Case Reports

Case 1

A 40-year-old female patient, weighing 68 kg, was scheduled to undergo bilateral PCNL under general anesthesia. She was a known case of hypothyroidism for 3 years, well controlled on medication. The ESP block was done before the start of anesthesia. The block was performed with the patient in a sitting position under all aseptic precautions, with the ultrasound probe held in craniocaudal direction, the spinous process of T11 vertebrae was identified on both sides. The transverse process was then visualized by tracing the probe laterally. Subcutaneous infiltration with injection lignocaine (2 ml of 2%) was administered at the expected site of entry of the needle bilaterally. A 10 cm Stimuplex® A needle (B Braun, Germany) was inserted under ultrasound guidance (SonoSite Edge II 6-13MHz Linear Probe) in the craniocaudal direction with the needle path being visualized as it reached the transverse process [Figure 1]. Bilaterally, 20 mL of 0.25% ropivacaine with 4 mg dexamethasone on each side was injected after verifying the plane and repeated negative aspiration. The patient was induced with injection fentanyl 2 mcg/kg, injection propofol 1.5 mg/kg and injection atracurium 0.5 mg/kg body weight and tracheal intubation was done. The patient was then mechanically ventilated with a mixture of oxygen, nitrous oxide, and isoflurane titrated to a MAC of 0.9–1.0. Throughout the intraoperative period, no hemodynamic response was noted at the incision, and during the dilation of the renal capsule. Intraoperatively, injection paracetamol 1 g was given. The surgery lasted for 100 min, after which the patient was awakened and extubated. The patient was shifted to post anesthesia care unit and observed. The Visual Analog Score (VAS) at rest, at 1-and 2-h postsurgery was 1 and 2, respectively. In the ward, the VAS (on movement) at 6, 12, 18 h postsurgery was 2, 2, and 1, respectively. Paracetamol 1 g intravenously eighth hourly was used as part of analgesia regime. The patient did not require any rescue analgesia.

Figure 1: Transverse process, the erector spinae plane after deposition of drug. ES: Erector spinae muscle; TP: Transverse Process

Click here to view

Case 2

A 28-year-old male patient, weighing 52 kg, was scheduled to undergo left-sided PCNL under ASA physical status 1. The block and anesthesia management was similar to the first case. The VAS (at rest) at 1- and 2-h postsurgery was 1 and 2, respectively, following which the patient was shifted to ward. The VAS (on movement) at 6, 12, and 18 h postsurgery was 1, 3, and 2, respectively. Paracetamol 1 g intravenously every eighth hourly was used as part of the analgesia regime. No rescue analgesia was required for this patient.

Discussion

The abdominal organs of the genitourinary system, i.e., the kidney and ureter receive their nerve supply from the sympathetic pathways from T8 through the L1 segments. The nociceptive fibres travel along the sympathetic pathways via the T10 to L2 spinal segments. Effective analgesia can be achieved if both visceral and somatic pain can be controlled. The use of neuraxial techniques, infiltration of local anesthetic (LA) in renal capsule, regional techniques like paravertebral block^[4] have been used to achieve analgesia in patients undergoing PCNL. Regional anesthesia techniques are effective as they help in reduced consumption of analgesics with potential nephrotoxic effects as these patients might already have compromised renal function, and reduced consumption of opioids and therefore reduction in its postoperative effects such as nausea and vomiting.^[5] The ESPB is a simpler, more superficial and a safer block as compared to the paravertebral block. The deposition of LA in the erector spinae fascial plane leads to the extensive spread of the LA craniocaudally in the fascial plane and anterior to paravertebral and epidural spaces as reported by Vidal et al. in their cadaveric studies^[6] and blockage of the dorsal, ventral and rami communicantes of spinal nerves. This helps in covering the visceral as well as somatic pain. In the cases we report, there was also no sympathetic hemodynamic response with regard to heart rate and blood pressure throughout the procedure, which may have been contributed by ESP block, thereby affirming the effective analgesic efficacy in the intraoperative period. There have been case reports of the use of catheters in the erector spinae plane in patients undergoing PCNL for postoperative management;^[7] here, we report the use of single-shot ESPB for perioperative analgesia management.

Conclusion

ESPB given as a single shot can be considered a better alternative for perioperative analgesia in PCNL with excellent pain scores, reduced opioid requirements and patient satisfaction as per our experience, and evidenced in these two cases. This technique needs to be further explored in the form of randomized controlled trials with adequate power.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Gropper M, Miller R, Eriksson L, Fleisher L, Wiener-Kronish J, Cohen N, et al. Miller's Anesthesia. 9^th ed. Philadelphia: Elsevier; 2020.
2.	Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.
3.	Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: A report of 3 cases. Reg Anesth Pain Med 2017;42:372-6.
4.	Ak K, Gursoy S, Duger C, Isbir AC, Kaygusuz K, Ozdemir Kol I, et al. Thoracic paravertebral block for postoperative pain management in percutaneous nephrolithotomy patients: A randomized controlled clinical trial. Med Princ Pract 2013;22:229-33.
5.	Gürkan Y, Aksu C, Kuş A, Yörükoğlu UH, Kılıç CT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: A randomized controlled study. J Clin Anesth 2018;50:65-8.
6.	Vidal E, Giménez H, Forero M, Fajardo M. Erector spinae plane block: A cadaver study to determine its mechanism of action. Rev Esp Anestesiol Reanim (Engl Ed) 2018;65:514-9.
7.	Resnick A, Chait M, Landau S, Krishnan S. Erector spinae plane block with catheter for management of percutaneous nephrolithotomy: A three case report. Medicine (Baltimore) 2020;99:e22477.