|Year : 2022 | Volume
| Issue : 2 | Page : 108-110
Role of erector spinae plane block in end-of-life care for a patient with advanced abdominal malignancy
Naina Kumar1, Sunny Malik1, Shraddha Malik2, Vibhu Ranjan Sahni1, Saurabh Joshi3
1 Department of Pain and Palliative Care, Rajiv Gandhi Cancer Institute and Research Centre, Niti Bagh, South Delhi, India
2 Department of Anaesthesia, Pain and Critical Care, GB Pant Hospital, New Delhi, India
3 Department of Pain and Palliative Care, Hospice, Hospice India, New Delhi, India
|Date of Submission||16-Feb-2022|
|Date of Decision||10-May-2022|
|Date of Acceptance||13-May-2022|
|Date of Web Publication||25-Aug-2022|
Dr. Sunny Malik
Department of Pain and Palliative Care, Rajiv Gandhi Cancer Institute and Research Centre, Niti Bagh, South Delhi - 110 049
Source of Support: None, Conflict of Interest: None
Celiac plexus block (CPB) is the most commonly used intervention in patients suffering from pain related to upper abdominal malignancies. Placing a CPB requires a patient to be placed in a prone position on the operating room table which becomes difficult in many patients with advanced disease and therefore makes it more challenging for the interventional pain physician, simultaneously risky for the patient. In such cases, a more superficial minimally invasive intervention is desirable. The erector spinae plane block (ESPB) is one such intervention that has been used in a large variety of settings and can be used in the abovementioned cases. So far, no reports have emphasized the role of this field block for chronic cancer pain relief in a patient with advanced and progressive malignancy nearing the end of life. We present such a case with end-stage carcinoma gallbladder, in which ESPB was used effectively for providing pain relief during her final days.
Keywords: End-of-life care, erector spinae plane block, malignancy, pain relief
|How to cite this article:|
Kumar N, Malik S, Malik S, Sahni VR, Joshi S. Role of erector spinae plane block in end-of-life care for a patient with advanced abdominal malignancy. Indian J Pain 2022;36:108-10
|How to cite this URL:|
Kumar N, Malik S, Malik S, Sahni VR, Joshi S. Role of erector spinae plane block in end-of-life care for a patient with advanced abdominal malignancy. Indian J Pain [serial online] 2022 [cited 2022 Sep 30];36:108-10. Available from: https://www.indianjpain.org/text.asp?2022/36/2/108/354719
| Introduction|| |
Pain is a prominent symptom of cancer, especially in cases where malignancy is advanced and progressive. Cancer pain can manifest at any stage of the disease but is more profoundly related to disease advancement or metastasis.
Celiac plexus block (CPB) is one of the common interventions for intractable pain associated with upper abdominal malignancies where conservative modalities have been exhausted and largely remained ineffective. However, in patients with advanced disease, it is challenging to perform these sympathetic nerve blocks due to significant disruption of the anatomy, heightened chances of bleeding due to neoangiogenesis, and increased risk of failure of the nerve block procedure. Thus, there is a continuing need to explore superficial minimally invasive interventional technique for pain relief that can provide supportive analgesia to supplement pharmacological therapy according to the World Health Organization analgesic ladder.
The erector spinae plane block (ESPB) is a versatile field block that has been used successfully in a broad variety of perioperative and pain settings. So far, none of the reports has underlined the role of this block for chronic cancer pain relief where the patients have poorly responded to other modalities of pain control.
Here, we present a case of end-stage carcinoma gallbladder with liver metastasis along with deposits in the lymph nodes of the abdomen where ESPB was effectively used for providing pain relief during her last days of life.
| Case Report|| |
A 29-year-old female was referred to the pain clinic with complaints of severe abdominal pain radiating to the back for the past 6 months. She was a known case of carcinoma gallbladder (T3N2M1-stage IVB) with involvement of the liver and abdominal lymph nodes. Her past medical history showed three cycles of chemotherapy with gemcitabine and cisplatin. Review positron-emission tomography scan after these cycles demonstrated progression of the disease and she was further advised to undergo two cycles of oxaliplatin, leucovorin, and fluorouracil-based chemotherapy-6 regimen. Radiographic scan showed diffuse gallbladder mass infiltrating into surrounding hepatic parenchyma and biliary confluence causing central and peripheral dilation of biliary radicle, loss of fat planes with duodenum, upper abdominal lymphadenopathy, and peritoneal deposits. A percutaneous transhepatic biliary drainage placement was suggested but was deferred owing to her poor general health, multiple levels of biliary obstruction, large disease bulk, and ascites. For complaint of pain, she underwent a CPB which provided her good relief for a few months during the early stages of the disease. At present, she described her pain to be arising from the right upper quadrant and spreading to the entire abdomen and back. Alongside complaints of abdominal pain, she also had severe abdominal distension, deranged liver function with severe constipation (Bristol stool chart, Type 1), excessive somnolence (Ramsay Sedation Scale 3) alternating with intense crying and shouting, oral cavity drying, and crusting. Her pain corresponded to a 9 on the numeric rating scale (NRS) and was not satisfactorily controlled despite being on daily oral morphine equivalent of 300 mg.
On admission, she was given immediate fluid and pharmacological resuscitation and pain management with simultaneous discussions on the prognosis, outcome, and palliative approach to the patient management. Once her restlessness settled, she was prepared for ESPB with indwelling catheter under ultrasound (USG) guidance as prone positioning for CPB or splanchnic plexus block was difficult. Following written informed consent, the patient was taken up for the procedure. Under all aseptic precautions (sitting position, standard monitors in place, and using a high-frequency linear ultrasound probe), the transverse process of the L1 vertebra was identified on the left side. The skin over the site of needle insertion was anesthetized using 2 ml of 2% lignocaine. A Tuohy needle was then inserted close to the probe and guided toward the transverse process using an in-plane technique. After hydrodissection, once the erector spinae plane was confirmed (plane deep to the erector spinae muscle [ESM] appreciated once, the muscle moves away from the transverse process on injecting volume), 20 ml of ropivacaine 0.1% was instilled. An epidural catheter was threaded in the same plane and secured at the skin as shown in [Figure 1]. The procedure was repeated on the right side. The patient tolerated the procedure well and reported more than 50% pain relief. Post the initial bolus, she was then given a 20 ml bolus of 0.1% ropivacaine twice a day. Her pain score fell to a 2 on the NRS, and opioid requirements were reduced to an optimal dose where she could comfortably interact with her family members consequently improving her quality of life (QOL) during her last days.
|Figure 1: Sonoanatomy of Tuohy needle just above transverse process with a catheter coming out of the needle|
Click here to view
| Discussion|| |
Gallbladder cancers are notoriously aggressive and lethal. They are the fifth-most common cancers of the gastrointestinal tract. It is the most common abdominal malignancy in northern India with a female prevalence and a typical survival of roughly 6 months. Fever with jaundice, abdominal pain, and loss of weight are the key symptoms of carcinoma gallbladder which amplify as the disease progresses contributing to poor QOL. Palliative care of such patients focuses on counseling regarding disease progression, pain relief, symptom burden reduction, and end-of-life care.
Pain is the most troublesome symptom accompanying any abdominal malignancy and presents two components ‒ visceral and neuropathic. Visceral pain is usually inflicted by distension, stretching, obstruction, or compression of the abdominal organ with additional infiltration of the surrounding tissue. The neuropathic pain is due to direct metastatic invasion or compression of the peripheral nerves and plexus., Sympathetic plexus blocks such as CPB is the intervention of choice for control of pain in such situations., The celiac plexus receives innervation from the greater, lesser, and least splanchnic nerves, which receive sympathetic fibers from T5 to T12 levels. The CPB is often done under fluoroscopy guidance and requires the placement of a needle deep into the space around the vertebral body with the patient lying in the prone position. This can be particularly problematic to achieve in patients with severe abdominal pain and distension such as in cases of advanced visceral cancers. Patients nearing the end of life with such advanced disease and possessing grave prognosis are often in poor general health as in our case and doing a celiac plexus neurolytic block may not be the best option. CPB also bears various other risks such as kidney injury, pneumothorax, bleeding, and unintentional neuraxial injection. In addition, in cases with large tumor masses near the celiac axis, it sometimes becomes obligatory to cross the tumor mass to reach the nerve plexus for neurolysis. This can result in bleeding within the tumor tissue owing to neoangiogenesis and seeding of the tumor to other areas.
Such cases are in dire need of pain control and the conventional CPB is difficult to perform. Apart from pharmacotherapy, supplementary analgesia is required through any nerve intervention that can act on the mixed component of cancer pain. The ESPB is an interfascial plane block where the local anesthetic is deposited between the ESM and the tip of the transverse process. The paravertebral space (PVS) contains somatic nerves and the sympathetic chain. Drug instilled during ESPB is said to enter the PVS through the costotransverse foramen and intertransverse connective tissue complex. This spread blocks the dorsal and ventral rami of the spinal nerves along with the rami communicantes to provide analgesia. ESPB also demonstrates extensive craniocaudal spread which makes this block extremely useful in settings where a wider dermatomal spread is mandated.
Case reports by Chin et al. highlighted the use of ESPB in the management of visceral abdominal pain following bariatric surgery. The rationale for using this block in the mentioned scenario was that drugs administered in the erector spinae plane trickle anteriorly to reach the PVS where they potentially cause sympathectomy by blocking the rami communicantes and providing pain relief. Bang et al. also emphasized the same principle but used the T1-T2 space for the management of complex regional pain syndrome of the upper extremity. Different from the case done by Chung et al., they used an indwelling catheter for delivering prolonged pain relief. Chung et al. also showcased the analgesic effects of ESPB in controlling functional abdominal pain by a similar mechanism. There is also literature providing information regarding the use of ESPB in cases of chronic cancer pain caused by Pancoast tumor and pleural mesothelioma., In both cases, a catheter was threaded in the erector spinae plane. This not only gave extended pain control but also lessened the opioid requirements and associated side effects.
Yet none of the reports so far highlight the capacity of this block to be used at the end-of-life care settings in patients with advanced abdominal tumors where the patient is poorly tolerant to other modalities of pain control as mentioned earlier. Our patient presented at the final stage of her disease in inadequate health with abdominal distension, deranged liver function, and distorted anatomy due to aggressive tumor growth. We realized the limitations of our patient and preferred to explore a less invasive and safer alternative that would provide her with sufficient pain relief. Using the same principle as promoted in the above cases, we selected the ESPB with an indwelling catheter over a traditional CPB or epidural. Placement of an epidural catheter, even though a pain control measure is poorly tolerated in such patients as the liver functions can further deteriorate at any point and the systemic hypotension associated with the procedure is also troublesome. Hence, analgesia was achieved through continuous ESPB which is one of the least invasive surface procedure techniques.
| Conclusion|| |
With this case report, we ascertain the use of ESPB in a palliative care setting. We underline the erector spinae plane drug delivery through an epidural catheter for alleviation of abdominal pain associated with advanced abdominal malignancy at end of life. This method provided effective analgesia and minimal side effects and maintained the QOL during the patient's last days.
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
Conflicts of interest
There are no conflicts of interest.
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