Key Clinical Message
ESP block can be a valid alternative to general anesthesia, specially in
patients with contraindications to GA - above all in the current Covid
19 pandemy - thanks to the anesthetic mixture diffusion in the epidural
space as described by Forero
Introduction
The ultrasound-guided erector spinae plane block (US-ESPB) at T5
transverse process is recently described as a technique for providing
thoracic analgesia [1,2].
From recent literature it is known that the injection into the deep
fascial plane to erector spinae muscle (the erector spinae plane, ESP)
at the level of the T5 transverse process can produce profound analgesia
of the ipsilateral hemithorax [3].
Anatomical dissection indicates that the likely action mechanism is the
diffusion of local anaesthetic anteriorly through the connective tissues
and ligaments spanning the adjacent transverse processes and into the
vicinity of the spinal nerve roots (consistent with other reports of
successful analgesia following injection into a similar tissue plane in
the thorax [4,5].
ESP is widely used, particularly in thoracic surgery, for intra and
postoperative analgesia. Erector Spinae Plane block that determines
anaesthesia and not only analgesia has currently little clinical
application. This case report shows that in certain cases ESP can also
be used as an anaesthetic plan, as an effective and safe alternative to
general anaesthesia. Moreover, it did not determine any discomfort of
the patient, on the contrary, it improved the surgeons’ work.
Case report
It is here by declared that the patient has consented to the publication
of this case report intended purely for scientific and clinical
purposes, maintaining the privacy of the processing of her personal data
Our 25-year-old female pz came in our operative block, without
comorbidity, to perform an intervention of capsulated under-apicalular
lipoma exeresis, under fascial plane, localized in the left hemithorax
of about 10 cm of diameter. The patient reported the story of Awareness
during a previous surgery and categorically rejects a second GA. It is
therefore decided for the execution of the US-ESPB. With the patient in
sitting position, a high-frequency linear probe (12 MHz) was placed in
longitudinal orientation at level of the T7 transverse process, 3 cm
from the midline. A 22 gauge 50-mm block needle was inserted in plane,
with a cephalad-to-caudad direction (Figure 1), until the tip laid into
the plane to deep of the erector spinae muscle. After hydrolocalization
with 3 mL of normal saline to open the plane, 20 mL of 0.75%
ropivacaine and dexamethasone 8 mg were injected.
A sensory block (Hollmen 4) is obtained with an extension from T5 to L1
- tested with Pin Prick and Ice tests - for the entire duration of the
surgery (30’) during which the pz was in prone position – in
spontaneous breathing – sedated with 0,7 mcg/kg/h of dexmedetomidine 10
minutes before the surgery.
The vital parameters were stable throughout the duration of the
intervention, on PA 110/70 mmHg, FC 70 bpm, SpO2 99%
average.
The pz was collaborating and awakening to verbal stimulus throughout the
intervention RASS scale -2
During the post-operative the pz reported Hollmen 3 analgesia at T1 (2h
from the surgery); Hollmen 2 analgesia at T2 (6h from the surgery);
Hollmen 1 analgesia at T3 (12h from the surgery).
Together with the full satisfaction of the pz, who reported
NRS<2 at 24h post intervention with no analgesic necessity,
even the surgeons were satisfied in proceeding with a constant plan of
anaesthesia that did not alter the anatomical planes.