Opioid-sparing multimodal analgesia with bilateral bi-level erector spinae plane blocks in scoliosis surgery: a case report of two patients
Postoperative pain following scoliosis correction surgery is severe and usually requires prolonged intravenous opioid therapy. Regional anesthesia options are limited and include intrathecal opioid and epidural analgesia; however, they remain little used because of side effects and inconsistent efficacy. We describe a novel multimodal anesthetic regimen incorporating bilateral bi-level erector spinae plane (ESP) blocks together with a combination of several evidence-based intraoperative opioid-sparing analgesic strategies.
Two healthy young adult patients with idiopathic scoliosis underwent posterior spinal fusion involving 12 vertebral levels (T2–L1 and T3–L2). Bilateral single-injection ESP blocks were performed at two levels (T4 and T10) prior to incision. Intraoperatively, patients received intravenous dexamethasone and infusions of dexmedetomidine and ketamine for multimodal analgesia. Remifentanil was omitted from the total intravenous anesthetic regimen to avoid opioid-induced hyperalgesia.
Both patients had minimal pain on emergence. They transitioned successfully to oral analgesia on the first postoperative day, with modest opioid requirements, no side effects, and low pain scores throughout their hospital stay.
Bilateral bi-level ESP blocks are a simple method of providing pre-emptive regional analgesia in extensive multi-level spine surgery. Integration of ESP blocks into a multimodal regimen that employs other opioid-sparing strategies may have additive, and potentially synergistic, benefits in improving postoperative analgesia and reducing opioid requirements.
KeywordsScoliosis Regional anesthesia Erector spinae plane block Postoperative pain Multimodal analgesia
Dr Ki Jinn Chin is supported by a Merit Award from the Department of Anesthesia, University of Toronto.
Compliance with ethical standards
Conflicts of interest
The authors declare no conflicts of interest.
- 14.Loftus RW, Yeager MP, Clark JA et al (2010) Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology 113:639–646Google Scholar
- 18.Adhikary SD, Bernard S, Lopez H, Chin KJ (2018) Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Reg Anesth Pain Med 43:756–762Google Scholar
- 22.Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT (2019) Ultrasound-guided erector spinae plane block: indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureus 11:e3815Google Scholar
- 23.Cuvillon P, Nouvellon E, Ripart J et al (2009) A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesth Analg 108:641–649CrossRefGoogle Scholar
- 26.Lee BH, Park J-O, Suk K-S et al (2013) Pre-emptive and multi-modal perioperative pain management may improve quality of life in patients undergoing spinal surgery. Pain Physician 16:E217–226Google Scholar
- 28.Pehora C, Pearson AM, Kaushal A, Crawford MW, Johnston B (2017) Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev 11:CD011770Google Scholar
- 29.Kang R, Jeong JS, Yoo JC et al (2019) Improvement in postoperative pain control by combined use of intravenous dexamethasone with intravenous dexmedetomidine after interscalene brachial plexus block for arthroscopic shoulder surgery: a randomised controlled trial. Eur J Anaesthesiol 36(5):360–368Google Scholar
- 34.Schwenk ES, Viscusi ER, Buvanendran A et al (2018) Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 43:456–466CrossRefGoogle Scholar