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The erector spinae plane block for acute pain management in emergency department patients with rib fractures

Abstract

Objective

Rib fractures represent a significant cause of morbidity and mortality in trauma patients. The erector spinae plane block has come to the forefront as a potential safe and effective option for analgesia in painful conditions of the thorax over multiple dermatomal levels. Given the high morbidity associated with rib fractures, the inadequacy of opioid analgesia and the strong safety profile of the erector spinae plane block, this pilot study sought to address whether this block can be used to safely and effectively provide analgesia in emergency department (ED) patients with acute rib fractures.

Methods

A total of nine patients underwent the procedure successfully. Patients were found to have a significant reduction in their pain score pre- and post-block. The reduction in mean pre- and post-block pain scores was 9.89 vs 3.56 which was statistically significant (p < 0.0001).

Conclusion

In a pilot sampling of emergency department patients with acute fractures who failed traditional analgesic therapy, the erector spinae plane block performed by emergency physicians provided safe and effective pain control. Further research is needed to fully establish the clinical benefit and safety of this procedure.

Résumé

Objectifs

Les fractures des côtes représentent une cause importante de morbidité et de mortalité chez les patients traumatisés. Le bloc du plan des muscles érecteurs du rachis est apparu comme une option potentiellement sûre et efficace pour l’analgésie dans les états douloureux du thorax sur plusieurs niveaux dermatomiques. Compte tenu de la morbidité élevée associée aux fractures des côtes, de l’insuffisance de l’analgésie opiacée et du profil d’innocuité solide d'un bloc du plan des muscles érecteurs du rachis, cette étude pilote visait à déterminer si ce bloc peut être utilisé pour fournir une analgésie sûre et efficace aux patients des urgences présentant des fractures aiguës des côtes.

Méthodes

Au total, neuf patients ont subi l’intervention avec succès. On a constaté que les patients avaient une réduction significative de leur score de douleur avant et après le blocage. La réduction des scores moyens de la douleur avant et après le blocage était de 9.89 contre 3.56, ce qui était statistiquement significatif (p < 0.0001).

Conclusion

Dans le cadre d’un projet pilote d’échantillonnage de patients des services d’urgence ayant subi des fractures aiguës et ayant échoué à la thérapie analgésique traditionnelle, le bloc du plan des muscles érecteurs du rachis effectué par les médecins urgentistes a permis de contrôler efficacement et en toute sécurité la douleur. Des recherches supplémentaires sont nécessaires pour établir pleinement les avantages cliniques et la sécurité de cette procédure.

Clinician’s capsule

What is known about the topic?

Pain associated with rib fractures is difficult to control and may contribute to significant morbidity and mortality.

What did this study ask?

Can the erector spinae plane block provide adequate analgesia in emergency department patients with acute rib fractures?

What did this study find?

The erector spinae plane block was an effective method for reducing pain associated with rib fractures with no complications seen.

Why does this study matter to clinicians?

This study provides insight into a potentially beneficial method of pain control in emergency department patients with rib fractures.

Introduction

Rib fractures represent a significant cause of morbidity and mortality in trauma patients. Hypoventilation secondary to pain and altered breathing mechanics frequently leads to respiratory distress and may necessitate intubation and admission to an ICU [1]. Currently, opioids are used for treatment in rib fracture pain management; however, they are often ineffective [1,2,3]. Recently, the erector spinae plane block has come to the forefront as a potential safe and effective option for analgesia in painful conditions of the thorax [4]. This technique involves identifying the erector spinae muscles at the level of a given thoracic transverse process and injecting local anesthetic into the fascial plane; the local anesthetic then spreads through the fascial plane both cephalad and caudad to the injection point and will anaesthetize the thoracic sensory nerves that run in this plane at multiple dermatomal levels. Moreover, because the target point of injection is both relatively superficial and protected by the bony transverse process, the incidence of complications is felt to be low [4, 5]. While this technique has been successfully used in outpatient clinics [6] and the operating room [7], the erector spinae plane block has yet to be integrated into the practice of emergency medicine physicians. Given the high morbidity associated with rib fractures, the inadequacy of opioid analgesia and the strong safety profile of the erector spinae plane block, this study sought to address whether this block can be used to safely and effectively provide analgesia in emergency department (ED) patients with acute rib fractures.

Methods

Study design and time period

This was a prospective observational study of a convenience sample of ED patients with acute rib fractures and pain that was incompletely managed by oral or intravenous opioids. This study took place from August 2018 to August 2020. Patients were eligible to be enrolled if they were deemed by their treating physician to have pain that was poorly controlled with traditional methods including opioid therapy. Once consented, patient pain scores were rated on a verbally administered numeric 0-10 standardized pain score developed by Bijur et al [8].

Study setting

This study took place at a tertiary care, level-1 trauma centre. Ethics approval was obtained by the University of Manitoba Ethics Review Board and the Health Sciences Centre Research Review Board.

Population

Patients 18 years of age or older with acute rib fractures confirmed on imaging (CT or X-ray), with ongoing pain despite maximal therapy at the discretion of the patient’s treating physician were eligible to be enrolled. Exclusion criteria were patients with hemodynamic instability as determined by their treating physician, infection overlying the site of injection, anticoagulant use, history of a bleeding disorder or thrombocytopenia, pregnancy, and incarceration.

Intervention

The erector spinae plane block differs from a traditional ultrasound-guided nerve block in that it does not require infiltration of local anesthetic around a particular nerve. Instead, local anesthetic is safely infiltrated in the erector spinae fascial plane between the erector spinae muscles and the transverse process. The local anesthetic then spreads in a cephalo-caudal manner and anaesthetizes both the ventral and dorsal rami of the thoracic spinal nerves providing coverage of both the anterior and posterior chest wall with up to nine dermatomes of distribution based on cadaveric models [9].

The technique for this study was based on the original paper describing the erector spinae plane block [4]. The investigators of the study assessed the anatomic level of the patient’s pain and decide on the appropriate thoracic vertebral level to initiate the block. Patients had intravenous access and cardiorespiratory monitoring established prior to the procedure. This is considered standard for any patient receiving regional anesthesia [10]. Patients were then placed in a seated or lateral decubitus position and the appropriate spinous process was palpated. Under sterile conditions, an ultrasound probe was placed in a longitudinal orientation with the block performed in-plane using an echogenic regional anesthesia block needle. An appropriate weight based dose of 0.50% bupivacaine without epinephrine was calculated for each patient to ensure toxic levels were not reached. A total block volume of 40 ccs was administered. If the calculated safe bupivacaine dose involved less than 40 ccs, the additional volume was made up by diluting the anesthetic with sterile saline. Ultrasound was used to confirm appropriate spread of the anesthetic in a cephalad and caudad direction.

Outcome measures

Patient who met inclusion criteria were offered an ultrasound-guided erector spinae plane block by one of the two study physicians. The primary outcome was subjective pain scores pre- and post-block. The post-block pain score was assessed one hour after the completion of the procedure. Secondary outcomes were complications associated with the erector spinae plane block including block failure, shortness of breath and pneumothorax which were reported as rates of occurrence per block.

Data analysis

The primary outcome was subjective pain scores pre- and post-block. These were analyzed using a Wilcoxon test.

Results

Twenty patients were screened for inclusion in the study. Nine patients were excluded. Of the excluded patients, seven were excluded due to anticoagulant use, one due to poor ultrasound landmark visualization secondary to subcutaneous emphysema and one due to patient refusal. Ten patients underwent the procedure. Despite maximal efforts, one patient could not undergo the block as the target fascial plane could not be reached with various needle lengths available. A total of nine patients underwent the procedure successfully. A breakdown of the patients can be found in Supplementary Material 1. Patients were found to have a significant reduction in their pain score pre- and post-block. The reduction in mean pre- and post-block pain scores was 9.89 vs 3.56 which was statistically significant (p<0.0001). Each patient’s pre- and post-block score can be found in Supplementary Material 2. Most patients reported a marked improvement in pain scores after the procedure; however, two patients (patients 1 and 4) experienced only minimal effect. There were no associated complications of this procedure, including pneumothorax or hemodynamic instability while the patients were in the ED.

Discussion

Interpretation of findings

This study represents the largest sample of ED patients undergoing the erector spinae plane block to date. The results of this pilot study demonstrate that the erector spine plan block appears to be an effective means for providing analgesia in ED patients with acute rib fracture pain with no acute complications observed. A summary of the study and findings can be found in Fig. 1.

Fig. 1
figure1

Study summary infographic

Comparison to previous studies

This study adds to the growing body of literature of the safety and efficacy of the erector spinae plane block in ED patients. It is consistent with works by Luftig et al. [11] and Kumar et al. [12] which showed similar efficacy in a small sample of ED patients with rib fractures undergoing the erector spinae plane block.

While larger, randomized studies are still needed, we feel that the erector spinae plane block should be considered in patients with acute rib fracture pain as a method of pain control in multi-modal analgesia.

Of note, other analgesic options for rib fractures do exist. Many guidelines advocate for the use of epidurals; however, these require placement by an anesthetist which limits the utility for ED providers [2, 3]. Other fascial plane blocks have also recently come to light, most notably including the serratus anterior plane block [13, 14]. This block has also been shown to provide adequate analgesia in small studies. The main advantage of the erector spinae plane block is coverage of the posterior chest wall which is not provided by the serratus anterior plane block. Ultimately, the choice of block should depend on individual patient factors as well as provider judgment and expertise.

Strengths and limitations

Strengths of this study include the secondary outcome assessment of potential complications of the erector spinae plane block, which to date have not been assessed or reported in ED patients. Limitations of our study include the fact that the erector spinae plane block was performed by two physicians with extensive experience in ultrasound-guided regional anesthesia. This may limit the generalizability to every ED. Our data were also derived via convenience sampling of patients which was primarily due to the availability of the physicians to perform the block. Another limitation is the fact that the block could not be performed on one patient due to technical difficulties and that two patients reported only minimal benefit from the procedure which dampens the overall strength of our conclusions.

The biggest limitation of our study however is our small sample size. While the erector spinae plane block does appear to be an effective means of providing pain control, further studies are required to assess whether the block has clinically meaningful benefit with respect to morbidity and mortality. Moreover, further data are required to clarify whether the block is in fact as safe as our very small study implies.

Clinical implications

The erector spinae plane block could have a potential role in acute pain management in the ED, particularly due to the general lack of availability of epidural placement. In the appropriate clinical setting, these results and those of similar studies provide a growing body of evidence that emergency physicians could consider consulting either an appropriately trained emergency physician or an anesthetist familiar with the erector spinae plane block to attempt this procedure in patients with acute rib fractures and poorly controlled pain. Early intervention with the erector spinae plane block could have potential positive impact on respiratory mechanics, reduce the need for mechanical ventilation support and intensive care admission rates.

Research implications

Further research involving larger studies is required verify both the safety profile and efficacy of the erector spinae plane block. Subsequent work should assess whether the improved analgesia offered by the erector spinae plane block results in decreased morbidity and mortality associated with rib fractures. Future studies focusing on longitudinal follow-up of these patients would be helpful to assess if the technique decreases complications, such as hypoxia, pneumonia, ICU admission and mechanical ventilation. Further research is also needed to assess training requirements for emergency physicians to perform erector spinae plane block, as well as resource concerns, such as time spent performing the procedure and length of stay in the department.

Conclusion

This pilot study of ten emergency department patients with acute rib fractures who failed traditional analgesic therapy showed that the erector spinae plane block could be a useful option pain control. Further research is needed to evaluate the overall clinical benefit and safety profile of this block.

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Correspondence to Tomislav Jelic.

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The study authors have no conflicts of interest to disclose.

Supplementary Information

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Surdhar, I., Jelic, T. The erector spinae plane block for acute pain management in emergency department patients with rib fractures. Can J Emerg Med (2021). https://doi.org/10.1007/s43678-021-00203-x

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Keywords

  • Rib fractures
  • Regional anesthesia
  • Ultrasound guided regional anesthesia
  • Analgesia