Ultrasound guided Erector Spinae Plane block versus thoracic epidural for post-mastectomy analgesia

Document Type : Original Article

Authors

Anesthesia and intensive care Department, Faculty of Medicine, Al Azhar University, Cairo, Egypt

Abstract

Background: Thoracic epidural analgesia (TEA) was considered as the gold standard for postoperative analgesia in thoracic surgeries, particularly in bilateral procedures. However, it isn't routinely used as it is associated with some haemodynamic side effects. Erector spinae plane (ESP) block is recognized as a promising post-operative analgesia technique.
Aim of the study: Primary outcome was to compare post-mastectomy pain control in TEA and ESP block groups, and secondary outcomes were to compare post-operative hypotension, number of morphine boluses and patient satisfaction.
Patients and Methods: Sixty female patients scheduled for elective mastectomy were enrolled in this study. Patients were allocated into 2 groups, 30 patients each. Group (TE) patients underwent ultrasound guided single shot TEA, while group (ES) were handled with ultrasound guided single shot ESP block. Peri-opertaive details, Post-operative hypotension, visual analogue scale (VAS) assessment of pain, number of post-operative morphine boluses, and patient satisfaction were recorded.
Results: Time needed to give block was shorter in group (ES) (p < 0.001). Group (ES) patients reported significantly lower pain scores according to VAS (P<0.001). Hypotension was more recorded in group (TE) patients, with statistical significance at 0 point (p < 0.001). Required post-operative morphine boluses were significantly lower in group (ES), as 3.3% of patients received 3 boluses compared to 27% in group (TE) (p=0.01). More patients were highly satisfied in group ES (60%) than group TE (30%) (p=0.037).
Conclusion: Ultrasound-guided ESP block is a choice with better outcome in patients undergoing elective mastectomy as regards lower frequency of hypotension, better efficiency and patient satisfaction.

Keywords

Full Text

INTRODUCTION

Breast surgery is a common procedure, particularly in middle-aged women1,2. The procedure is associated with an increased incidence of acute and chronic pain2. Postoperative analgesia following breast surgery extending beyond lumpectomy is sometimes challenging, about 20% to 50% were recorded to develop post-mastectomy pain syndrome3. Multimodal techniques for pain management have been recommended by The American Society of Anesthesiologists (ASA) task force for the management for acute postoperative pain 4,5. These techniques include regional analgesia, intravenous (IV), and oral analgesics as opioids, paracetamol, and nonsteroidal anti‑inflammatory drugs (NSAIDs) 5. Inappropriate postoperative analgesia may increase morbidity and mortality6. Satisfactory postoperative analgesia prevents unnecessary patient discomfort, may play a role in decreasing morbidity, postoperative hospital stay, and the cost 7. When opioids are used solely for analgesia, they may cause nausea, vomiting, pruritus, and respiratory depression. Regional techniques, especially Thoracic Epidural Analgesia (TEA) have been described to reduce the postoperative pain with improved outcome 5,8.

Posterior dural complex

Ultrasound-guided (USG) erector spinae plane (ESP) block has become a recognizable technique for regional analgesia in thoracic surgeries 9. This block can be given unilaterally for simple mastectomy surgery. A local anaesthetic (LA) is dripped deep to the erector spinae muscle and superficial to the tip of the transverse process at the myofascial plane. The instilled LA can induce sensory block at the multi-dermatomal levels across the posterior, lateral, and anterior thoracic wall, probably due to the diffusion into the paravertebral space. In addition to its effect at the rami communicans that supply the sympathetic chain 10, the ESP block affects the dorsal and ventral primary rami of the thoracic nerves 11. ESP is relatively easier to apply in breast surgeries as compared to neuraxial, nerve blocks, TEA, and other regional modalities 5,9,12. 

Aim of the work

The primary outcome was to compare post-mastectomy pain control in TEA and ESP block groups, and the secondary outcomes were to compare the post-operative hypotension, the number of morphine boluses, and patient satisfaction.

 

PATIENT AND METHODS

 

Time to give the block was assessed in both groups in minutes. Extubation was done after satisfying extubation criteria, then patients were transferred to the recovery room.

The pain assessment after full recovery was performed using a 10 cm visual analog scale (VAS) (0- no pain and 10 cm maximum pain) 13. The postoperative pain assessments using VAS at rest and during cough were performed postoperatively at 0 point (the full recovery state), 1 hr, 2 hr, 4 hr, 6 hr, and at 24 hr. IV paracetamol 1 g every 6 hours was administered. Rescue analgesia was administered, if VAS was ≥ 4 at rest or on patient’s demand, with IV morphine sulphate 0.03 mg/kg. the number of morphine boluses and the total amount in the first postoperative 24 hours was calculated. Mean arterial blood pressure (MABP) was assessed post-operatively at 0 point (immediately after the procedure), 1 hr, 2 hr, 4 hr, 6 hr, and at 24 hr. Patient satisfaction related to block performance, post-operative pain relief was evaluated by an 11- point satisfaction score (0=unsatisfied and 10 = most satisfied) 14, and the score was divided as follows 0-3 (not satisfied), 4-6 (partly satisfied), and 7-10 (highly satisfied).

                                                                                                                       

 

Spinous Process

Figure (1): Ultrasound view. Thoracic Epidural.

Erector Spinae muscle

 

Plane of injection

Transverse Process

Figure (2): ultrasound view. Erector Spinae Plane.

Statistical analysis

A pilot study was conducted on 20 females indicated for elective mastectomy and post hoc analysis was performed using VAS scores with an alpha error (Type I) of 0.05 and calculated the beta error (Type II) 90%. A total of 30 patients in each group completed the study; Group TE and Group ES.

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp). The Kolmogorov- Smirnov test was used to verify the normality of distribution of variables, Comparisons between groups for categorical variables were assessed using Chi-square test (Fisher or Monte Carlo). The student t-test was used to compare two groups for normally distributed quantitative variables. Mann Whitney test was used to compare between two groups for non-normally distributed quantitative variables. P-value was considered significant at <0.05.

 

RESULTS

The demographic data (age, weight), ASA status were comparable between the studied groups (𝑃>0.05) as shown in Table (1). Surgery duration was comparable between the 2 groups, while time to give the block was significantly lower in group ES as shown in Table (2). Post-operative MABP readings were lower in group TE of patients with statistically significant decrease at 0 point (p<0.001) as shown in table (3).As regards post-operative pain using VAS score, there were statistically significant decrease in group (ES) patients (P<0.001) as shown in table (4). The required post-operative morphine boluses were significantly lower in group (ES) than group (TE) patients, as 3.3% of patients in 2nd group received 3 boluses compared to 27% of the first group (p=0.01) as shown in table (5). As regards patient satisfaction, more patients were highly satisfied in this study in group ES (60%) than group TE (30%) (p=0.037) as shown in table (6).

 

 

 

Group TE
(n = 30)

Group ES
(n = 30)

P-value

Age (years)

50.5±5.3

51.2±4.9

0.596

BMI

29.48±2.36

28.84±2.03

0.26

ASA

 

 

 

I

17(65.7%)

21(70.0%)

0.422

II

13(43.3%)

9(30.0%)

Duration of surgery (min)

64.4±11.3

64.9±12.0

0.869

             Table 1: Comparison between the two studied groups according to demographic data

             *: Statistically significant (p < 0.05).

 

 

Group TE
(n = 30)

Group ES
(n = 30)

P-value

Time to give the block

14.1±2.1

7.8±1.8

<0.001*

             Table 2: Comparison between the two studied groups according to the time needed to give block 

             *: Statistically significant (p < 0.05).

 

Mean arterial blood pressure (mmHg)

Group TE
(n = 30)

Group ES
(n = 30)

P-value

0

68.2±3.6

80.4±3.4

<0.001*

60 min.

68.1±2.2

68.5±3.2

0.61

120 min.

68.0±2.2

67.6±3.3

0.52

3 hr.

67.7±2.5

68.0±3.1

0.64

4 hr.

68.1±2.6

68.7±3.5

0.41

6 hr.

67.4±1.8

68.3±2.5

0.12

12 hr.

67.8±2.0

68.4±2.8

0.37

24 hr.

67.6±2.7

68.5±2.9

0.21

             Table 3: Comparison between the two studied groups according to Mean arterial blood pressure (mm Hg)

             *: Statistically significant (p < 0.05).

 

 VAS
(IQR-median)

Group TE
(n = 30)

Group ES
(n = 30)

P-value

0

1(0–1)

0(0–1)

<0.001*

2 hr.

1(1–2)

1(0–1)

<0.001*

4 hr.

2(1–2)

1(1–1)

<0.001*

6 hr.

2(2–3)

1(1–2)

<0.001*

12 hr.

3(2–4)

2(1–3)

<0.001*

24 hr.

3(2-4)

2(1-3)

<0.001*

            Table 4: Comparison between the two studied groups according to visual analogue scale

            VAS: visual analogue scale, IQR: interquartile range, *: Statistically significant (p < 0.05).

 

Number of morphine boluses

Group TE
(n = 30)

Group ES
(n = 30)

P-value

0

9(30.0%)

19(63.3%)

0.01*

1

6(20.0%)

6(20.0%)

1.00

2

7(23.3%)

4(13.3%)

0.51

3

8(27.0%)

1(3.3%)

0.01*

            Table 5: Comparison between the two studied groups according to Number of morphine boluses

            *: Statistically significant (p < 0.05).

 

Group TE
(n = 30)

Group ES
(n = 30)

P-value

Patients satisfaction

 

 

 

0-3 (not satisfied

11(36.7%)

4 (13.3%)

0.072

4-6 (partly satisfied)

10(33.3%)

8(26.7%)

0.779

7-10 (highly satisfied)

9(30.0%)

18(60.0%)

0.037*

                   Table 6: Comparison between the two studied groups according to Patients satisfaction

                   *: Statistically significant (p < 0.05).

 

 

 

DISCUSSION

 

The need for ideal post-operative pain management is crucial. Although thoracic epidural analgesia (TEA) has been considered as the golden standard, Erector spinae plane (ESP) block is now emerging as a better alternative technique. The value of ESP block as a rescue analgesic technique was highlighted by Forero et al 15 in a case report discussing thoracotomy after a failed epidural technique.   

In the present study, the time needed to give the anaesthesia block, mean arterial blood pressure (MABP), visual analogue scale (VAS) assessment for post-operative pain, boluses of morphine, and patient satisfaction were evaluated. Main complications as hypotension were recorded.

The time needed in our study to give the anesthesia block was found to be significantly lower in group ES that received erector spinae plane (ESP) block (p<0.001) as compared to group TE. The pain score assessed in this work according to the visual analogue scale (VAS) was significantly better in group ES as compared to group TE (p<0.001). Post-operative readings of MABP tended to be lower in the group (TE), but without statistically significant difference (p>0.05). In support of our results, Nagaraja et al 16, recorded VAS scores persistently ≤4 until 48 h in 2 study groups of TEA and ESP block performed for post-thoracotomy pain until 12 h post-extubation. They stated that the VAS scores were comparable between both groups, with the relative advantage of ESP block to be easier to perform as compared to TEA and paravertebral block (PVB) in breast surgeries. Similarly, Chin et al 17 stated that ESP block avoided the complications attributed to those two major methods, as they had negligible effects on the dorsal, ventral, or communicant rami of the spinal nerve roots. Furthermore, Bonvicini et al 18 suggested that the use of ultrasound-guided (USG) ESP block in bilateral breast cancer reconstructive surgery can be an effective safe alternative to TEA and paravertebral block techniques.

The administered boluses of morphine recorded in our results were significantly lower in group ES in comparison to group TE patients, as 3.3% of patients in group ES received 3 boluses compared to 27% (p=0.01). In accordance, Singh and colleagues 10 documented that a significant decrease in the requirement of postoperative morphine in patients who received erector spinae plane block, and patient satisfaction scores were better in ESP group. Similarly, Gürkan and coworkers19 in a randomized control trial on the analgesic effect of US-guided single shot ESP for breast surgery observed a statistically significant decrease in postoperative morphine consumption, establishing its role for analgesia and postoperative opioid-sparing effect. Nair et al 20 reported efficacy of this block in a case series of 5 patients subjected to thoracic surgery. Also, previous authors stated in their case reports that both visceral and somatic pain were efficiently abolished by the use of ESP block 21,22.

In agreement, Kimachi et al 23 used US-guided ESP for accomplishing surgical anesthesia for a right-sided mastectomy and axillary dissection in a patient with high cardiovascular risk, and she had a minimal requirement of postoperative analgesia. They explained that the ability to carry out the anesthesia was attributed to that ESP isn't a limited area surrounded by the spinal column as compared with the epidural zone. The ESP plane is larger than the epidural space as the erector spinae muscle runs along the length of the thoracolumbar spine, thus providing extensive craniocaudal spread 24.

More patients were highly satisfied in this study in group ES (60%) than group TE (30%) (p=0.037). This coincides with Forteo et al 9 who recommended the use of ESP block for patients with chronic thoracic neuropathic pain, who were poorly responsive to oral pharmacotherapy. The authors attributed this effect to the extent of the cutaneous sensory block when an injection of 25 ml of LA was administered at the level of T5, as it spreads cephalocaudal over the anterior‑posterior thorax ranging from T1 to T11.

 

CONCLUSION

 

Ultrasound-guided ESP block is a good choice with a better outcome in patients undergoing elective mastectomy as regards better efficiency, satisfaction, and fewer complications.

References

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