ultrasound-guided erector spinae plane block (ESP block) is new US-guided technique which became widely known 6 yrs ago. ESP block was described very first time by Dr. Mauricio Forero et al.  in 2016 [1] for thoracic neuropathic pain. ESP block is paraspinal neurofascial plane nerves blockade that aims ventral, dorsal and communicans spine nerves branches. There are only few controlled clinical trials available about this topic due to its short history of use. At the same time, many articles are published, where well results of ESP block are described. [2,3] In the original publication’s authors stated that ESP block could be used for postoperative analgesia after thoracic surgery. Further observations showed a wide range of indications for its use also in orthopedic surgery [4,5], neurosurgery [6] and after nephrectomy [7]. Method became extremely popular after its describing (figure 1).

Aim of our review is to analyze 5 clinical cases where Lumbar ESP block was used for postoperative analgesia after total hip replacement surgery.

Figure 1: Position of the ultrasound transducer in the lumbar region.

Materials and Methods

Patient A, female, 68 yo, was admitted to orthopedic department for elective surgery with complaints of pain in right hip joint (VAS 70 mm), gait disturbances and limited motion in the joint. Known comorbidity: hypertension stage 2, risk III; type 2 diabetes; class III obesity. Prehospital assessment included hip joint x-ray, joint space narrowing and femoral head destruction were diagnosed. Pre-anaesthesia physical status was classified as ASA III. Main diagnosis: hip joint osteoarthritis III-IV. Coxarthrosis. Uncemented total hip replacement was performed.

Patient B, female, 81 yo, was hospitalized to ICU with diagnosis: fracture of neck femur. Anamnesis: domestic accident, patient has tripped over a mat and has fallen due to limited motion in hip joint. Objective at hospitalization moment: awake, fully orientated; haemodinamically stable – BP 140/85; HR 83/min; spontaneous breathing, SpO2 96%. Complains of pain in right hip joint (VAS 70-80 mm after receiving analgesia in ICU). X-ray of right hip joint has shown fracture of right femoral neck. Comorbidity: coronary artery disease; hypertension stage 3, risk III; chronic cerebral ischemia. Risk ASA IV. Main diagnosis: fracture of neck femur. Hip joint osteoarthritis III-IV. Coxarthrosis. Cemented hip replacement was performed.

Patient C, male, 52 yo, was admitted to trauma unit for elective surgery with complaints of pain in left hip joint at rest and during activities (VAS 40-70 mm), limited motion in the joint. Comorbidity: hypertension stage 2, risk III; class II obesity. Prehospital assessment included hip joint x-ray, degenerative changes in the joint were detected. Risk ASA II. Main diagnosis: hip joint osteoarthritis III-IV. Coxarthrosis. Uncemented total hip replacement was performed.

Patient F, male, 75 yo, was admitted to trauma unit for elective surgery with complaints of pain in right hip joint that increases during activities (VAS 70 mm), limited motion in the joint. Comorbidity: hypertension stage 2, risk III; uncemented total left hip replacement was performed 5 years ago. Prehospital assessment included hip joint x-ray, degenerative changes in the joint were detected. Risk ASA II. Main diagnosis: hip joint osteoarthritis III-IV. Coxarthrosis. Cemented total hip arthroplasty was performed.

All patients received intravenous paracetamol (acetaminophen) 1000 mg and ketoprofen 100 mg for analgesia, dexmedetomidine at dosage 0,2-07 mcg/kg/h was used for sedation. All patients received spinal anaesthesia: 12-15 mg 0,5% bupivacaine was administrated intrathecally. Subsequently unilateral US-guided lumbar ESPB was performed using convex probe. Patient positioning for this procedure may vary, depending on block level, level of sedation and operator choice – sitting, lateral or prone position.

Classic ESP block technique involves primary identification of vertebrae, then linear US probe should be placed longitudinally, laterally from a spinous process and a facet joint at Th5 transverse process level. Our team performed block at lumbar level, we used convex probe and it was located on transverse processes to identify one on L4 level.

Upon L4 transverse process verification erector spinae muscle should be identified superficially to the hyperechogenic transverse process. A 22 G needle should be inserted in craniocaudal direction to transverse process in plane approach until the needle encounters it. Then a local anaesthetic bolus should be given for muscle hydrodissection with aim to open neurofascial plane of erector spinae muscle. Our team injected 30 ml of local anaesthetic (0,5% ropivacaine without adjuvants).

All patients evaluated their pain level as 30 mm VAS or less 8 hours after surgery. Single dose of ketoprofen 100 mg was administered to all patients 12 hours after surgery. All patients evaluated their pain level 20-40 mm VAS 24 hours after surgery during postoperative wound dressing and early activization.

patients suffer from severe pain after hip replacement surgery. Neuroaxial anaesthesia techniques traditionally are method of choice for this type of surgical intervention; epidural block is performed more often that can postpone early mobilization and has a branch of side effects due to risk of sympathetic block especially in elderly patients. Hip joint innervation is complex. The anterolateral aspect is innervated by the femoral nerve branches, the posterior aspect is innervated by sciatic nerve branches from its tibial portion, muscular branches supply long head of femoral biceps muscle, semitendinosus muscle, semimembranosus muscle and adductor magnus muscle, the anteromedial aspect is innervated by obturator nerve branches [8,9]. Starting from L3 level contrast completely surrounded the psoas muscle in the sacrococcygeal region. At L5 level significant distribution of contrast around the spinal nerves L4-5, femoral and obturator nerves was noted. Authors concluded that lumbar ESP block performed at L4 level provides effective postoperative analgesia (figure 2).

Figure 2: 1 – body of L4, 2 – psoas major, 3 – quadratus lumborum, 4 – erector spinal muscles, 5 – latissimus dorsi muscle, 6 – transverse muscle, 7 - internal oblique abdominal muscle, 8 - neurofascial space.

1. Celik et al. [10] during performing ESP block at L4 level demonstrated distribution of local anaesthetic with contrast between L1 to S4 vertebrae according to MRI. Contrast was found around erector spinae muscle and surrounding fascias. Contrast distribution was noted at L1 / L2, L2 / L3, L3 /L4 and L4 / L5 level transforaminaly and in anterior and posterior epidural space on block side as well. Volume of local anaesthetic (0,5% ropivacaine) was 30 ml. The authors note that large volumes of local anesthetic used for plane block may show a wide distribution spectrum. All nerves innervating the hip joint and the thigh area are formed In L1-S4 segments of the spinal cord, and the local anesthetic solution surrounds dorsal and ventral roots of the spinal nerves on the insertion side. Technical features of ESP block allowed to achieve unilateral – block (figure 3).

Figure 3: Ultrasound image indicated spreading of the local anaesthetic.

In our study patients had no need for additional analgesia. Ketoprofen was administrated once before bedtime because we did not know the length of ESP block analgesic effect (method was used first time). Ultrasound anatomical mark is transverse process, this makes the technique relatively simple and safe.

ESP block at lumbar level for postoperative analgesia in elderly polymorbid patients after hip replacement surgery is promising method that provides prolonged high-quality postoperative analgesic effect. Further studies are needed to determine the optimal dose of local anesthetic, as well as the effectiveness and safety of this technique.

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