Chronic low back pain: should we be adopting novel analgesic techniques?
Lombalgia crônica: devemos adotar as novas técnicas de analgesia?
We read with interest the recently published study by Sakae et al.1 comparing the postoperative analgesic efficacy between Erector Spinae Plane Block (ESPB) and epidural block in patients submitted to open cholecystectomies. Our colleagues1 found poorest pain relief both 2 and 24 hours after the surgery in the group where the ESPB was performed, with statistical significance, which they mainly correlate with the volume and anatomical spread of the local anesthetic injected in their ESPB technique.
As anesthesiologists currently managing patients with chronic Low Back Pain (LBP), we have been facing this same doubt and curiosity: should we prefer the novel ESPB or the well-established lumbar epidural analgesia?
The ESPB was originally described by Forero M. et al.2 as a simple and safe interfascial plane technique that led to neuropathic thoracic chronic pain relief. Since then, it has increasingly been used in lumbar spinae surgeries,3 as well as in chronic conditions of various origins.4
Since chronic LBP if often multidimensional and rarely exclusively myofascial, and agreeing with Galacho J. et al.5 when affirming that ESPB does not only block somatic fibers but also the sympathetic chain, we have been using the ultrasound-guided ESPB more often in our ambulatory patients with fairly good results. In a recent and not yet submitted to publication in BJAN case series (10 patients) of our Pain Clinic, we found a mean of 20.8 days of pain relief after L1-L2 bilateral injection of 20 mL ropivacaine 0.2% and dexamethasone (4 mg), with no need for systemic pharmacological therapy escalations or rescue analgesia.
As most of the chronic pain management tools, ESPB could be part of a multimodal and multidisciplinary approach. It shows preliminary advantages as an alternative to epidural blocks in these patients since it is easily performed with a lower complication risk; allows immediate discharge home with the absence of motor block; it seems easier to be consented by the patient and it can produce a good “therapeutic window” time span: time for patients’ physical rehabilitation and exercise with tolerable levels of pain (interruption of pain cycle).
1 T. Sakae, L. Yamauchi, A. Takaschima, et al. Comparison between erector spinal plane block and epidural block techniques for postoperative analgesia in open cholecystectomies: a randomized clinical trial Rev Bras Anestesiol, 70 (2020), pp. 22-27
2 M. Forero, S.D. Adhikary, H. Lopez, et al. The erector spinae plane block.a novel analgesic technique in thoracic neuropathic pain Reg Anesth Pain Med, 41 (2016), pp. 621-627
3 J.P. Melvin, R.J. Schrot, G.M. Chu, et al. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series Can J Anaesth, 65 (2018), pp. 1057-1065
4 S. Tulgar, O. Selvi, O. Senturk, et al. Ultrasound-guided erector spinae plane block: indications, complications, and effects on acute and chronic pain based on a single- center experience Cureus, 11 (2019), p. e3815
5 J. Galacho, M. Veiga Erector spinae plane block and anterior sympathetic chain spread: a matter still under discussion Reg Anesth Pain Med (2020), 10.1136/rapm-2020-101375 Online ahead of print