Spinal erector spinalis block for postoperative analgesia for transfemoral amputation in an ontologic patient: Case Report

DOI: https://doi.org/10.21203/rs.3.rs-1992278/v1

Abstract

Post-surgical pain management during the first 24 hrs before a supracondylar amputation is difficult to control, so the use of multimodal analgesia is essential, regional anesthesia is increasingly used as part of this. The ESP block was described in 2016 by Mauricio Forero for analgesia at thoracic level in patients with chronic neuropathic pain as well as for post-surgical and post-traumatic pain also at thoracic level, in this case we demonstrate a correct and novel use for post-surgical analgesia for a lower limb procedure by placing it at lumbar level. We describe the successful use of single-dose erector spinae plane blockade (ESP) as part of postoperative analgesic management in a patient who underwent transfemoral amputation. ESP was shown to produce sensory blockade in several dermatomes and successful analgesia for the first 72 hr post-surgery.

Introduction

The management of postoperative pain in a lower limb amputation is difficult to control since it is also constituted by neuropathic pain, this responds little to the use of analgesics and the use of high doses of opioids causes poorly tolerable adverse effects such as vomiting, nausea, constipation, drowsiness among others (1); these can be reduced or avoided with the use of regional anesthesia (2). According to the ERAS protocol for oncologic patients, a reduction in opioid consumption provides benefits in the postoperative period and reduces the number of days of hospital stay (7). 

In order to plan which anesthesia technique to use in a lower limb amputation, we must know that the femoral nerve and the obturator nerve innervate the thigh in its anterior and medial aspect; the posterior part is innervated by the sciatic nerve. All thigh nerves come from the anterior branches of the lumbar plexus, and second and third sacral nerves (9)(10). 

The erector spinae block (ESP) was described in 2016 by Forero as an interfascial ultrasound-guided technique in a series of 4 successful cases for neuropathic pain and acute postoperative pain, given the complete resolution of neuropathic pain and the extensive cutaneous blockade of the lateral, anterior and posterior aspect of the chest wall described in the cases, demonstrated that both the dorsal and ventral branches of the spinal nerves were reached by the local anesthetic (3).

In 2018, De Cassai et al. demonstrated through a literature review that administration of 3.4 mL is the volume needed to cover one dermatome. The maximum number of dermatomes reached by a single bolus dose is nine with 30 mL (4). In the same year, Scwartzmann et al. presented a contrasted magnetic resonance imaging study that provides anatomical information on the mechanism of action of ESP, where a transforaminal and epidural distribution of the local anesthetic was observed, which would explain the achievement of a somatic and visceral blockade (5)(6). In 2021, Taskaldiran in a randomized controlled study in 62 patients scheduled for lumbar disc herniation surgery concluded that patients who received ESP did not require additional doses of opioids in the intraoperative period (8). 

Based on the case report published by Langnas et al, June 2022, we decided to use ESP in our oncologic patient for opioid sparing during the intraoperative period and as postoperative analgesia (11)(12), adding his recent diagnosis of COVID it was better to use regional anesthesia to avoid airway manipulation. 

Presentation Of The Case

This patient authorized by signing an informed consent form to describe the case for publication.

We describe the case of a 39-year-old male patient with a diagnosis of giant cell tumor of the left distal femur scheduled by the emergency department for surgical management consisting of transfemoral amputation of the left pelvic limb vs. disarticulation.  

Previously healthy patient, his current condition began in January 2020 when he had a motorcycle accident in which he received a contusion in the left thigh, which evolved into continuous stabbing pain, VAS 6/10, located at the level of the distal third of the left thigh, which improved with non-steroidal anti-inflammatory, then presented progressive increase in volume for four months, subsequently presented progressive increase in volume for four months and was evaluated by a physician. An incisional biopsy was performed in May 2022 which reported an aneurysmal bone tumor and was sent to our institute for management.

He was admitted to the institute for surgical management, however when he obtained a positive result of SARS COV 2 (figure 1), he was rescheduled. Ten days later he presented in the emergency room in a wheelchair with fever, intense pain, foul odor and hematopurulent exudate in the tumor of the left femur (figure 2). On physical examination the patient was found conscious, oriented, cooperative, on physical examination directed, left pelvic extremity with increased volume in the distal third of the left thigh (++++/++++) with a circumference of 59 cm against 42 cm of the contralateral, soft consistency tumor, with erythematous lesion with purulent exudate measuring 10 x 10 cm, knee mobility arches abolished, ankle mobility arches preserved only posterior tibial activity performing plantar flexion of 10 degrees and abduction of the forefoot, sensitivity of the entire limb without alteration with respect to the contralateral, normal distal capillary filling. MRI of left pelvic extremity showing hyperintense image in distal third of femur and knee, lobulated, expansive, with involvement of soft and bony tissues of 13.4x19 cm in diameter (Figure 3).

He was scheduled for urgent surgery. Labs on admission: leukocytes 13,000, hemoglobin 8.9, hematocrit 28.5%, platelets 266,000, Tp 11.6, Ttp 27.6, INR 1.08. Fibrinogen 485, glucose 100, creatinine 0.57. 

The management of the anesthetic technique was performed with: intravenous (IV) sedation plus subarachnoid block (SAB) plus erector spinae plane block (ESP).

After signing the informed consent form, the patient was admitted to the operating room, weight 70 kgs, height 160 cm, BMI 27.3 kg/m2. Peripheral venous catheter holder 16 G in left forearm permeable. Type I monitoring was placed, PANI 113/65 mmHg, HR 116 bpm, SpO2 96%, oxygen was placed through nasal prongs at 2 bpm. Administration of IV coadjuvant drugs was started: cephalothin 1 g, parecoxib 40 mgs, paracetamol 1 g, metoclopramide 10 mgs, dexamethasone 4 mgs, sedation with midazolam 1.5 mg IV plus fentanyl 100 mcg IV. Asepsis of the right neck region was performed, a linear transducer was placed with sterile technique, it was approached out of the plane with a needle up to the jugular vein, a guide was placed, an increase in the amplitude of the P wave was observed in the electrocardiogram (18), 1 cm was removed, a 3 lumen catheter was placed, it was fixed to the skin, a control X-ray was taken where it was observed in the cavo atrial junction. The patient was placed in right lateral decubitus, asepsis of the dorsolumbar region was performed, the patient was punctured with a #25 Quincke needle at L3-L4 level up to the subarachnoid space, clear cerebrospinal fluid was obtained, bupivacaine 12.5 mgs was administered, the needle was removed without incident. Latency 5 minutes, linear transducer was placed with sterile technique, transverse process was identified at L4 level, since at this level we expect a dispersion of two to three levels above and below, 100 mm ultrasound-guided needle was approached up to transverse process of L4, dose of ropivacaine 112.5 mgs at 0.5% total volume of 20 ml was administered, adequate cephalocaudal dissemination of local anesthetic was observed under the erector spinae muscle. Sedation was maintained with dexmedetomidine infusion at 0.5 mcg/kg/hr. During transanesthesia hemodynamically stable, with spontaneous ventilation. Surgical time of 3 hours.

In the recovery area the patient was monitored and pain was evaluated with a numerical scale from 0 to 10 (0 no pain and 10 the worst pain imaginable). At 3 hours the patient reported pain 2/10 . At 8 hours he reported pain 4/10, paracetamol 1 g orally plus ketorolac 30 mg IV was started and he reported improvement. That same day he was also started on gabapentin and amitriptyline. He was followed up by the anesthesiologist who was in charge of him in the operating room during the following 72 hours. Without reporting pain above 6 at any time, he continued with the dose of paracetamol and ketorolac every 8 hrs, at rest reporting an ANE of 0/10 and on movement of 2/10, at 48 hrs he walked with crutches and was discharged at 72 hrs without complications.

Discussion

There is little literature on the use of erector spinae blockade in lower limb surgery for postoperative analgesia. 

Abdelnasser in 2020 described the use of ESP at the L4 level for total hip replacement surgery, achieving local anesthetic distribution to the lumbosacral region (13). 

Analgesic management for supracondylar lower limb amputation is usually performed with epidural anesthesia, lumbar plexus block, femoral nerve block, among some options of peripheral nerve blocks. We must consider that the aforementioned blocks have some considerations such as ensuring the correct placement of the epidural catheter, contraindications such as parameters of coagulation studies, anticoagulant drugs or infection of the puncture site, as in this case we present, the femoral nerve block was not considered because of its proximity to the site of infection.

An advantage of using single-dose peripheral nerve blocks compared to epidural catheter placement is that it is a blind procedure, where it is unknown whether the catheter tip was left in the desired site, and the catheter could malfunction at any time. In comparison with the lumbar plexus block, the ESP is a simple and safer block since having a bony structure as a reference makes it easier to identify the target and it works as a barrier so that our needle does not go deeper and does not generate such drastic hemodynamic changes (3)(14).  

Another benefit of the use of regional anesthesia in oncologic patients is the reduction of opioid administration during trans-surgery (15), in addition cancer multiplies the risk of venous thrombotic disease (VTE), regional anesthesia allows them to move faster and reduce this risk (16).

Based on the case report by Langnas and collaborators in July 2022, where they describe the use of ESP at the L3 level, for an above-knee amputation (4), in our case we performed it one level below, at the L4 level, and without the use of balanced general anesthesia. 

In the first 72 hours our patient also reported no phantom limb pain, a very common symptom, which is difficult to control and increases morbidity (17).

In the future, a study of the management of this type of surgery with ESP plus catheter placement to extend the analgesia time could be performed. We should increase the number of cases in lower limb orthopedic procedures where ESP is used, to compare its effectiveness in comparison with other regional block strategies.

ESP is a block that can be included as part of multimodal analgesia for patients undergoing supracondylar amputations. 

Conclusions

Lumbar plexus block is the gold standard for lower limb analgesia management, its complications are infection, hematoma, vascular puncture, local anesthetic toxicity, nerve injury, severe hypotension due to the susceptibility of the oncologic patient, we must prevent hemodynamic changes that may occur. The erector spinae block does not produce such drastic hemodynamic changes and in these cases gave an effective analgesia in a crucial surgery without the need of requiring intravenous opioids in the trans-surgical as well as in the postoperative period as rescue therapy.

This case adds clinical evidence to the limited existing literature. It supports that it indeed has a cephalocaudal distribution, since we performed the block at the L4 level, most likely an adequate distribution of caudal dermatomes was achieved until reaching branches of the sacral plexus to cover branches of the obturator nerve, sufficient for a supracondylar lower limb amputation.

Abbreviations

ESP

Erector spinae plane

L4

fourth lumbar space

L3

Third lumbar space

VTE

venous thrombotic disease

BMI

Body Mass Index

SAB

subarachnoid block

MRI

Magnetic Resonance Imaging

Declarations

Acknowledgements:

None to disclose

Authors´contributions

MG is the first autor and she performed the literature review, data collection and wrote the manuscript. JM made a critical revisión of the manuscript and also provided literatura review. Both authors read and approved the final manuscript.

Funding:

None to disclose.

Availability of data and materials:

Data sharing is not applicable to this article as no datasets were generated or

analyzed during the current study.

Ethics approval and consent to participate

The patient provided written HIPAA authorization for details of the case to

be published. Case reports are not required to undergo IRB review at our

institution.

Consent for publication

Competing interests

The authors declare that they have no competing interests.

Author details

1 High Specialty Resident in Regional Anesthesia. INRLGII Instituto Nacional de rehabilitación Luis Guileermo Ibarra Ibarra, Calz México-Xochimilco 289, Coapa, Guadalupe Tlalpan, Tlalpan, 14389 Ciudad de México, CDMX

2 Physician attached to the division of Anesthesiology. INRLGII 

References

  1. - Attal N, Bouhassira D. Pharmacotherapy of neuropathic pain: which drugs, which treatment algorithms? Pain. 2015;156(suppl 1):S104–S114.
  2. - Kurd MF, Kreitz T, Schroeder G, Vaccaro AR: The role of multimodal analgesia in spine surgery. J Am Acad Orthop Surg. 2017, 25:260–8. 10.5435/JAAOS-D-16-00049
  3. - Forero, M., Adhikary, S. D., Lopez, H., Tsui, C., & Chin, K. J. (2016). The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Regional Anesthesia & Pain Medicine, 41(5), 621–627.
  4. - De Cassai, A., & Tonetti, T. (2018). Local anesthetic spread during erector spinae plane block. Journal of clinical anesthesia, 48, 60–61.
  5. - Schwartzmann, A., Peng, P., Maciel, M. A., & Forero, M. (2018). Mechanism of the erector spinae plane block: insights from a magnetic resonance imaging study. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 65(10), 1165–1166.
  6. - Adhikary, S. D., Bernard, S., Lopez, H., & Chin, K. J. (2018). Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Regional Anesthesia & Pain Medicine, 43(7), 756–762.
  7. - Debono, B., Wainwright, T. W., Wang, M. Y., Sigmundsson, F. G., Yang, M. M., Smid-Nanninga, H., … & de Boer, H. D. (2021). Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. The Spine Journal, 21(5), 729–752.
  8. - Taşkaldıran, Y. (2021). Is Opioid-free Anesthesia Possible by Using Erector Spinae Plane Block in Spinal Surgery?. Cureus, 13(10).
  9. - Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth. 2015;8:45–55. Published 2015 Aug 12. https://doi.org/10.2147/LRA.S55322.
  10. - Acland. Video atlas of human anatomy. Wolters Kluwer. Retrieved from: https://es.aclandanatomy.com/multimediaplayer.aspx?multimediaid=11053905
  11. - Liu, M. J., Zhou, X. Y., Yao, Y. B., Shen, X., Wang, R., & Shen, Q. H. (2021). Postoperative analgesic efficacy of erector spinae plane block in patients undergoing lumbar spinal surgery: a systematic review and meta-analysis. Pain and Therapy, 10(1), 333–347.
  12. - Langnas, E. M., Gray, A., & Braehler, M. (2022). Erector spinae plane block for postoperative analgesia for above-the-knee amputation: a case report. Perioperative Medicine, 11(1), 1–3.
  13. - Abdelnasser, A., Zoheir, H., Rady, A., Ramzy, M., & Abdelhamid, B. M. (2020). Effectiveness of ultrasound-guided erector spinae plane block for postoperative pain control in hip replacement surgeries; A pilot study. Journal of Clinical Anesthesia, 62, 109732–109732.
  14. - Adhikary SD, Prasad A, Soleimani B, Chin KJ. Continuous erector spinae plane block as an efective analgesic option in anticoagulated patients after left ventricular assist device implantation: a case series. J Cardiothorac Vasc Anesth. 2019;33(4):1063–7 PMID: 29753668.
  15. - Raigón Ponferrada, A. (2021). How anesthetic and analgesic techniques during cancer surgery may affect postoperative oncologic outcomes: Differences in recurrence of infiltrating bladder cancer.
  16. - Kearon, C., Akl, E. A., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., … & Moores, L. (2016). Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest, 149(2), 315–352.
  17. - Subramaniam B, Pomposelli F, Talmor D, Park KW. Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics. Anesth Analg. 2005;100(5):1241–7 PMID: 15845661.
  18. - Argoti-Velasco, Y. L., Carrillo-Torres, O., Sandoval-Mendoza, R. A., Paez-Amaya, W. G., & Cahuantzi-Caballero, X. Y. (2018). Proper electrocardiography-guided placement of a central venous catheter. Revista Médica del Hospital General de México, 81(4), 262–267.