Bilateral Erector Spinal Plan Block in Postoperative Analgesia After Total Abdominal Hysterectomy
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Observational [Patient Registry]

Summary: 
      The importance of effective postoperative pain management is well known. Overall, for total
      abdominal hysterectomy operations are related with severe postoperative pain. The undesired
      effects of pain can be prevented with multimodal analgesia for the patient. Many regional
      anesthesia techniques can be preferred for total abdominal hysterectomy. The aim of this
      study is to investigate postoperative analgesia effect of erector spina plane block for total
      abdominal hysterectomy.
    

Detailed description: 
      Postoperative pain, which starts with tissue damage as a result of surgical procedures,
      gradually decreases with wound healing and ends. Pain due to tissue damage is an acute pain
      that varies in severity according to its size and region. It creates physiopathological
      changes in many organs and tissues and has negative effects on systems. This situation causes
      serious postoperative morbidity and mortality in patients. For these reasons, postoperative
      pain control is very important. Inadequate pain control can cause acute pain to turn into
      chronic pain. The occurrence of pain in the diseased area before the operation, the severity
      of surgical tissue damage, environmental, psychological and genetic factors increase the rate
      of development of chronic pain.

      Multimodal analgesia in postoperative pain management is a strategy that combines different
      analgesic methods to provide more effective analgesia and to reduce side effects. Compared to
      monotherapy, less dose requirement and better pain management are targeted thanks to the
      additive and synergistic effect of different analgesic drugs. Thanks to this reduced dose,
      the incidence of drug-related side effects in patients is also reduced.

      Erector spina plan block (ESPB) is a new regional anesthesia method used especially in
      abdominal and thoracic surgeries. It was first described by Forero et al. for the treatment
      of thoracic neuropathic pain. ESP block in 2017 and 2018; Many case reports for analgesic
      purposes in cervical, thoracic, abdominal and pelvic pain have been published, but detailed
      clinical studies have not been found. Since then, it has been considered that this
      interfascial plane block can be applied as an alternative to the neuraxial block for certain
      surgeries.

      Under the guidance of ultrasonography, regional anesthesia applications can be performed more
      safely, easily and effectively than methods such as electrical stimulation and loss of
      resistance based on the determination of superficial landmarks. Uncertainty about the
      relationship of the needle with the surrounding tissue in peripheral nerve blocks performed
      with the traditional blind method causes a higher risk of failure and complication of the
      application. For this reason, Erector spina plan blocks made in our clinic are performed
      under ultrasound guidance. Complication due to erector spina plane block (pneumothorax) was
      reported in only two articles. There is also a report in the literature reporting that lower
      thoracic erector spina plane block causes involuntary motor block. However, it is stated that
      the possible complications associated with the block may be due to the failure of the
      technique.

      The erector spina plane block technique consists of an injection of 20 mL of 0.25%
      bupivacaine, guided by USG, between the erector spinae muscle and the transverse process
      below it. The procedure is performed after the patient is seated, in the prone position, or
      in the lateral decubitus position and the target vertebral level has been defined. A high
      frequency linear USG probe is placed 3 cm lateral to the spinous process. On the hyperechoic
      transverse process, hypoechoic M.latissimus dorsi and M.rector spina are defined. The needle
      is then advanced from cephal to caudal or from caudal to cephalad until it remains in the
      interfascial plane. The correct position of the needle is confirmed by observing
      intramuscular diffusion of the drug following bupivacaine injection.

      In the studies, the effectiveness of the erector spina plan block was controlled with the
      Visual Pain Scale (VAS) in the postoperative period. Therefore, in our study, we evaluated
      the effectiveness of postoperative pain with VAS. In our study, the patients in the control
      group will be those who did not undergo the block procedure. There is a 10 cm long line drawn
      horizontally on the Visual Pain Scale. The left end of this line represents no pain (VAS 0),
      and the other end represents the most severe pain imaginable (VAS 10). The patient is asked
      to mark a point on this 10 cm line according to the severity of the pain at that moment.

      In our clinic, the efficacy of erector spina plane block has been demonstrated in studies
      performed in various surgeries. These studies include cholecystectomy, thoracic surgery,
      breast surgery, etc. made in operations. It has been shown in the literature that erector
      spina plane block is also effective in total abdominal hysterectomy operation. In this study,
      we aimed to show the effectiveness of the erector spina plane block, which is routinely
      applied in our clinic to prevent postoperative pain after total abdominal hysterectomy
      operations.
    

Intervention name(s): Erector spinae plane block (ESPB)
Intervention type(s): Procedure
Intervention description(s): Bilateral erector spinae plane block will be performed with 20 mL, 0.25% bupivacaine at T9 level preoperatively.
Observational model: Case-Control
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        patients who undergo elective total abdominal hysterectomy surgery
      
Keywords: postoperative pain; total abdominal hysterectomy; erector spinae plan block; morphine; visuel analog scale