Erector Spinae Plane Block for Post-thoracotomy Pain
Condition: Pain, Postoperative
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Post-thoracotomy pain is one of the most severe forms of post-operative pain. Among the most
      common techniques for the management of post-thoracotomy pain, there are the intercostal
      nerve block, and a recently described block, the erector spinae plane block (ESP).To date,
      there are no studies that compare the efficacy of ESP block with other pain relief methods in
      acute post-thoracotomy pain. The objective of this randomized study is to compare the
      analgesic efficacy of these two techniques in the control of acute post-thoracotomy chest
      pain, block of erector spinae vs intrapleural intercostal block.
    

Detailed description: 
      Post-thoracotomy pain is one of the most severe forms of post-operative pain that can be
      attributed to muscle incision, rib retraction or resection, and damage to the intercostal
      nerves. Inadequate control of this post-operative pain can contribute to a deterioration of
      the respiratory function, with limitation of the ventilation, appearance of atelectasis,
      ineffective cough, and increased risk of infectious complications. Moreover, recent evidence
      shows that persistent pain after surgery, in addition to being responsible for chronic
      post-surgical pain syndrome, is associated with a delay in post-operative recovery and a
      return to normal daily life activities. The most common techniques for the management of
      post-thoracotomy pain are in addition to systemic intravenous analgesia, thoracic epidural,
      paravertebral nerve block and intercostal nerve block. Although the thoracic epidural has
      been considered for years the gold standard for the control of post-operative pain following
      thoracotomy, it is not risk-free, requires an expert operator, and can be contraindicated in
      some categories of patients. The intercostal nerve block, performed through the injection of
      the local anesthetic in multiple intercostal spaces before performing thoracotomy, may be one
      of the alternatives to a thoracic epidural in terms of safety and efficacy and is technically
      easy and quick to perform. This block is found to be particularly effective in reducing
      post-operative pain when associated with a mini-thoracotomy, helping to improve the outcome
      of patients undergoing major lung resection. A technique of more recent description (2016) is
      the erector spinae plane block (ESP) . This interfascial block is performed in the posterior
      thoracic region homolaterally at the site of the intervention at the level of the T5
      transverse process (fifth thoracic vertebra), the ultrasound marker of the block. The ESP
      block is easy and safe to perform thanks to the ultrasound-guided method and the absence of
      vascular-nerve structures at risk of damage in the vicinity of the injection site and allows
      analgesia of the posterior and anterolateral thoracic wall and of the axillary region. In
      fact, cadaveric studies have shown an anesthetic distribution both in the cranial caudal
      sense (T2-T8) along the fascia between erector spinae and large rhomboid, and in the
      anteroposterior direction, with the blockage of the spinal thoracic nerve roots. ESP block
      was described in the treatment of chronic chest pain in the first place, but was subsequently
      used as rescue therapy in acute post-thoracotomy pain; it has also been tested in upper
      abdominal surgery, performed bilaterally. Use in four cases of acute post video thoracoscopy
      pain management has also been described. Recently, some randomized controlled trials have
      been carried out that showed: greater analgesic efficacy of ESP compared to intravenous
      multimodal analgesia standard for the treatment of post-operative pain, with less recourse to
      rescue doses of morphine following laparoscopic cholecystectomy, mastectomy and cardiac
      surgery. To date, there are no studies that compare its efficacy with other pain relief
      methods in acute post-thoracotomy pain. The objective of our study is to compare the
      analgesic efficacy of these two techniques in the control of acute post-thoracotomy chest
      pain, blockade of erector spinae vs intrapleural intercostal blockade.
    

Intervention name(s): erector spinae plane block with ropivacaine; Intercostal nerve block with ropivacaine
Intervention type(s): Procedure; Procedure
Intervention description(s): The block is performed immediately before surgery. by an ultrasound guide, with the probe positioned longitudinally, the spinous process of T5 is identified. A peripheral block needle is inserted in the cephalo-caudal direction (caliber 21G and length 10 cm) and 3 ml of physiological solution are injected to confirm the injection site: fascial plane between the erector spinae muscle and the large rhomboid, near the tip of the transverse process of T5. Once the correct position of the needle tip has been confirmed, ropivacaine 0.75% 20 ml is injected.; The intercostal nerve block will be performed by the surgeon at the time of thoracotomy from the 4th to the 8th intercostal space, by injecting 20 ml of 0.75% ropivacaine (4 ml for each space). The injection is performed at about 2-3 cm from the spine.
Intervention MeSH terms: Ropivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 60 patients will be enrolled to undergo thoracotomy lung resection surgery.
The population will be divided into two groups based on the type of block made:
Group E: ESP block (n = 30)
Group I: Intercostal block (n = 30)
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: erector spinae plane block; thoracotomy; ultrasound guided nerve block; analgesia