For many years, epidural corticosteroid injection has been considered the gold standard in the management of 33 6 Department of Neurosurgery Unit - S. Maria Hospital, terni, Italy Corresponding Author : Gian Marco Petroni, via belvece 4, Contigliano, Rieti, Italy [02043] Tel : 3392197226, Fax : 0744205261, E-mail : [email protected] Dear Editor, 34 35 low back pain unresponsive to non-invasive treatment. Today, thanks to the numerous studies on the efficacy of ESP block in the management of acute and chronic pain, many centers use this fascial plane block as an 36 alternative to epidural injection.1 New studies have demonstrated the mechanism of action of the ESP block, 37 which in addition to spreading in the epidural space, causes an activation of free nerve endings, 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 mechanoreceptors, proprioceptors and autonomic nerves fibers inside the deep fascia followed by a reduction in muscles stiffness, as described with the use of ultrasound elastosonography.2-3 For these reason we must consider the fascia an important link in non-specified chronic pain. As described by C. Stecco et al, the lumbodorsal fascia represents a possible source of idiopathic low back pain. In fact, histological studies have demonstrated the presence of nociceptive free nerve endings within the lumbodorsal fascia, which, furthermore, appear to exhibit morphological changes in patients with chronic low back pain.4-5 We describe a case of a patient in their 70’ s with failed back surgery syndrome. He had to spinal stabilization L3-L4 for lumbar spinal canal stenosis. The patient had functional limitation in daily activity and a VAS score of 9. We decided to perform a biliteral ESP block at the L4 level. Prior to the procedure, the patient was connected to standard monitors such as an invasive blood pressure monitor, an ECG, and a pulse oximeter . Using an in-plane approach, a 20G needle was inserted in a caudal-cephalic direction until the tip was under 2 3 4 fascial plane. The same procedure was carried out bilaterally. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 At the end of the procedure the pain perceived by the patient went from a VAS 9 to VAS 2. Page 2 of 5 1 the erector spinae muscle as evidenced by the opening of the fascial plane after 3 ml normal saline solution injection. Then a bolus of naropine 0.1% + methylprednisolone 40 mg (total 20 mL) was injected into the After two weeks, in follow-up visit the patient had a VAS of 5. An ultrasound-guided ESP block was performed again in L4 on the right, with naropine 0.1% + methylprednisolone 40 mg (total 30 mL). At the end of the procedure the pain perceived by the patient went from a VAS 5 to VAS 1. After two weeks, in second follow- up visit the patient had a VAS of 2 and he reported less muscle stiffness, as demonstrated with the use of ultrasound elastography. FIG.1 Based on our experience we believe that the use of ESP block instead of epidural corticosteroid injection results in longer lasting pain relief, due to the reduction of muscle stiffness and consequently with the improvement of mobility resulting from the fascial stimulation, in addition to analgesic effect of the local anesthetic due to diffusion into paravertebral space. Further studies are needed to evaluate whether ESP block will replace epidural injection in the treatment of chronic back pain.
Low Back pain:is it time for erector spine plane block?
Scarcella M;
2023
Abstract
For many years, epidural corticosteroid injection has been considered the gold standard in the management of 33 6 Department of Neurosurgery Unit - S. Maria Hospital, terni, Italy Corresponding Author : Gian Marco Petroni, via belvece 4, Contigliano, Rieti, Italy [02043] Tel : 3392197226, Fax : 0744205261, E-mail : [email protected] Dear Editor, 34 35 low back pain unresponsive to non-invasive treatment. Today, thanks to the numerous studies on the efficacy of ESP block in the management of acute and chronic pain, many centers use this fascial plane block as an 36 alternative to epidural injection.1 New studies have demonstrated the mechanism of action of the ESP block, 37 which in addition to spreading in the epidural space, causes an activation of free nerve endings, 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 mechanoreceptors, proprioceptors and autonomic nerves fibers inside the deep fascia followed by a reduction in muscles stiffness, as described with the use of ultrasound elastosonography.2-3 For these reason we must consider the fascia an important link in non-specified chronic pain. As described by C. Stecco et al, the lumbodorsal fascia represents a possible source of idiopathic low back pain. In fact, histological studies have demonstrated the presence of nociceptive free nerve endings within the lumbodorsal fascia, which, furthermore, appear to exhibit morphological changes in patients with chronic low back pain.4-5 We describe a case of a patient in their 70’ s with failed back surgery syndrome. He had to spinal stabilization L3-L4 for lumbar spinal canal stenosis. The patient had functional limitation in daily activity and a VAS score of 9. We decided to perform a biliteral ESP block at the L4 level. Prior to the procedure, the patient was connected to standard monitors such as an invasive blood pressure monitor, an ECG, and a pulse oximeter . Using an in-plane approach, a 20G needle was inserted in a caudal-cephalic direction until the tip was under 2 3 4 fascial plane. The same procedure was carried out bilaterally. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 At the end of the procedure the pain perceived by the patient went from a VAS 9 to VAS 2. Page 2 of 5 1 the erector spinae muscle as evidenced by the opening of the fascial plane after 3 ml normal saline solution injection. Then a bolus of naropine 0.1% + methylprednisolone 40 mg (total 20 mL) was injected into the After two weeks, in follow-up visit the patient had a VAS of 5. An ultrasound-guided ESP block was performed again in L4 on the right, with naropine 0.1% + methylprednisolone 40 mg (total 30 mL). At the end of the procedure the pain perceived by the patient went from a VAS 5 to VAS 1. After two weeks, in second follow- up visit the patient had a VAS of 2 and he reported less muscle stiffness, as demonstrated with the use of ultrasound elastography. FIG.1 Based on our experience we believe that the use of ESP block instead of epidural corticosteroid injection results in longer lasting pain relief, due to the reduction of muscle stiffness and consequently with the improvement of mobility resulting from the fascial stimulation, in addition to analgesic effect of the local anesthetic due to diffusion into paravertebral space. Further studies are needed to evaluate whether ESP block will replace epidural injection in the treatment of chronic back pain.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
