In the age of the opioid epidemic, there is a need for multi-modal pain control techniques, and nerve blocks will likely be an increasingly important piece of the puzzle, particularly in the Emergency Department. Ultrasound-guided nerve blocks for musculoskeletal complaints are now standard practice for many emergency physicians, so it is a reasonable next step to utilize this modality in lieu of opioids for abdominal complaints as well.
The erector spinae plane (ESP) block has been shown to improve pain control for rib fractures in the emergency department, and a more inferior approach has demonstrated success in the perioperative period for abdominal surgeries (1,2). However, this type of block has not been studied for the management of abdominal pain in the emergency department.
This study examined the efficacy of the ESP block on patients with acute appendicitis to see if it could reduce opioid use.
Can an inferiorly located, ultrasound-guided erector spinae plane block successfully manage the pain of acute appendicitis in the emergency department setting?
Methods & Study Design
Case report in which ultrasound guidance was used to perform an ESP block at the L1 level.
The patient was a 24-year-old male with uncomplicated appendicitis as diagnosed on CT. The location for needle insertion was identified by palpating the L1 spinous process and placing a linear probe 3 cm lateral, at the transverse process. A Touhy needle was advanced under ultrasound guidance to the level of the transverse process, and saline hydrodissection was used to confirm the needle tip in the fascial plane. Then, 20mL of 1% lidocaine was injected.
Initially, the patient was reporting 7/10 pain following analgesia with 0.5 mg IV hydromorphone, 30 mg IV ketorolac, and 1 g IV acetaminophen. Thirty minutes following placement of the erector spinae plane block, the patient reported 0/10 pain without palpation, and 3/10 pain with deep palpation. Testing to cold revealed loss of sensation between the T10-L2 dermatomes. The patient did not require additional analgesia during the rest of his 5.5-hour emergency department stay.
Strength & Limitations
While this is a case study of only one patient, it provides explicit guidance on performing an erector spinae plane block in the emergency department setting. However, the primary method of assessing pain control is inherently subjective and may be limited by the patient’s perception of the efficacy of the block. Further, the patient had already received analgesia, which may have impacted the efficacy of the block over the course of the ED stay.
“A single injection, ultrasound-guided erector spinae plane block can provide complete analgesia for appendicitis.”
Performing an erector spinae plane block at the L1 level was an effective adjunct to opioid analgesia in this case. Because of the relative safety of this block and efficacy in this case, it warrants further investigation as to the ideal level for pain control, particularly in a larger sample of patients.
This post was written by Kaley Waring, MS4 at UCSD School of Medicine, Charles Murchison MD and Amir Aminlari MD.
Mantuani et al. A Novel Technique to Reduce Reliance on Opioids for Analgesia from Acute Appendicitis: The Ultrasound-guided Erector Spinae Plane Block. Clin Pract Cases Emerg Med. 2019 Aug; 3(3): 248–251.
1. Luftig J, Mantuani D, Herring AA, et al. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018;36(8):1391–6
2. Chin KJ, Adhikary S, Sarwani N, et al. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017;72(4):452–60