ESP Block Is Safe, Effective During Surgery in EDS Patient, Report Says

Erector spinae plane (ESP) block can improve the safety of surgical procedures in patients with Ehlers-Danlos syndrome (EDS) and offer effective pain relief, according to a case report. The study evaluated pain perception in a patient after vascular ring repair surgery.

The case report, “The erector spinae plane block in a high-risk Ehlers-Danlos syndrome pediatric patient for vascular ring repair” was published in the Journal of Clinical Anesthesia.

EDS is an inherited genetic disorder with a wide range of symptoms, including skin fragility, excessive joint mobility and dislocations, and cardiovascular conditions. Vascular conditions associated with EDS, including fragile blood vessels, can cause complications during surgery. Routine surgical procedures such as anesthetic injections can result in ruptured blood vessels and subsequent hemorrhage.

ESP block is a potent regional anesthetic technique for surgical procedures associated with the relief of intense pain. ESP block is used together with ultrasound to guide the anesthetic injection between the erector spinae (muscles that straighten and rotate the back) and the vertebra, to an area that is relatively distant from neural or vascular (blood vessels) structures, making the procedure safer in certain conditions.

The study evaluated the safety of ESP block in a 17-year-old female with hypermobility EDS undergoing surgery. The patient had a history of easy bruising, difficulty swallowing, worsening dyspnea (shortness of breath), and spontaneous bleeding symptoms.

The patient needed  surgery to repair a vascular ring — an inherent abnormal vasculature formation — compressing the trachea (windpipe) and the esophagus (food pipe). This type of surgery can result in severe post-operative pain.

First, the medical team identified the proper injection spot for primary anesthetic administration (0.5% ropivacaine). Next, the patient was infused with 0.2% ropivacaine (8 mL/hour) through a ESP catheter aided by ultrasound guidance.

ESP analgesia was supplemented with one dose of short-acting opioid during the procedure.

The operation lasted four hours, and the patient was then taken to the intensive care unit, where she received further (although lower) doses of ropivacaine and supplemental anesthetics.

The patient completed pain assessment tests through a numeric pain score — a self-reported pain scale from 0-10, where 0 implies no pain and 10 implies the worst possible pain.

One day after the surgery, the patient-reported numeric pain score was estimated to be 0-1, while objective pain score (usually based on patient observation by healthcare professionals) was estimated as 0.

Two days after, the patient was transferred from the intensive care unit to the acute care unit. Four days after the operation, the chest tube and ESP catheter were removed.

Based on this case report, the team suggested that ESP block can be considered a safer alternative compared with more common anesthesia, such as epidural, when treating a patient with spontaneous bleeding. The team found that the approach can offer effective pain relief.

“Although regional anesthesia is safe in EDS patients, the success of local anesthetics when used for peripheral nerve blockade has been disputed as suspected collagen and tissue scarring may contribute to reduced spread and/or block failure,” the researchers said.

Furthermore, the results showed that “ESP block with continuous catheter infusion allowed for enhanced post-surgical recovery,” improving the rehabilitation time, and reducing post-surgery opioid consumption, the team concluded.