Original article
The erector spinae plane block in 4 cases of video-assisted thoracic surgery
Bloqueo del plano del músculo erector de la columna en 4 casos de cirugía torácica videoasistida
J.C. Luis-Navarro
, M. Seda-Guzmán, C. Luis-Moreno, J.L. López-Romero
Corresponding author
Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Luis-Navarro, M. Seda-Guzmán, C. Luis-Moreno, J.L. López-Romero" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Luis-Navarro" "email" => array:1 [ 0 => "jcluis@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Seda-Guzmán" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Luis-Moreno" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Romero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo del plano del músculo erector de la columna en 4 casos de cirugía torácica videoasistida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 701 "Ancho" => 950 "Tamanyo" => 72835 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Horizontal ultrasound image of the vertebra.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">AE: spinous process; AT: transverse process; L: lamina.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Thoracic surgery, even video-assisted procedures involving far smaller incisions, is associated with intense postoperative pain. For this reason, multimodal anaesthesia, which usually combines locoregional techniques such as epidural nerve block with general anaesthesia, is a common approach that gives optimal perioperative pain relief. However, thoracic epidural anaesthesia can be contraindicated in some patients, or may be impossible to perform due to technical difficulties.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A recent study describes a novel analgesic technique, the erector spinae plane (ESP) block.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This blockade is similar to the epidural technique, but with unilateral analgesia, and has occasionally been used successfully for postoperative or rescue analgesia when other alternatives have failed in various thoracic procedures.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–5</span></a> The safety profile and contraindications for ESP may differ from those of the other techniques currently in use, since the catheter is inserted under ultrasound vision. In thoracic surgery, the target is the transverse process of T5, an easily identified structure located relatively far from the pleura and major neural or vascular structures,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> which makes ESP an easy and possibly safe, albeit deep, technique.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Finally, it provides extensive analgesia with a single administration. This means that the blockade can be performed relatively distant from the incision area in patients with specific local characteristics, such as infection, tattoos or deformities, among others.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Case reports of ESP in thoracic surgery have so far described administration of the blockade at the end of the intervention,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> after epidural failure,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> administration without a catheter before the intervention,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> or as part of a multimodal anaesthetic approach in which the catheter is placed before the start of surgery in order to provide both intraoperative and continuous postoperative analgesia.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> However, the ESP blockade has not been compared with other techniques, such as epidural, paravertebral or intercostal blockades in large series.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 52-year-old woman scheduled for resection of left upper lobe metastases using video-assisted thoracic surgery (VATS). Her history included type II obesity and colon cancer treated with left hemicolectomy, left oophorectomy and bilateral salpingectomy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The preoperative laboratory workup showed a platelet count of 89 x10<span class="elsevierStyleSup">9</span>/L (normal range 130–440<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L). Although this finding is not an absolute contraindication for epidural puncture, we chose to perform an ESP block after obtaining the patient's informed consent.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After anaesthesia induction (fentanyl 100<span class="elsevierStyleHsp" style=""></span>μg, propofol 180<span class="elsevierStyleHsp" style=""></span>mg, rocuronium 70<span class="elsevierStyleHsp" style=""></span>mg) and intubation, the patient was placed in the right lateral decubitus position. Following the technique described by Forero et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> T5 was located by palpation, taking C7 as reference. After surgical skin prep, a linear probe (Esaote<span class="elsevierStyleSup">®</span> LA523 4–13<span class="elsevierStyleHsp" style=""></span>MHz, Maastricht, Holland) with a sterile sheath was placed over the site and slid laterally 3<span class="elsevierStyleHsp" style=""></span>cm to the transverse process (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The probe was rotated vertically and an 80<span class="elsevierStyleHsp" style=""></span>G 18<span class="elsevierStyleHsp" style=""></span>mm Tuohy epidural needle was inserted in plane in a craniocaudal direction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). When the needle reached the transverse process, 1<span class="elsevierStyleHsp" style=""></span>ml of local anaesthetic was injected, making sure the fluid entered the fascial plane between the erector spinae muscle and the transverse process (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). After confirming correct location, we injected 20<span class="elsevierStyleHsp" style=""></span>ml of 0.5% bupivacaine and placed an epidural catheter for continuous postoperative infusion.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The surgical procedure was uneventful. Anaesthesia was maintained with the100<span class="elsevierStyleHsp" style=""></span>μg of fentanyl administered at induction. Before eduction, 2<span class="elsevierStyleHsp" style=""></span>g metamizol and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron were administered, following the protocol in place in our hospital.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the post anaesthesia care unit (PACU), an infusion device was connected to the catheter to deliver continuous infusion of 12<span class="elsevierStyleHsp" style=""></span>ml/h of 0.15% ropivacaine, which was maintained for the first 48<span class="elsevierStyleHsp" style=""></span>h. Postoperative pain was assessed on a visual analogue scale (VAS), obtaining score of between 0–1/10 at 6, 12, 24 and 48<span class="elsevierStyleHsp" style=""></span>h after surgery, ruling out the need for additional analgesia.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 30-year-old man scheduled for resection of cystic bronchogenic carcinoma extending to the posterior mediastinum by VATS through the right hemithorax. The patient had no medical or surgical history, except for type II obesity. Given the impossibility of inserting a thoracic epidural catheter, we decided to perform an ESP block.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After anaesthesia induction (fentanyl 150<span class="elsevierStyleHsp" style=""></span>μg, propofol 180<span class="elsevierStyleHsp" style=""></span>mg, rocuronium 70<span class="elsevierStyleHsp" style=""></span>mg) and intubation, the patient was placed in the right lateral decubitus position and the ESP block was performed as describe above. Introduction of the catheter proved difficult.</p><p id="par0055" class="elsevierStylePara elsevierViewall">No opioids were required during trocar insertion or at the start of surgery. During mediastinal surgery, the patient received up to 0.07<span class="elsevierStyleHsp" style=""></span>μg/kg/min of remifentanil infusion, which was maintained up to 20<span class="elsevierStyleHsp" style=""></span>min before the end of surgery, when an infuser was connected to the ESP catheter to deliver 12<span class="elsevierStyleHsp" style=""></span>ml/h of 0.15% ropivacaine; 10<span class="elsevierStyleHsp" style=""></span>mg ketorolac, 2<span class="elsevierStyleHsp" style=""></span>g metamizol, and 6<span class="elsevierStyleHsp" style=""></span>mg ondansetron were also administered intravenously.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the PACU the patient reported mechanical pain in the centre of the thorax (VAS 5/10), which was relieved with 4<span class="elsevierStyleHsp" style=""></span>mg of morphine chloride and 2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h of metamizol. Subsequent VAS evaluation showed a pain score of 0–1/10, and no further rescue analgesia was required. The catheter was removed after 48<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 3</span><p id="par0065" class="elsevierStylePara elsevierViewall">A 71-year-old man with lung cancer was scheduled for right upper lobectomy with VATS. His history included hypertension treated with bisoprolol and enalapril, stable chronic ischaemic heart disease with percutaneous coronary intervention in the right coronary and circumflex arteries 9 years previously and no new events since then, colonic diverticulosis, and hip osteoarthritis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The preoperative laboratory workup showed 1.43<span class="elsevierStyleHsp" style=""></span>mg/dl creatinine and blood pressure of 183/84<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0075" class="elsevierStylePara elsevierViewall">After obtaining informed consent, ESP block was performed before induction of general anaesthesia. With the patient sitting and monitored (ECG, pulse oximetry and non-invasive blood pressure), and after sedation with 3<span class="elsevierStyleHsp" style=""></span>mg of intravenous midazolam and local infiltration of 2% lidocaine in the area of the transverse process of T5, we performed the ESP block as described above. After completion of right-side ESP block with 20<span class="elsevierStyleHsp" style=""></span>ml of 0.5% bupivacaine and insertion of the catheter, anaesthesia was induced with 150<span class="elsevierStyleHsp" style=""></span>μg fentanyl, 180<span class="elsevierStyleHsp" style=""></span>mg propofol and 75<span class="elsevierStyleHsp" style=""></span>mg rocuronium.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Two incisions were made: 1 right anterior 4th interspace mini-thoracotomy incision, and another for the optics in the 7th intercostal space. The surgery was laborious, and consisted of an upper right lobectomy and an extensive lymphadenectomy, including hilar adenopathies. With regard to analgesia, after induction with 150<span class="elsevierStyleHsp" style=""></span>μg of fentanyl, we maintained a continuous infusion of remifentanil (0.01–0.03<span class="elsevierStyleHsp" style=""></span>mg/kg/min), which was withdrawn 30<span class="elsevierStyleHsp" style=""></span>min before the end of surgery. An infusion pump was connected to the catheter for continuous infusion of 7<span class="elsevierStyleHsp" style=""></span>ml/h of 0.15% ropivacaine together with intravenous administration of 2<span class="elsevierStyleHsp" style=""></span>g metamizol and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the PACU, the patient reported discomfort in the area of the sternum (VAS 5–6/10), which subsided with 4<span class="elsevierStyleHsp" style=""></span>mg of morphine chloride and increasing the rate of infusion through the ESP catheter to 12<span class="elsevierStyleHsp" style=""></span>ml/h. At subsequent evaluations, the patient reported no pain (VAS 0/10). He was able to use the incentive spirometer with no discomfort and did not need rescue analgesia. The catheter was removed after 48<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 4</span><p id="par0090" class="elsevierStylePara elsevierViewall">A 77-year-old man with squamous cell carcinoma was scheduled for upper right lobectomy with VATS. He had a history of heavy smoking, type I obesity (BMI 30<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), hypertension, type 2 diabetes mellitus, transient ischaemic attack in 2007, and prostate cancer.</p><p id="par0095" class="elsevierStylePara elsevierViewall">After explaining the technique and obtaining his consent, we performed the ESP block with the patient in a seated position, before anaesthetic induction. The procedure was performed as described in the previous cases and was uneventful.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The surgery was uneventful. The patient received a single dose of 150<span class="elsevierStyleHsp" style=""></span>μg of fentanyl for induction. We did not administer continuous intraoperative infusion of remifentanil, and 30<span class="elsevierStyleHsp" style=""></span>mg ketorolac, 2<span class="elsevierStyleHsp" style=""></span>g metamizol and 4<span class="elsevierStyleHsp" style=""></span>mg ondansetron were administered before eduction.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the PACU, infusion of 12<span class="elsevierStyleHsp" style=""></span>ml/h of 0.15% ropivacaine was started through the ESP catheter. Rescue analgesia with 1<span class="elsevierStyleHsp" style=""></span>g paracetamol was prescribed, but not required. The patient reported no pain (VAS 0/10) at each assessment. The catheter was maintained for 48<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The erector spinae plane (ESP) block is a novel nerve block that has so far been used for thoracic analgesia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> ESP is performed by injecting local anaesthetic in the plane between the erector spinae muscle and the transverse process. Its effect seems to be due in part to the spread of local anaesthetic to the paravertebral space through the adjacent intervertebral spaces, acting not only on the dorsal and ventral rami of the thoracic spinal nerves<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,8</span></a> but also on the rami communicates that transmit sympathetic fibres.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The effect of ESP is similar to retrolaminar or paravertebral block.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,10</span></a> The technique was first performed at the level of the transverse process of T5, with local anaesthetic spreading from C7-T1 to T8 to give effective analgesia in the ipsilateral chest wall.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The ESP block could be a safer alternative to thoracic or paravertebral epidural, since the ultrasound target (the transverse process) is easily visualised, the injection site is far from the neuroaxis, pleura and major vascular structures<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), and the needle is inserted in plane, with simultaneous vision of the transverse process, the needle and the trajectory. This is an advantage in patients with added difficulties,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> such morbid obesity or spinal deformities, and could reduce the risk in patients with, for example, platelet or coagulation disorders or recent doses of LMWH. It also eliminates the risk of neural lesions when performing the technique in an anesthetised patient.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> An additional advantage over other blocks is that it can be performed with the patient in the seated, prone or lateral decubitus position, or after anaesthetic induction with the patient placed in the surgical position. Furthermore, the wide craniocaudal spread of the anaesthetic provides extensive blockade with a single injection, allowing the needle to be inserted at a point relatively distant from the surgical site.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> However, no comparative studies have yet confirmed or refuted the potential benefit of this technique.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">In our experience, the analgesia obtained with ESP is comparable to what could be expected with an epidural (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), although in procedures involving the mediastinum, patients reported pain in the centre of the thorax after eduction, possibly due to bilateral innervation of this central structure. This pain was managed with single doses of morphine and NSAIDs, or by increasing perfusion through the ESP catheter.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">All catheters were removed 48<span class="elsevierStyleHsp" style=""></span>h after surgery, following our hospital's epidural catheter protocol; however, some authors have kept the catheter in for up to 4 days, with no complications.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">ESP block is an alternative to thoracic epidural or paravertebral block in thoracic surgery. The target site is easily visualised on ultrasound, and the point of injection is far from the neuroaxis, the pleura and major vascular structures. Therefore, ESP is an interesting option in patients with added difficulties, or as a rescue technique in patients in whom epidural catheter placement proves impossible.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1018428" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec976798" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1018427" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec976799" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 3" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Case 4" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-24" "fechaAceptado" => "2017-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec976798" "palabras" => array:4 [ 0 => "Thoracic surgery" 1 => "Erector spinae plane block" 2 => "Multimodal anaesthesia" 3 => "Interfascial blocks" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec976799" "palabras" => array:4 [ 0 => "Cirugía torácica" 1 => "Bloqueo del plano del erector de la columna" 2 => "Anestesia multimodal" 3 => "Bloqueos interfasciales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multimodal anaesthesia, combining epidural catheter and general anaesthesia, is a common technique in thoracic surgery, however, epidural catheter placement is not always possible.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Recently, erector spinae plane block has been described, which provides analgesia like that of the epidural block, although unilateral, and which has been used in various procedures at thoracic level. At present, there are no studies comparing the efficacy or safety of this block with those commonly used in thoracic surgery. However, its safety profile and contraindications seem different from those of the epidural catheter, since its placement is done under ultrasound view, the needle introduction is done in plane and the ultrasound target, the transverse process, is easily identifiable and is relatively remote from major neural or vascular structures and the pleura. Unlike other blockages made by anatomical references, erector spinae plane block can be done with the patient in different positions.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We describe our experience with erector spinae plane block as part of a multimodal anaesthetic approach in thoracic surgery.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La anestesia multimodal, combinando catéter epidural y anestesia general, es una técnica habitual en cirugía torácica, sin embargo, la colocación del catéter epidural no siempre es posible.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Recientemente se ha descrito el bloqueo del plano del músculo erector de la columna, que proporciona analgesia similar a la del bloqueo epidural, aunque unilateral, y que se ha utilizado en diversos procedimientos a nivel torácico. En la actualidad no hay estudios que comparen la eficacia o la seguridad de este bloqueo con los habitualmente empleados en cirugía torácica. Sin embargo, su perfil de seguridad y contraindicaciones parecen diferentes a las del catéter epidural, ya que su colocación es ecodirigida, la introducción de la aguja se realiza mediante control en plano y la diana ecográfica, la apófisis transversa, es fácilmente identificable y está relativamente alejada de estructuras neurales o vasculares mayores y de la pleura. A diferencia de otros bloqueos realizados por referencias anatómicas, el bloqueo del plano del erector de la columna puede realizarse con diferentes posiciones del paciente.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Describimos nuestra experiencia con el bloqueo del plano del músculo erector de la columna como parte de un abordaje anestésico multimodal en cirugía torácica.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Luis-Navarro JC, Seda-Guzmán M, Luis-Moreno C, López-Romero JL. Bloqueo del plano del músculo erector de la columna en 4 casos de cirugía torácica videoasistida. Rev Esp Anestesiol Reanim. 2018;65:204–208.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 701 "Ancho" => 950 "Tamanyo" => 72835 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Horizontal ultrasound image of the vertebra.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">AE: spinous process; AT: transverse process; L: lamina.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 519 "Ancho" => 950 "Tamanyo" => 79679 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Inserting the needle in plane. The image shows T8, cranial to the left.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AT: transverse process; MEC: erector spinae muscle; MT: trapezius.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 539 "Ancho" => 950 "Tamanyo" => 81154 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Test injection. The image shows T8, cranial to the left.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AT: transverse process; HD: linear spread of local anaesthesia, which raises the erector spinae muscle; MEC: erector muscle of the spine; MT: trapezius.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 708 "Ancho" => 950 "Tamanyo" => 146712 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Tomographic image of T5 and adjacent structures. The muscular plane (trapezius, rhomboid, and erector spinae) is marked with an asterisk. The target injection site is marked with an arrow. Observe the distance to the neuroaxis, the pleura and major vascular structures.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VAS</th><th class="td" title="table-head " align="left" valign="top" scope="col">Observations \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">30<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No iv analgesia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain in centre of chest after eduction, 4<span class="elsevierStyleHsp" style=""></span>mg morphine<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h metamizol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain in centre of chest after eduction, 4<span class="elsevierStyleHsp" style=""></span>mg morphine<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>increased infusion rate through ESP catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patient 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No iv analgesia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1727270.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Evolution of pain in the postoperative period.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. 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