High thoracic erector spinae plane block for forequarter amputation: A new perspective

Dear Editor, Erector spinae plane block (ESP) is a relatively novel technique for managing patients with acute and chronic pain and postsurgical pain. It can be performed as a single-shot injection or a catheter placed in situ for continuous injection.[1] Literature has mentioned its successful application at T5–T7 levels or lower thoracic and lumbar levels.[2] We share our experience of using ESP block at T1–T2 level with effect from C4 to T4 dermatome. A 76-year-old female patient weighing 59 kg was posted for forequarter amputation of ulcerative growth on the lateral aspect of the arm up to the right deltoid region and posteriorly extending over the back [Figure 1], with limited range shoulder joint movement. It was diagnosed as squamous cell carcinoma of right arm and shoulder. She had received 10 cycles of palliative radiotherapy (30 Gy) and two cycles of chemotherapy (5-Fluorouracil + Cisplatin) one year back. She had no other comorbidity.Figure 1: Ulcerative lesion of right arm and shoulderThe patient was planned for forequarter amputation under general anesthesia. Preoperatively, single-shot unilateral ESP block was given to the patient in sitting position at T1–T2 interspace, using 18 G Tuohy needle under ultrasound guidance (Sonosite EDGE II) [Figure 2]. Fifteen ml of 0.25% ropivacaine with 4 mg of dexamethasone was injected with visualization of its spread between the deep cervical muscles and the middle and posterior scalene muscle. Sensory examination after giving the block exhibited loss of cold sensation at C4 to T4 dermatome. The patient was then premedicated with midazolam (1 mg), fentanyl (2 mcg/kg), and induced with propofol (2 mg/kg) and rocuronium (0.6 mg/kg). The patient remained hemodynamically stable intraoperatively. Postoperative pain intensity was assessed using numeric rating scale (NRS). NRS at rest was 1 and 2 at movement in the immediate postoperative period. Twelve hours after the surgery, NRS was 2 at rest and 3 on movement. Rest of the hospital stay was uneventful.Figure 2: Ultrasound image of ESP blockAcute postoperative pain is a severe pain that most surgical patients experience after surgery. In case of amputation, it can lead to the development of residual pain and phantom limb pain. This can be avoided by regional anesthesia.[3] ESP block is relatively easy to apply and the complication rate is also less with ESP block compared to the epidural and para-vertebral block.[4,5] Insertion of the catheter for continuous injection of the drug is the best way to provide postoperative analgesia but this could not be done in our case because the surgical field was expected to encroach up to the erector spinae muscle, so there was a chance of catheter coming in the surgical field which could have led to catheter tearing or shearing. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.