Analgesia Clinical Trial
Official title:
Erector Spinae Plane Block for Video-assisted Thoracoscopic Surgery: a Randomized Controlled Trial
Video-Assisted Thoracoscopic Surgery (VATS) is a minimally invasive surgery that utilizes camera based scopes and specialized instruments through keyhole sized ports to remove lesions in the thoracic cavity. Despite reduced surgical trauma compared to the traditional thoracotomy approach, patients continued to experience moderate to severe postoperative pain. Pain medication such as opioids is commonly utilized for postoperative pain control but is associated with side effects. The use of nerve blocks, such as the recently described erector spinae plane block (ESPB) has been shown in case reports to reduce pain and thus has the potential to improve patient recovery and decrease the risk of pulmonary complication. This study aims to investigate the analgesic effect of ESPB in managing pain following VATS.
VATS is a minimally invasive surgical technique to remove intrathoracic lesions. Using a
camera based scope and specifically designed instruments, the surgery can be initiated with
three "key-hole" sized incisions. At the end of the surgery, an incision is enlarged to allow
removal of surgical specimen. Chest tubes are inserted at the end of procedure and sutured in
between the ribs.
While acute pain after VATS is less than the traditional thoracotomy, patients still
experience moderate amount of pain within the first 24 hours. Source of pain may be from
diaphragm irritation, surgical incisions and chest tubes. Because of its origin on the chest
wall, pain from VATS worsens with breathing. When pain is poorly controlled, it will lead to
a shallow breathing pattern called "splinting" and this can progress to respiratory distress
or failure. Given the high incidence of smoking history in this patient population, many
would have presented with poor baseline respiratory function. Therefore, it is important to
provide good pain control to allow deep breathing and cough to reduce respiratory
complications[1][2].
Despite the smaller incisions, the incidence of chronic post-surgical pain (CPSP) after VATS
is surprisingly similar to thoracotomy. The mechanism may be due to nerve compression by the
trocar, an instrument inserted between the ribs to allow smooth manipulation of camera and
surgical instruments in the thoracic cavity. Additionally, poorly controlled acute pain has
also been postulated to lead to the development of CPSP, further emphasizing the importance
of good analgesia[1].
Many regional analgesia techniques have been tried to improve postoperative analgesia.
Thoracic epidural analgesia (TEA) remains the gold standard of pain control after thoracic
surgery. Although it provides superior analgesia, its use is hindered by the rare but serious
complication of epidural hematoma and abscess which may cause paralysis. Further, pain from
VATS tends to be short-lived (less than 24 hours), making the risk to benefit ratio less
ideal for TEA. An alternative to TEA is paravertebral block (PVB). Compared to TEA, it causes
less hypotension and hematoma or abscess at the paravertebral space may be less
consequential. Nevertheless, PVB is a deep block and is technically demanding which limits
its wide adoption[3].
Erector spinae plane block (ESPB) is a novel nerve block that has been used for analgesia for
surgeries of the chest and abdominal wall. Using a bony structure, the transverse process, as
the end point, the block needle is very unlikely to cause injury to vital structures as is
possible with TEA or PVB (for examples, the spinal cord, lungs and blood vessels). It is also
technically easy to perform. ESPB has only been reported in case series but so far, no
adverse events such as hypotension, hematoma or infection has been reported. ESPB has also
showed promise in managing CPSP after thoracic surgery in a small case series[4].
Given its safety, ease of performance and efficacy, the study aims to study the analgesic
efficacy of ESPB in addition to systemic analgesia compared to systemic analgesia alone in
patients undergoing VATS. The hypothesis is that ESPB and systemic analgesia will provide
better analgesia when compared to systemic analgesia alone.
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