1. 2022;25;483-490Comparison of Thoracic Erector Spinae Plane Block With Thoracic Paravertebral Block for Pain Management in Patients With Unilateral Multiple Fractured Ribs
   Randomized Trial
   Abdelraheem Elawamy, MD, Mohamed R. Morsy, MD, and Mohamed A.Y. Ahmed, MD.

BACKGROUND: Rib fractures occur most commonly because of blunt thoracic trauma and occur in up to 12% of all trauma patients. Adequate analgesia is paramount in enhancing pulmonary hygiene aimed at preventing atelectasis and pneumonia. Erector spinae plane block, one of the novel multiple thoracic ultrasound-guided techniques, can provide analgesia to both the anterior and posterior hemithorax, making it particularly useful in the management of pain after extensive thoracic trauma.

OBJECTIVES: This work aimed to compare the analgesic efficacy and safety of ultrasound-guided erector spinae plane block versus ultrasound-guided thoracic paravertebral block in patients suffering multiple rib fractures.

STUDY DESIGN: A double blinded randomized clinical trial.

SETTING: A university hospital.

METHODS: The study was conducted with 60 patients with multiple fracture ribs. Patients were randomly allocated into 2 equal groups of 30 patients.

RESULTS: Both techniques were effective in reducing pain scores and opioid consumption with no significant difference between the 2 groups. Time to first analgesic administration was comparable between the 2 groups. Twenty patients in the thoracic erector spinae plane group required rescue morphine compared to 17 patients in the thoracic paravertebral block group (P > 0.05). Visual Analog Scale scores at rest and on coughing were also comparable between the groups at all measuring points except at 0.5 hours following the block performance. Occurrence of hypertension was higher in the thoracic paravertebral block group compared to the thoracic erector spinae plane group (P = 0.024).

LIMITATIONS: There was no catheter inserted and we use intermittent injections, which is not the ideal, continuous block with fixed catheter is the ideal. We use dexamethasone as adjuvant with local anesthetics, which delay the need for booster dose of local anesthetics and make comparison between the 2 techniques not ideal. The sample size is small to some extent. We did not exclude addict patients.

CONCLUSION: Ultrasound-guided thoracic erector spinae plane block was as effective as thoracic paravertebral block for pain alleviation in patients with unilateral multiple fractured ribs with a comparable duration of analgesic effect, reduction of opioid consumption, and stable hemodynamic profile. However, thoracic erector spinae plane block had the advantage of a lower adverse effect incidence. Clinicians could choose either of the 2 techniques according to their clinical experience and personal choice.

KEY WORDS: Multiple fracture rib, anesthesia, ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TBVP), rescue analgesia, visual analog scale, pain