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Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 38-40

Erector spinae plane block for postherpetic neuralgia in a patient on anticoagulants

Department of Pain Medicine, Malabar Institute of Medical Sciences, Kozhikode, Kerala, India

Date of Submission22-Dec-2020
Date of Acceptance22-Jan-2021
Date of Web Publication22-Oct-2021

Correspondence Address:
P T Najwa
Department of Pain Medicine, Malabar Institute of Medical Sciences, Kozhikode, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_16_20

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Severe neuropathic pain in postherpetic neuralgia (PHN) is challenging for physicians especially in patients with altered hemostasis. Several interventional techniques have been described in the literature to treat this refractory pain. We report the successful management of PHN with thoracic erector spinae plane block in a patient on anticoagulants.

Keywords: Anticoagulants, erector spinae block, postherpetic neuralgia

How to cite this article:
Najwa P T, Nishad P K. Erector spinae plane block for postherpetic neuralgia in a patient on anticoagulants. J Recent Adv Pain 2020;6:38-40

How to cite this URL:
Najwa P T, Nishad P K. Erector spinae plane block for postherpetic neuralgia in a patient on anticoagulants. J Recent Adv Pain [serial online] 2020 [cited 2023 Jan 29];6:38-40. Available from: http://www.jorapain.com/text.asp?2020/6/3/38/329010

  Introduction Top

Herpes zoster is caused by the reactivation of the latent varicella-zoster virus. Acute severe pain and postherpetic neuralgia (PHN) is a feared complication of herpes zoster infection. The pain of PHN is typically described as lancinating or electric shock-like sensation along the dermatomal distribution of the rash caused by herpes zoster and usually associated with allodynia. Acute and chronic postherpetic pain is treated with medical management in the form of anticonvulsants and antidepressants. However, patients with severe pain refractory to medical management or developing intolerable adverse effects to medications should be offered interventional pain management options. A variety of interventional procedures have been described for the treatment of refractory pain, including intercostal nerve blocks, thoracic paravertebral blocks, epidural steroid injections, thoracic sympathetic blocks, pulsed radiofrequency ablation of the dorsal ganglion, and spinal cord stimulation.[1],[2] But most of these procedures are contraindicated in patients on anticoagulants. Ultrasound (US)-guided erector spinae plane (ESP) block is a relatively new interfascial plane blocks that target the dorsal and ventral rami of the spinal nerves.[3] We describe the management of refractory PHN pain with thoracic ESP in a patient on oral anticoagulants.

  Case Report Top

Our patient, a 70-year-old female (160 cm, 70 kg), was a known case of hypertension and with a history of deep-vein thrombosis on warfarin 5 mg daily for the past 1 year. She developed herpes zoster along left T2–T4 dermatomes 6 weeks back and was treated by primary physician with acyclovir and analgesics. She was referred to pain clinic with severe neuropathic pain over the left T2-4 dermatomes. Her pain was 9/10 in the numeric rating scale which was of burning in character and was associated with allodynia. The pain was affecting her sleep and she was not able to do her daily activities. She was already on pregabalin 75 mg, nortryptilline 10 mg, and tramadol 100 mg daily with minimal relief of pain. She was not allowing to increase the dose of medications due to drowsiness and dryness of the mouth. Hence, we planned for erector spinae block. The patient was counseled regarding the risks and benefits of the ESP block and consented to proceed with the procedure. We performed left-sided ESP block at the level of the T3 transverse process. A high-frequency linear-array transducer was used to identify the T3 transverse process by counting down from the first rib. The transducer was placed in a longitudinal parasagittal orientation to identify the tip of the transverse process deep to the overlying muscles. A 26G spinal needle (10 cm) was inserted in-plane to the US beam in a caudal-to-cranial direction to place the needle tip between the posterior fascia of the erector spinae muscle and the T3 transverse process. This was verified by hydrodissection with 0.5–1 mL of normal saline and visualization of linear fluid spread deep to the erector spinae muscle followed which 10 ml of 0.25% bupivacaine and 40 mg triamcinolone was injected [Figure 1]. Thirty minutes later, the patient reported significant improvement in pain (NRS decreased to 2/10 and absence of allodynia). Her pain relief persisted for 2 weekss then pain gradually increased but to NRS of 6/10 by end of 6 weeks. We repeated ESP block similiarly at 6 weeks and her pain remained 2–3/10 for the next 2 months and we tapered and stopped tramadol and she was continued on pregabalin and nortriptyline.
Figure 1: TP: Transverse process, TRZ: Trapezius, RHM: Rhomboids, ESM: Erector spinae muscle

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  Discussion Top

PHN refers to the chronic neuropathic pain that persists beyond the initial varicella-zoster rash. When pain is severe or not responding to medications various regional analgesia techniques are adopted. Sympathetic and somatic block techniques for treating herpetic pain include central neural blocks (mostly continuous epidural block), paravertebral blocks, stellate ganglion blocks, intercostal blocks, cervical plexus blocks, and intra-cutaneous injections. Intrathecal steroid and local anesthetic injections, various peripheral nerve blocks have also been used.[4],[5] However, most of these procedures are relatively contraindicated in patients on anticoagulants. Hence, we selected The ESP block in our patient who was on antocoagulants.

The ESP block is an interfascial regional analgesic technique that was described initially by Forero et al.[3] in 2016, to treat thoracic neuropathic pain. It consists of an US-guided local anesthetic injection in a plane between the erector spinae muscle and the underlying transverse process. The ESP block is easy to perform and to learn the technique with unique features compared to other interfascial blocks. The target point is a bone structure making the block execution really safe. The ESP block mimic paravertebral block. Even though the mechanism of action is not well established, several studies have shown the involvement of ventral and dorsal rami of spinal nerves by local anesthetics.[6],[7] This technique became popular soon in managing various acute and chronic pain due to its relative simplicity of performance and efficacy. This block has been adapted for acute and chronic pain control with ease and low complications for a variety of surgeries and conditions including spine surgery, breast surgery, limb amputation, video-assisted thoracoscopic surgery, rib fractures, PHN, complex regional pain syndrome, cardiac surgery, laparoscopic and open abdominal surgery, and hip surgery.[6] ESP blocks were also effective for pain relief in chronic thoracic pain, rib fractures, and pulmonary malignancy.[8],[9],[10] In one study they used the ESP block single-shot technique and catheter placement for acute and chronic herpetic pain respectively and they reported adequate analgesia for 3 months.[4] ESP block has been reported as useful in control of acute herpes zoster pain in emergency department.[11] One case repoted the successful use of lumbar ESP block for management of PHN in a patient with chronic lymphocytic leukemia.[12]

The ESP block is a superficial block compared to the epidural and paravertebral blocks, with a lower risk of hemorrhage, especially in patients with altered hemostasis, i e., the risk of spinal hematoma and spinal cord compression is lower, as the block is administered superficial to the transverse processes, allowing the spinal cord to be protected by the vertebral canal. It is potentially a safer alternative in the presence of contraindications to an epidural or paravertebral technique, including systemic anticoagulation, coagulation disorders, use of antiplatelet medications, and following heparinization.[13] There is a safe distance between the anatomical fascial plane and neuraxis or pleura, which renders this block suitable for patients with altered hemostasis under ultrasonographic guidance.

We performed ESP block using smaller guage needle (26G) and observed for paraspinal hematoma by clinical examination and US evaluation after 2 h and the next day. No complications were noted in our patient.

We conclude that the thoracic erector spinae plane block is a safe alternative to thoracic epidural or paravertebral block for the pain management of PHN in patients on anticoagulants. Further studies with an adequate sample size are required to confirm this.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cohen JI. Clinical practice: Herpes zoster. N Engl J Med 2013;369:255-63.  Back to cited text no. 1
Aggarwal A, Suresh V, Gupta B, Sonthalia S. Post-herpetic neuralgia: A systematic review of current interventional pain management strategies. J Cutan Aesthet Surg 2020;13:265-74.  Back to cited text no. 2
  [Full text]  
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 3
Aydın T, Balaban O, Ahiskalioglu A, Alici HA, Acar A. Ultrasound-guided erector spinae plane block for the management of herpes zoster pain: Observational study. Cureus 2019;11:e5891.  Back to cited text no. 4
Kim HJ, Ahn HS, Lee JY, Choi SS, Cheong YS, Kwon K, et al. Effects of applying nerve blocks to prevent postherpetic neuralgia in patients with acute herpes zoster: A systematic review and meta-analysis. Korean J Pain 2017;30:3-17.  Back to cited text no. 5
De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: A systematic qualitative review. Minerva Anestesiol 2019;85:308-19.  Back to cited text no. 6
Ueshima H, Hiroshi O. Spread of local anesthetic solution in the erector spinae plane block. J Clin Anesth 2018;45:23.  Back to cited text no. 7
Forero M, Rajarathinam M, Adhikary S, Chin KJ. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series. Scand J Pain 2017;17:325-9.  Back to cited text no. 8
Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth 2017;118:474-5.  Back to cited text no. 9
Aydın T, Balaban O, Acar A. Ultrasound guided continuous erector spinae plane block for pain management in pulmonary malignancy. J Clin Anesth 2018;46:63-4.  Back to cited text no. 10
Tekin E, Ahiskalioglu A, Aydin ME, Sengun E, Bayramoglu A, Alici HA. High-thoracic ultrasound-guided erector spinae plane block for acute herpes zoster pain management in emergency department. Am J Emerg Med 2019;37:375.e1.  Back to cited text no. 11
Kumar A, Mistry T, Gupta N, Kumar V, Bhatnagar S. Lumbar erector spine plane block for pain management in postherpetic neuralgia in a patient with chronic lymphocytic leukemia. Indian J Palliat Care 2020;26:134-6.  Back to cited text no. 12
[PUBMED]  [Full text]  
Maddineni U, Maarouf R, Johnson C, Fernandez L, Kazior MR. Safe and effective use of bilateral erector spinae block in patient suffering from post-operative coagulopathy following hepatectomy. Am J Case Rep 2020;21:e921123.  Back to cited text no. 13


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