Single continuous erector spinae plane block for multiple rib, clavicle, and scapula fractures: A case report

The aim of this study is to describe the ability of a continuous erector spinae plane (ESP) block to provide analgesia in an extended territory (brachial plexus and thoracic nerves) with a single catheter. A continuous ESP block at T4 was performed in a 74-year-old man, two days after trauma involving clavicle, scapula, and multiple posterior rib fractures (first to ninth). The technique was maintained for 12 days and provided effective analgesia not only to the thoracic region but also the scapula and clavicle area (C5-T12 dermatomes). Concomitant respiratory insufficiency was ameliorated, which helped to avoid mechanical ventilation and intensive care unit admission. Moreover, this analgesia technique promoted patient's ambulation. ESP block, as an alternative to a thoracic epidural, is a more straightforward and safer procedure than paravertebral block (PVB). To obtain an extensive dermatome block using PVB, more than one paravertebral catheter would be necessary. Extensive cephalad-caudad spread of the PVB is primarily related to analgesia due to the concomitant epidural spread. PVB frequently causes bilateral block and may produce significant motor or sympathetic block. Additionally, proximal extension of the block under the erector spinae muscle fascia can provide a significant extension of the block to the cervical region, which allows brachial plexus block (cervical plexus block was not observed clinically). This is a unique feature of ESP block, as there is no communication between adjacent paravertebral levels in the cervical region that could allow the same pattern of analgesia using PVB.