Transcript
- [Chris] All right, well welcome everybody.
My name is Chris Pennell.
I'll be moderating today's webinar.
Welcome to the rerun of the Behind the Scan Webinar
titled Opioid Sparing US
Ultrasound Guided Regional Anesthesia Technique
for Pain Management After Spine Surgery.
Before we begin, I just have a few things to cover.
All attendees are muted and we will be conducting
Q&A session at the end of the presentation.
However, we're currently broadcasting this webinar
on multiple platforms
and in order to ask those questions you must be
on the main Zoom stream.
We also have Jody from Sonosite here
to answer your questions
so you can type your questions into the Q&A box
on the toolbar located at the bottom
or the side of your screen.
Feel free to enter them throughout the presentation
and we'll get to those once the main presentation is over.
This webinar will be recorded and archived
for future reference on our webinars page.
Here today we have Dr. Theresa Bowling.
Theresa Bowling is a recognized leader
in regional anesthesia training,
acute pain management program development
and enhanced recovery after surgery program implementation.
From 2008 to 2015,
she developed and led the regional anesthesia program
at the Stanford Hospital, which was awarded
a Center of Excellence designation in 2010.
In 2012 she found the Stanford School
of Regional Anesthesia.
In 2017, Dr. Bowling joined Integrated Anesthesia Associates
where she's the director of regional anesthesia
and joined the faculty of Quinnipiac University,
Frank H. Netter School of Medicine
as an assistant professor,
she's a board member
of the Connecticut Quality Surgical Collaboration
where she serves on the ERS Task Force Committee
for Connecticut.
Thanks for Dr. Theresa Bowling for recording this earlier
and I'll get this recording started now.
- [Theresa] Welcome to the webinar talking about
erector spinae blocks for spine surgery.
Something I'm really passionate about.
I really didn't know much about erector spinae blocks
prior to the summer of 2020
when we introduced it to our practice for spine surgery
and since then I've had a tremendous amount of experience
with the block and I've really seen the dramatic effect
it's had on our patients from pre block spinal fusion
to post block spinal fusion.
So I can hope I can share my enthusiasm about this block
with you, teach you about the anatomy, the technique,
share some exciting data we've published
and entertain some questions at the end of the webinar
and certainly feel free to contact me at any time
via my email address, which Laura will share
with you, going forward, I love answering questions
and if I can help anybody get their program off the ground,
I'm happy to share the success we've had at St. Vincent's.
So my perspective is unique
in some respects because of access to a lot
of different practice cultures.
I'm a partner at Integrated Anesthesia Associates,
which is the largest physician-owned private practice
in the state of Connecticut.
We service over 34 practice locations
that include private community hospitals,
academic hospitals.
We have a regional anesthesia fellowship
at St. Vincent's Medical Center
and we also have ASCs where we do outpatient joints
and spines where we do nerve blocks for all of our patients.
We're also a teaching hospital for Quinnipiac
where we have medical students
and we also have student CRNAs from Yale
and from Quinnipiac.
So we have a private community hospital
at St. Vincent's Medical Center
with a real academic flare providing a unique culture.
Hartford Hospital purchased Mid-State Medical Center
where they created
the first Connecticut Orthopedic Institute
and that is Meriden, Connecticut
in the center part of the state.
The collaborations between the surgeons in the hospital
was really unique in the state of Connecticut
and it was really created a tremendous culture
of patient care and quality outcomes.
The orthopedic center there became successful
very quickly and subsequently
when the Hartford Healthcare bought St. Vincent's in 2019,
they decided to open up
a second Connecticut Orthopedic Institute,
otherwise known as COI at St. Vincent's.
So we are known as COI South and COI North.
Both facilities are joint commission certified
for advanced total hip and total knee
and I'm excited to share
that our sister hospital in Meriden is also certified
in spine, which is unique to the state of Connecticut.
We are currently undergoing review
and preparation for joint certification, excuse me,
for joint commission certification for spine.
Really, you know, putting our quality of care specifically
with regional anesthesia high on the charts
and the new benchmark.
Between the two institutions,
we do about 3000 spine cases a year providing a large pool
of data that's created us the opportunity to publish
and really look at outcomes
and change our methods as needed
to really provide superior care.
In 2020, I was tasked with creating
an enhanced recovery after surgery protocol
at St. Vincent's.
So we reviewed the literature,
the team got together
and we decided we were going
to introduce erector spinae blocks for spine.
We're gonna talk now a little bit about
erector spinae blocks, how they work
and the anatomy and indications and contraindications.
It's a relatively newer interfacial nerve block.
First introduced in 2016 to treat neuropathic pain related
to metastatic disease to ribs.
Shortly thereafter got adopted for a chest wall surgery
for abdominal surgery,
but there wasn't a whole lot of literature related
to spine in 2019.
We did know it could be used for a wide variety
of procedures, however,
there was a positive literature related to its use
for laminectomies and spinal fusions.
The specific mechanism of action is still controversial,
however, there are some new hypotheses I'll share
with you briefly.
Like any other nerve block you have
to understand the gross anatomy, the neuroanatomy,
the sonoanatomy and technique,
all those four components are critical
to have a positive outcome and reliable
and predictable successful blocks.
If you look at the posterior wall of a patient,
the paraspinous muscles are divided into superficial
and deep muscles.
The muscles course bilaterally from the base of the skull
to the sacral region
and landmarks to remember as you're trying
to identify anatomy so that you place
the erector spinae block at the correct level
where the surgical stimulation will be
is the rhomboid muscle typically terminates
at the fifth thoracic vertebrae
and the distal edge of the scapula terminates
at the seventh thoracic vertebrae.
Needle placement is always in the paraspinal fascial plane
between the erector spinae muscle
and the transverse process,
you can achieve a multi dermatomal somatosensory block
due to cranial and caudal spread of local anesthetic
conceptually the same as an epidural.
Analgesia is achieved to the incision site,
the bony structures
and that's why it's so effective for spine surgery
and the surrounding tissues.
So when you introduce these blocks for spine surgery,
there's no need for the surgeons
to use local anesthetic in the subcu tissue
or around the incision site.
It also provides the added benefit of visceral analgesia.
This is a cross section
of the spine in the thoracic area showing
the three muscle layers from superficial to deep
and the needle insertion site is again at the distal edge
of the transverse process.
Now we know there's consistent involvement
of the dorsal rami across the entire course
of the spine, however there's variable involvement
of the ventral rami, it is more likely blocked
in the thoracic region.
It appears that the thoracolumbar fascia
likely plays a role, but in more recent cadaver studies
that I'll show you in a bit, it's unlikely that power
of vertebral spread, which we were thinking might be
a mechanism until recently.
Indications for this block are widespread.
We do use it at our institution for breast surgery.
Our cardiothoracic team uses for their thoracic cases,
large abdominal surgery, rib fractures
for pain related to trauma.
It is documented for hip surgery.
I have no experience with that.
We have a different protocol for our hips.
And of course, spine.
Contraindications are relatively few.
Like any other regional anesthesia, patient refusal,
infection at the site of an the injection site.
Anticoagulation is a relative contraindication,
so you really have to use your best judgment
and use a risk benefit profile.
If you don't already have the Azure app on your smartphone,
I highly recommend it for a reference
when you're deciding about whether to do regional anesthesia
in patients on anticoagulation.
Complications are also relatively few.
In 2019, in the Journal of Clinical Anesthesia,
there was a review of 85 publications from 21 journals
and the pooled review yielded 242 reported cases
between 2016 and 2018.
Infection, bleeding, epidural hematoma, pneumothorax,
epidural spread and failed block were all cited
although incredibly rare.
Local anesthetic toxicity is certainly a concern
with any kind of plane block
because of the large volume of local anesthetic being used.
So always be cognizant of the patient's weight
and the dose of local anesthetic you're using
when you're doing this block.
Now we're gonna talk about technique.
This block can be done in the sitting, prone
or lateral positions.
If you're doing a lumbar spine ESP, it's really critical
to use a curvy linear transducer and one of the examples
or clinical pearls from this is my partner up at Miss State
started doing these blocks after we introduced it
at St. Vincent's and had such great success
and she's excellent at regional anesthesia
and she was really struggling, which I found surprising.
So we kind of talked around what was going on
and they did not have a curvy linear transducer there.
So they got one and she immediately called me
and said it was a game changer.
So that is a really important clinical pearl
if you're doing this in the lumbar region
that you should definitely start
with a curvy linear probe if it's available.
As far as the other parts of the spine in the thoracic area,
it really just depends on the patient's anatomy.
I often start with linear,
but I don't hesitate to change
to a curvy linear if I'm having trouble
visualizing the structures.
And one of the key components of successful
of regional anesthesia is being able
to clearly see the anatomy so that you can put the needle
in the appropriate target.
We use a single shot technique for these procedures
for spine, obviously putting a catheter
in the erector spinae space in the spinal area
where the surgeons are operating would be technically
impossible and would be in the way.
And we do have access to long-acting local anesthetic,
which means that we can get a longer duration
of block without placing an indwelling catheter.
Our practice is to place these blocks in the operating room
after the patient goes to sleep,
whether they're in the prone position
or the lateral position,
depending on the surgeon's preference, you really have
to remember you have to do parallel processing.
So after these patients are flipped
or turned on their side, that's when we do the block.
We're immediately at the bedside.
All of our local anesthetic is drawn up,
we have a tegaderm on our transducer, we're ready to go.
So while they're doing the neuromonitoring setup,
we can place the block so we don't slow the surgeons down.
The most common reason for blocks not to be successful
or for regional anesthesia programs
to not get off the ground is
that the anesthesia team does not do parallel processing
and they wait to do sequential processing which slows
the procedure down.
We use a parasagittal approach,
which is the most common approach for this block.
We start our scan in the midline over the spinous processes,
then we move the transducer laterally
until we see the transverse process
and we try to get the distal edge of the transverse process
to optimize the placement of the local anesthetic.
You can see the needle is an in-plane technique.
It doesn't matter if you go cephalad to caudal
or caudal to cephalad in this photograph.
The patient's head is at this end
and their feet is at this end.
It really depends on which side
of the patient you're standing on.
You don't switch sides for this block
and whether you're left-handed
or right-handed, the end result is the same
as long as you have the needle tip
between the erector spinae muscle
and the transverse process.
You can see here in this picture the needle coming in
in-plane hitting the transverse process
and the blue color here is representing the local anesthetic
dissecting the erector spinae muscle
off the transverse process.
For ultrasound imaging, the needle here is represented
with an orange dotted line.
The tip is on the transverse process.
You can notice they are using a curvy linear probe
because there is a deep level of penetration for the target.
The transverse processes are bony structures.
So you see the white hyperechoic bone
and the ultrasound beam is unable to penetrate the bones.
You see what's called the block,
the black bony dropout below.
Once you hit the bone, you cannot inject
because the tip of the needle is against a hard structure.
So you pull the needle back ever so slightly,
ask your assistant to aspirate and inject.
If you're in the right place,
the local anesthetic will spread, dissect the muscle
and spread from a cephalad
and caudal direction, giving you a multi dermatomal spread.
This is a pre-injection ultrasound image
and a post-injection image in the thoracic spine area.
In the TP4 and TP5 area.
So you have your three muscle layers here which are
identified in color here, your trapezius, your rhomboid
and your erector spinae muscle.
Your target would be here again deep
to the erector spinae muscle.
Post-injection, you'll see local anesthetic pooling
between the erector spinae muscle
and the transverse process.
And you can see that here identified transverse process,
local anesthetic, erector spinae
and more superficial muscles.
So like every other plane block,
this is a large volume block
and that's why you're always keeping local anesthetic
toxicity in the back of your head.
Having said that, I've been doing this for 25 years now.
I've only seen one case of local anesthetic toxicity
after an intra scaling block,
so it is still incredibly rare.
We do do this block for posterior cervical fusions
and that's where we do a decreased volume of 20 mls per side
of quarter percent Marcaine.
More recently we've started using EXPAREL
for our posterior cervical fusions
and for those we do 10 mls of EXPAREL
and 10 mls of quarter percent Marcaine.
We do not add Decadron if we're using EXPERAL.
For spinal fusions four levels or less,
we up our volume to 30 mls per side
and our add mixture for those procedures
are 10 mls of EXPAREL
and 20 mls of quarter percent Marcaine.
As our incisions and our operations get bigger
in spinal fusions for five levels or more,
we up our volume to 40 mls per side.
Again, we only use 10 mls of EXPAREL per side
and up our quarter percent Marcaine to 30 mls per side
for a total volume of 60 mls of quarter percent Marcaine
which is what we use for our tap blocks.
So we're very comfortable with this volume
of local anesthetic.
In this picture on the right hand side here,
I did this block for this patient
who had a nine level fusion.
For this case I did use the 40 mls per side.
However, once we get to above six levels,
I'll often split the levels
and do two injections a side
to really optimize my spread of local anesthetic.
There is studies on cadavers that shows that you get three
to four levels cranially
and caudally with an injection site of 30 CCs
of local anesthetic.
But more recently just published in Anesthesiology News
by Jeff Gadson of Duke was a review of craniocaudal spread
and lumbar ESP blocks
and looking at where the spread goes
based on anesthetic volume on cadavers.
In this image on the right, the red represents 10 mls
of local anesthetic injected.
The purple is 20 mls and the yellow is 30 mls.
And this is what they found.
There was actually no evidence
of epidural power vertebral spread in these cadavers
in the lumbar region.
There was no anterior spread.
So there is no interference with neuromonitoring
and that is a question your surgeons will ask you.
And having done about 500 of these cases at St Vincent's,
there's never been an issue with neuromonitoring.
So really a critical answer
you need to be prepared to give your surgeons.
As we expected, they got four levels of spread with 30 mls
of local anesthetic in the lumbar region.
However, because of anatomic differences
in the thoracic region,
you can get up to six levels of spread with 30 mls.
And that's why we do reduce our volume when we inject a T1
for posterior cervical fusions to 20 mls.
So does it really work for spine cases?
The answer is a resounding yes,
and we have the data to show you.
In 2020, as I mentioned,
and we started our erector spinae, sorry, 2019, 2020
as we got our erector spinae blocks off the ground
for lumbar spinal fusions,
we did a case series.
My partners, Dr. Vlad Frank, Robert Seriani
and David Verdurham and I got together
and we looked at 35 patients undergoing lumbar fusions
for erector spinae patients versus controls.
We injected in the lower lumbar spine in the areas
between L1 and L4
and we saw a decrease, significant decrease
of morphine consumption, opioid consumption
over the first 72 hours.
That poster was actually accepted
at the 74th PJA meeting last year,
which unfortunately was held virtually,
but we were really excited to get that off the ground.
So we went on to do a retrospective case control study
and we looked at 41 patients
and we saw a significant decrease in opioid requirements
at 24, 48 and 72 hours.
And this was presented at our recent ASA meeting
and actually got special recognition
and was in a special session
because the data was recognized as being
so clinically significant.
In this study, the blue are the control patients
and the orange are the ESP patients.
So you can see there is up to an 85% decrease
in narcotic consumption over the course of three days.
We also saw a meantime to first opioid
ingestion was up higher in the ESP group,
which you would expect because they had less pain.
The take home from this study was
that ESP blocks are an effective method
for postoperative pain management for open fusions.
We saw a decrease in opioid consumption up to 85%.
So our goal this year is to do additional investigations
to help determine the role for ESPs in terms
of other measures including rehab metrics,
quality of recovery and a cost benefit analysis.
This is a ultrasound video of an L4 ESP block I did.
You can see it's a curvy linear probe.
Here's the needle coming in.
The tip touches the transverse process
and you can see the spread
of the local anesthetic dissecting the erector spinae muscle
off the transverse process.
And the needle is here.
This can be a challenging block.
This is at about a 45 degree angle.
It's at large depth about six centimeters.
That's why linear transducer would not be helpful.
So sometimes you really can only see motion artifact
and the spread of your local anesthetic.
This really is less of an issue in the thoracic spine,
but in the lumbar spine, especially when the patient's
in the prone position where we do it in the operating room
and they're in a lordotic position,
often the visualization
is not as good as you'd like it to be.
Having said that, it's a very forgiving block
and if you see the local anesthetic spreading,
it's going to work.
So after we really hit home
that we were having tremendous success
with our lumbar ESP blocks
and we saw it from everybody, the recovery room nurses,
the physical therapist, the physician's assistants,
and the surgeons, they were asking us, well,
why aren't you doing this for cervical spinal fusions?
And the answer was, was because there was
nothing published on it.
However, at this point we felt comfortable proceeding
with a trial
to see if the blocks would work, and did they work?
Once again, the answer was resounding yes.
And if you ask our physical therapists
and our physician's assistants
who follow these patients postoperatively,
they will tell you that posterior cervical fusions actually
have significant more pain than lumbar fusions.
And the profound difference they saw in these patients
really astounded everyone on the team.
So we did the first case series of ESPs
for posterior cervical spine surgery patients.
That was also accepted at the IARS meeting
in May of 2021.
We saw the exact same results we saw in spine
for lower spinal fusions, including excellent analgesia
to multiple cervical levels due to the spread
of local anesthetic.
So we are confident that the combination of ESP blocks
with our ERAS protocol really
provided robust analgesia for these cases.
One thing I wanted to mention was we talk about morphine
equivalents because even though our patients
are on a protocol where they get Dilaudid postoperatively
when they go home or they're getting ready to go home,
different surgeons have different protocols
as far as what opioid they want to use.
So it would be challenging if we didn't compare it
into a single type of equivalent to figure out
what they were actually using.
So just to give you an idea what 24 looks like,
it essentially it's the equivalent of 1.2 milligrams
of IV dilaudid
or essentially 15 milligrams of PO Oxy.
So that's not a lot of opioid for the first 24 hours
of patients having major spine surgery, especially in light
of the fact our patients were getting Dilaudid PCA
for two days prior to this protocol.
It's a huge change.
We also tracked opioid consumption in the recovery room
and our goal for spine fusions is less than 30%.
And over the last year we've met that target consistently.
This is one of the patients we had
in the posterior cervical spine case series.
This patient's in the prone position,
their head is here and they're in pins.
I'm scanning the first thoracic vertebrae.
You can see the needle is a very acute angle when you get
to this level in order to achieve the target.
This is the ultrasound image we obtained
with the three muscle layers, the trapezius,
the rhomboid and the erector spinae.
There's the T1 transverse process.
My needle's coming in from the right hand side.
The needle tip is right above the transverse process
and this block area is the local anesthetic.
Now, I hadn't really thought of it
before we got in the room,
but of course the fluoro was there
'cause the surgeons were gonna do that
as soon as I was done with the block.
So I said to the radiology tech, why don't we take an x-ray?
And here it was, the needle tip
is right here on the first thoracic vertebrae.
Here's the ultrasound video,
the transverse process right here,
the erector spinae muscle.
The needle will be coming in from
the right hand side of the screen.
Now as you can see, I'm using a linear transducer.
This is a much more superficial block
and a curvy linear transducer would not be helpful.
The needle is gonna go right here.
The tip is there.
You can see the local anesthetic spreading cephalad.
Now often once I have some hydro dissection
with the local anesthetic, I'll readjust the needle
to really optimize my spread of local anesthetic.
In this case, I want it to go
to the left hand side of the screen.
So I know, or I'm very confident this is gonna be
a successful block
because you're seeing excellent spread of local anesthetic.
So in summary, I'm very confident
and I can tell you with the utmost certainty
that ESP blocks were safe, they're reliable,
and they provide predictable results.
Of course when they're done correctly.
They're simple to perform, they're simple to teach,
they provide excellent pain relief
for posterior spine surgery.
And we've seen with our protocol a decrease
in narcotic consumption by 85%.
And as a result of that, decrease in all the side effects
associated with narcotics.
At the end of the day, we have incredible
patient satisfaction.
Our surgeons are happy.
Our hospital has gone on a media blitz
talking about pain management, opioid reduction,
and using it as a marketing tool for our surgeons
to get patients from other hospitals
to come have surgery at our hospital.
So with that, I'd really love to entertain some questions
and certainly again, feel free to email me at any time.
- [Chris] So thank you all so much
for joining us here today.
Keep an eye on sonosite.com/behindthescanwebinars
for information on the webinars that are coming up next
and to make sure you are registered for those.
Thanks so much for joining us today
and we'll see you next time.
Watch Dr. Theresa Bowling, MD to explore Erector Spinae Plane (ESP) blocks for post-op pain management after spinal fusion surgery. Learn about their role in Enhanced Recovery After Surgery (ERAS) protocol for spinal fusion surgery, developed at Dr. Bowling's institution, and the subsequent research that shows a decrease in opioid use.
Learn more about
- ESP blocks in ERAS Protocol for spinal fusion surgery
- The critical role that ESP blocks play in ERAS protocols for spine surgery
- The use of ESP blocks for posterior cervical and lumbar spinal fusions
- How to utilize ESP blocks as part of a multi-modal pain management program to decrease the need for perioperative opioids
Dr. Bowling is the Director of Regional Anesthesia for the Integrated Anesthesia Associates and an Assistant Professor at Quinnipiac University, Frank H. Netter School of Medicine. She is also a board member of the Connecticut Quality Surgical Collaboration where she serves on the ERAS Task Force Committee for Connecticut.
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