The anatomical description of the erector spinae, paravertebral and epidural block for post-operative pain management in paediatric care.

Abstract

Summary The anatomical description of the erector spinae -, paravertebral - and epidural block for post-operative pain management in paediatric care

S Govender

Supervisor: Prof AN van Schoor Co-supervisor: Prof AT Bosenberg

Department of Anatomy: Clinical Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

The fundamental indicative constituent for any successful clinical procedure is patient satisfaction, which is directly related to post-operative analgesia. In paediatric care, due to the nature of the patient – and depending on the age group – it is often difficult, or even impossible, to fully understand the extent of pain perceived, leading to insufficient pain management. A variety of regional anaesthetic techniques have been thoroughly investigated for the ease of administration, as well as enhanced patient satisfaction. Coupled with image modalities, these blocks can be safe and efficient. However, these investigations mainly apply to an adult population. Paediatric procedures may be inaccurately extrapolated from an adult population, when the anatomical discrepancies that exist between population groups are not taken into consideration. Until recently, the gold standard for paediatric truncal procedures relied solely on paravertebral and epidural blocks. With the discovery of the novel interfascial erector spinae plane block, however, this is no longer the case. This block is hypothesised to target the ventral and dorsal rami of spinal nerves, as local anaesthetic is deposited into the erector spinae fascial plane space. The therapeutic effect of the block is attributed to the cranio-caudal spread of anaesthetic over multiple vertebral levels within the tissue plane. This ‘happily accidental’ block serves as a “paravertebral block by proxy” and is an alternative approach, targeting similar nerves as in the paravertebral and epidural blocks. However, the anatomy of the erector spinae plane block is not fully understood. This study aimed to investigate the anatomical differences of these three blocks for the management of post-operative pain in paediatric care, based on observations and measurements from a fresh paediatric cadaver sample, as well as ultrasound and computed tomography scans. Apart from the easily identifiable bony landmarks, together with the distant application of the erector spinae plane block, the block offers a higher safety profile with various clinical advantages such as improved pre- and post-operative pain management, as well as reduced opioid requirement. In conclusion, it is vital to acknowledge the anatomical differences that exist in a paediatric population for the safe and successful administration of any regional technique to improve the management of pain in a vulnerable population.

Keywords: Erector spinae plane block, paravertebral block, epidural block, interfascial block, paediatric, regional anaesthesia, pain management