Introduction: Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL) can be associated with significant postoperative pain and opioid requirements, which may prevent timely discharge and recovery. The erector spinae plane (ESP) block, first described as a single injection for treating thoracic neuropathic pain, has been applied to retroperitoneal surgeries. We sought to study whether continuous ESP blocks—either via continuous pump infusion or by single injection at time of surgery—lead to better postoperative pain control and decreased opiate requirements after PCNL.
Methods: We retrospectively reviewed PCNL cases in patients without chronic opiate use and without comorbidity resulting in moderate or severe functional limitation who stayed in house for at least 23 hours. Those who accepted an ESP block were compared to those who did not receive a block. For block administration, patients were positioned prone and ultrasound guidance was used to advance a catheter to the depth of the erector spinae muscle plane superficial to the 10th transverse process. Patients received either a single injection or a disposable ambulatory pump delivering intermittent boluses of ropivacaine 0.2% (15mL automatic bolus every 2 hours with 5 ml patient-controlled bolus available every 30 minutes). Demographic and perioperative data were analyzed. The primary outcomes were opiate use measured in morphine equivalent dose (MED) and patient reported pain scores during the first 24 hours of hospitalization, as assessed by nursing staff at regular intervals.
Results: 44 patients were identified from March 2019 to August 2021. Average stone size 27.6 8.6-53) mm and operative time 99 (49-170) minutes. 31 patients received an ESP block, of which 16 were continuous blocks. The patients who received blocks had significantly decreased opiate use (18.1 vs 89.7mg MED, p=.0090), lower self-reported pain scores during the first 24 hours after surgery and higher reported satisfaction with the procedure. Continuous blocks had similar opiate use to single shot blocks (20.3 vs 15.7mg MED, p=.53), but patients experienced longer duration of self-reported pain control. Patients reported ease of use with the disposable pump system.
Conclusions: Erector spinae plane blocks offer an effective adjunct method for pain control after PCNL. Continuous ESP blocks may offer superior duration of pain control, decreasing the need for opiates and possibly enhancing the recovery process via a pump that can be taken home. This approach can help facilitate same day surgical discharges as well as opiate sparing surgical pathways.