Update in Pediatric Regional Anesthesia

Erector Spinae Plane Catheters for Posterior Spine Fusion Surgery Postoperative Pain Management

By Carole Lin, MD; Stephanie Pan, MD; Ban C.H. Tsui, MD
Lucile Packard Children’s Hospital at Stanford
Stanford University School of Medicine
Stanford, California

Pain management following posterior spine fusion and instrumentation continues to be a challenge. One factor stems from the approach and application of pain management techniques from the adult environment directly to the pediatric setting. Although enhanced recovery after surgery (ERAS) protocols for pediatric posterior spine fusion (PSF) often include a multimodal approach, a standardized approach has been difficult to establish. Some protocols incorporate intrathecal morphine or epidural techniques, but the use of new regional anesthesia techniques remains limited. We briefly explore the differences between adult and pediatric PSF, describe the current techniques for postoperative pain management, and introduce a new technique involving erector spinae plane (ESP) catheters that has the potential to play a key role in ERAS protocols for pediatric patients undergoing PSF.

Pediatric PSF surgery differs from adult spine surgery in several ways. Pediatric PSF typically involves multiple levels with increased torque on the musculoskeletal system to correct for scoliosis. Adult posterior spinal fusions rarely involve the whole spine. Disease processes such as degenerative disc disease, disc herniation, spondylolisthesis, or spinal stenosis require short segment repair where stabilization is the goal.  In fact, many adult surgeries have adopted more minimally invasive approaches that are difficult to translate to the more extensive pediatric surgical instrumentation. Adult patients are commonly exposed to higher rates of chronic pain and opioid use prior to surgery as compared to pediatric patients.3,4 Pain management for pediatric patients can be complicated by additional comorbidities such as neuromuscular syndromes, hypotonia and congenital cardiac disease. Minimizing opioids for pain management is desired due to the risk of hypoventilation and airway obstruction. The cognitive and psychological development of a child and adolescent also greatly impacts the perception of pain.

ERAS protocols for pediatric posterior spine fusion surgery currently relies on opiates with large variations in the dosing protocol and combination of opioid-sparing agents such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, and anti-spasmodic agents. These evolving pain regimens have shown improved pain scores and decreased opioid consumption in the pediatric population.5

Since its use as early as 1985,1 intrathecal morphine (ITM) has been beneficial in postoperative pain management while reducing intraoperative blood loss, transfusion requirements, and hemodynamic fluctuations.6 The intraoperative advantages have more recently been explained by achieving lower blood pressure7 which can also be achieved by systemic narcotic infusions.8 Unfortunately, ITM does not provide pain coverage throughout the duration of a patient’s hospital stay and includes side effects such as pruritis, nausea, and vomiting.

 In 2003,10 epidural catheters were introduced as a pain management adjunct. Over time, there has been moderate to low quality evidence11 of significantly decreased postoperative pain in the first 72 hours with local anesthetic infusions without opioids possibly improving postoperative ileus. Complications such as respiratory depression, wound infection, epidural abscess, neurological deficits from epidural placement in these patients were rare. A separate review by Tobias et al. in 2004, accounting for different epidural techniques (e.g. single vs. double catheter placements, local vs. narcotic or combination infusions with adjuncts, as well as infusion vs. bolus delivery methods), cite equivalence of analgesia efficacy,12 possible decrease in opioid requirements and possible increase in return to normal gastrointestinal function.13

Erector spinae plane catheters have been utilized for postoperative pain control in various pediatric surgical procedures including cardiothoracic surgeries,15 palliative abdominal and thoracic pain management,16 breast surgery,17 pelvic and hip surgery.18  To date, no complications have been reported. Recently, there have been a few case reports of ESP blocks for multi-level posterior spine fusion. These cases involve adult patients where either single injection ESP blocks were performed prior to surgical incision or ESP catheters were placed during the postoperative course following recent spine surgery. 20,21,  For example, Chin and Lewis  described a case of opioid-free perioperative analgesia by performing bilateral ESP single injections prior to incision for a 35-year-old patient undergoing a T2 to T8 revision repair of scoliosis.23  The only report of a pediatric patient involves placement of bilateral ESP catheters in a 17-year-old patient undergoing a Ravitich procedure for the correction of severe pectus excavatum in the presence of Harrington rods from a previous posterior scoliosis repair.24

In 2020, Tsui et al. reported the use of bilateral ESP catheters in a 16-year-old after posterior spinal fusion for adolescent idiopathic scoliosis.25 The patient notably did not report any muscle spasms with activity and was discharged on day two. Since this case report, our institution has placed bilateral ESP catheters in over 20 healthy adolescent patients undergoing posterior spine fusion for adolescent idiopathic scoliosis. These ESP catheters are placed with direct visualization after correction and decortication. The catheters are positioned lateral to the rods posterior to the transverse processes with insertion points 3-4 cm cephalad of the surgical incision.  Lidocaine is administered through each ESP catheter after the overlying erector spinae muscle and fascia are closed. Neuromonitoring is continued for at least 20 minutes after the lidocaine boluses to assess for spread to the epidural and intrathecal spaces. Lidocaine boluses are continued every hour for three postoperative days with daily serum lidocaine concentrations to monitor toxicity for the duration of the catheters. A multimodal analgesia ERAS protocol is implemented in conjunction with the ESP catheters.

Our experiences thus far since incorporating bilateral ESP catheters for PSF has been a trend towards earlier physiotherapy, lower pain scores and opioid consumption, and decreased lengths of stay. Although our sample size is small, we are cautiously optimistic in the potential implications of this new application of regional anesthesia for spine surgery. 

There are several advantages of the ESP block over current neuraxial techniques. The location of catheters on both sides of the spinal column ensures more optimal spread bilaterally as compared to a centrally placed epidural catheter. Although the presence of a catheter for both techniques is a potential risk, there have been no reports of retained or broken ESP catheters to date as compared to case reports of retained epidural catheters.26,27 Care must still be taken when removing the ESP catheters and when dressing the insertion sites once the catheters are removed to decrease the potential risk of infection from the external environment to the internal hardware. 

Lidocaine is our preferred local anesthetic for the ESP catheters given our familiarity with its pharmacology in ESP catheters for congenital cardiac ERAS cases21. Lidocaine’s rapid onset and offset allow for quicker detection through intraoperative motor evoked potential neuromonitoring in the case of inadvertent spread to the epidural or intrathecal spaces.  Serum lidocaine concentrations are easily measurable and have a faster response time as compared to other local anesthetics. Among both cardiac and spine cases, serum lidocaine concentrations have peaked around 2-2.5 mg/mL, well below the toxicity threshold of 5 mg/ml. In addition, lidocaine has known systemic analgesic, anti-arrhythmic, and antimicrobial properties.29

Overall, the preliminary results of placing ESP catheters in healthy patients with adolescent idiopathic scoliosis undergoing posterior spine fusion are promising. We have seen little to no opioid use immediately after surgery, lower overall pain scores, decreased time to ambulation, and earlier hospital discharge times without any complications. Despite these results, we remain cautious in our application of such a novel use of regional anesthesia for spine surgery. Future investigations are required to further elucidate the efficacy, safety, and optimal dosing and placement of the ESP catheters. Prospective studies directly comparing the various regional and neuraxial techniques, as well as various ERAS protocols, will guide the optimal standardization of pain management techniques to improve the care of pediatric patients undergoing posterior spine fusion.

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