Erector spinae plane block for relief of chronic intercostal neuralgia after chest tube placement

The erector spinae plane (ESP) block is a regional technique that can be used to provide analgesia for a variety of acute and chronic pain indications. This block is relatively new as the first reported successful use of this procedure was in 2016 to manage thoracic neuropathic pain in a patient with metastatic disease with rib fractures [1]. The usage of this block has expanded dramatically in acute pain management for a variety of surgeries including thoracotomies, ventral hernia repairs, and even lumbar fusions [2, 3]. The block is relatively easy to perform and continues to have an expanding role in the perioperative and acute postoperative setting. Interestingly, this block has been infrequently used in the setting of chronic pain but has been slowing increasing in popularity. There have been reports of both single shot use as well as long-term catheter placements for chronic pain as well as palliative pain control [4, 5]. We describe an interesting case with the use of this block at our pain clinic for the treatment of chronic intercostal neuralgia after a history of chest tube placement.
The patient was a 45-year-old male with a past medical history of viral pericarditis with recurrent pericardial and pleural effusions requiring bilateral chest tube placements and drainage. His recovery was complicated by chronic intercostal neuralgia and chest wall pain that was not relieved with conservative therapy. The patient had bilateral chest wall pain with right sided pain more axillary and left sided pain more posterolateral. The pain was sharp and burning in nature, averaging 7/10 in intensity on a numerical rating scale. He reported severe pain with sneezing and deep breathing, and that his pain was especially problematic at night and interfered with his sleep. The patient tried a variety of medications for pain control including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), lidocaine patches, neuropathic medications, as well as tizanidine. He was also using opioids at night to help him sleep. Given that the patient failed a variety of medications for his pain control we opted to try an ESP block for his pain.
We initially performed the block on the right side under ultrasound guidance at the T8 level using an 8 cm, 22 G, sonovisable needle. We used 8 mL of 1% lidocaine with 2 mL of 4 mg mL-1 dexamethasone for a total of 10 mL volume of injectate for this block. The block was performed using an in-plane technique and...


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