Opioid-sparing multimodal analgesia with bilateral bi-level erector spinae plane blocks in scoliosis surgery: a case report of two patients

Purpose Postoperative pain following scoliosis correction surgery is severe and usually requires prolonged intravenous opioid therapy. Regional anesthesia options are limited and include intrathecal opioid and epidural analgesia; however, they remain little used because of side effects and inconsistent efficacy. We describe a novel multimodal anesthetic regimen incorporating bilateral bi-level erector spinae plane (ESP) blocks together with a combination of several evidence-based intraoperative opioid-sparing analgesic strategies. Methods Two healthy young adult patients with idiopathic scoliosis underwent posterior spinal fusion involving 12 vertebral levels (T2-L1 and T3-L2). Bilateral single-injection ESP blocks were performed at two levels (T4 and T10) prior to incision. Intraoperatively, patients received intravenous dexamethasone and infusions of dexmedetomidine and ketamine for multimodal analgesia. Remifentanil was omitted from the total intravenous anesthetic regimen to avoid opioid-induced hyperalgesia. Results Both patients had minimal pain on emergence. They transitioned successfully to oral analgesia on the first postoperative day, with modest opioid requirements, no side effects, and low pain scores throughout their hospital stay. Conclusion Bilateral bi-level ESP blocks are a simple method of providing pre-emptive regional analgesia in extensive multi-level spine surgery. Integration of ESP blocks into a multimodal regimen that employs other opioid-sparing strategies may have additive, and potentially synergistic, benefits in improving postoperative analgesia and reducing opioid requirements.