Background:
Although, intercostal nerve blocks are sometimes approached with caution due to concerns about potentially high local anesthetic uptake, they remain a valuable tool in specific clinical situations. On the other hand, the erector spinae plane block is nowadays often favored for its broader coverage and versatility. We hypothesized that the intercostal nerve block, applied directly by surgeons under direct vision in patients undergoing uniportal video-assisted thoracoscopic surgery, might offer superior analgesia and fewer complications compared to the erector spinae plane block.
Methods:
In this multi-center, double-blind placebo controlled, randomized trial, 100 patients undergoing uniportal thoracoscopic surgery (wedge excision or lobectomy) within an enhanced recovery program received either a surgical intercostal nerve block under thoracoscopic guidance or an ultrasound-guided erector spinae plane block, followed by 30 ml of ropivacaine 0.5% (n=50) or saline (n=50). Primary outcome measured was 12-hour morphine consumption post-extubation. Secondary outcomes included 24-hour morphine use, pain severity, rescue analgesia need, postoperative complications, and length of stay. Plasma levels of local anesthetics were also assessed.
Results:
The intercostal nerve block group had significantly lower mean 12-hour morphine consumption compared to the erector spinae plane block group (10.9 mg vs. 17.6 mg, p=0.0015), as well as lower mean 24-hour consumption (18.7 mg vs. 26.7 mg, p=0.018). Intercostal blocks also led to lower pain scores in the first two hours postoperatively and a reduced need for rescue analgesia (16% vs. 40%, p=0.0033). No differences were found in patient satisfaction, complications, or length of stay. Notably, the erector spinae plane block group showed higher systemic absorption of local anesthetics.
Conclusion:
For uniportal thoracoscopic surgery, intercostal nerve block significantly reduces morphine consumption and systemic anesthetic absorption compared to erector spinae plane block.