A case of vertical spine plane blocking for lumbar incision

Patients, male, 75 years old, 158 cm, 87.6kg, due to "intermittent lameness for 2 years, lower back pain more than half a month"diagnosisfor L4-L5, L5-S1 lumbar disc protruding, in my hospital full hemp down L4-L5, L5-S1 lumbar vertebral fusion, after surgeryinfection, after conservative treatment is not significantly improved after 8 dayspatients with no obvious abnormalities, check: HR 81 times / minute, RR 13 times / minute, body temperature 37 degrees C, BP 145/ 90mmHg, SpO2 97%, ShenqingPreoperative assessment takes into account the patient's severe obesity, old age, and a history of smoking (30 years, 20 units /day), in the short term again the risk of hemp is higherdiscussed, an anaesthetic plan is developed for two-sided vertical spine plane block (Erectorspinae plane block, ESPB)Patients are given ECG, BP and SpO2 monitoring after entering the chamber, with mask oxygen absorption (FiO2 60%, 3L/min) and open venous passages in the upper extremitiesThe patient is instructed to lie down and adjust the position on his ownAfter opening the incision gauze to checkinfectionoozing is confined to the surgical incision, the surrounding tissue no obvious redness and tendernessIntravenous lysazin 5mg, fully disinfected, with a sterile set to cover the low-frequency ultrasonic probe, and the use of side sadum (side opening about 3 cm) for scanning, respectively, to find the two-sided L4 and L5 vertebral transverse, using flat needle technology into the transverse surface, injection of 0.4% luopycain a total of 40ml (10ml each)blockafter after 20min measurement pain reduction range to the two-sided shoulder scapula line, pain reduction plane is about L2-S2, basic coverage of surgical incisionGive the right metoris at 2?g.kg-1-h-1 continuous pump injection, the patient sleeps smoothly, after smelling and snoring reduced to 1?g.kg-1-h-1, at this time the call patient can answer After disinfection and spreading the aseptic hole, the operation begins After the removal of the suture can be seen the wound deep into the vertebral arch root, physiological saline, hydrogen peroxide repeatedly rinse the wound, pulse rinser flushing the wound surface, completely remove the inactivated tissue, bipolar electrocoade strict hemorrhage patients HR, BP during this period are no significant changes, HR 76 to 85 times / minute, RR 12 times / minute, BP 108 to 128 / 70 to 90mmHg, SpO2 100%; Before the end of the operation 10min stop the right metamine intravenous pump, after the completion of the skin 5min patients to wake up, turn over the bed patients with a postoperative 30min VAS score of 0, after surgery 2hVAS score 0, patients self-confessed double-sided thighs, knees and lower legs inside the slightly numbness, double lower limb muscle strength 5 levels; after surgery 6h follow-up patients, patients generally in good condition, VAS score 0, double lower limb numbness The sense of slightly aggravated, double lower limb muscle strength 4 levels, after surgery 12h follow-up, VAS score 0, double lower limb numbness than before no significant change, muscle strength 5 level; postoperative 24h follow-up, VAS score 0 points, double lower limb numbness than the previous significant reduction, muscle strength 5 levels The patient was discharged from the hospital within 1 week after the clean-up, with no anaesthetic-related complications discussion this case patient due to L4-L5, L5-S1 lumbar fusion after incision infection, liquefaction, the need for reclining again a larger range of clean-up surgery to completely remove necrotic tissue, full flushing, drainage, conventional hemp can not meet the requirements of surgical analgesic In the past, the anaesthetic management of this type of surgery method spent more with full hemp re-line tracheotomy intubation, mechanical ventilation, to minimize the patient's pain in surgery and long-term reclining body position caused by discomfort The case is for elderly obese patients, and has a long history of large-scale smoking, in the short term secondary full hemp may increase the incidence of anaesthetic-related complications during the perioperative period Therefore, the first use of ESPB, to avoid the complications that may cause by whole hemp, improve the postoperative and postoperative analgesia, shorten the hospital stay, improve the patient's prognosis, improve patient satisfaction ESPB as a new interfaplane plane block, initially used by Forero and others for neuropathic pain in the chest Ueshima and others have applied ESPB to advanced patients with thoracic vertebral surgery for the first time; Based on the neuroanatomical similarity of the thoracic lumbar spine, this case successfully attempted the two-sided ESPB spinal surgery anesthesia for the first time, avoiding the complications of whole hemp and reducing the use of opioids during surgery; The literature reports that the three possible channels of the vertical spinal muscle blocking fluid diffusion to the vertebrae are: the back branch channel of the spine nerve, the vertical ridge muscle channel, the rib transverse tunnel channel, because of the uncertainty of the drug diffusion, the clinical can observe its vertebral blockage degree is light, does not affect the evaluation of the motor function of the lower limb after surgery , ESPB can be used not only as a new analgesic method, but also as a viable anaesthetic in less traumatic back-path spinal surgery, especially for older patients with highER ASA grades