Administration Case Report

A dual-site bilateral open ESP block is performed after the spinal deformity correction has been completed. A midline incision extending over the levels of planned instrumentation and fusion is performed from T2 to L2 (45 cm). Typical subperiosteal dissection is performed to the tips of the transverse processes as is common for posterior spinal surgery. Self-retaining retractors are placed to expose the spine, translating the paraspinal muscles laterally.

Following the scoliosis instrumentation and bone graft placement, but prior to initiation of wound closure, the EXPAREL injections are made.

The open ESP block is performed by injecting 30 mL in 4 locations (right T5, left T5, right T11, and left T11). A 22-gauge 3-inch spinal needle is placed through the paraspinal muscles from dorsal fascia, just lateral to the previously exposed portion of the transverse processes at the levels noted above. With a fingertip on the transverse process, the needle is directed through the muscle until the needle contacts the unexposed lateral aspect of the transverse process. The needle needs to be at the junction between the transverse process and the rib. Given that the wound is open and much of the transverse process is exposed, locating the needle tip approximately 5 to 10 mm more lateral is straightforward. Then 30 mL of injectate is placed at each of the 4 locations within the erector spinae plane. The dispersion of the injectate can be seen and palpated as it flows proximally and distally within the tissue plane.

Occasionally, the initial dissection of the transverse process violates the ESP and the injectate can be seen leaking into the wound. This should be watched for as the injections are made. Moving the needle more laterally or to an adjacent level may eliminate the leaking into the wound. If these adjustments are not successful, a classic multisite injection with infiltration may be used instead of the ESP block.

The right T5 injection site is shown representing the needle path to the lateral aspect of the T5 transverse process. The starting point for the needle should be lateral to the midline fascial incision and directed through the paraspinal muscle. Administer 30 mL of EXPAREL^® (bupivacaine liposome injectable suspension) injectate in all 4 locations (right T5, left T5, right T11, and left T11).

MRI: Yellow highlighting shows the transverse processes where injections are made.

Preoperative and Postsurgical Posterior-anterior (PA) Radiographs

The ESP block injection sites are noted by the yellow circles. The injectate of 30 mL at each site flows proximally and distally through several levels to provide coverage of the entire area of the spinal exposure (blue shaded area).

POSTSURGICAL INSTRUCTIONS INCLUDING PRESCRIPTIONS PROVIDED AND RECOVERY MILESTONES AND GOALS

POD #1 – patient out of bed, sits in chair, begins oral intake—can start on POD #0 if tolerable

POD #2 – drains removed, patient ambulates in room and out of room

POD #3 – patient showers, continues getting up out of bed and ambulating; discharge expected

PATIENT FOLLOW-UP

• Home on POD #3, on the same dosing of PO medications as last hospital day
  • Neurontin^® (gabapentin) 300 mg HS x 2 weeks
  • Pepcid^® (famotidine) 10 to 20 mg x 2 weeks
  • Acetaminophen 15 mg/kg Q6 hours x 2 weeks
  • Naproxen BID 5 to 10 mg/kg or ibuprofen 5 to 10 mg/kg Q8 hours x 2 weeks
  • Senna-S, MiraLAX^® scheduled until off all narcotics
  • Dulcolax^® suppository or MOM prn
  • Oxycodone 2.5 to 7.5 mg Q4 to 6 hours prn (20 doses)
  • Valium^® (diazepam)/Ativan^® (lorazepam) low dose (0.1-0.3 mg/kg) (10 doses) prn for anxiety or muscle spasm
• Bandages are removed week 2 at home
• Pain medications are discontinued week 2 at home
• 2 to 3 weeks back to school
• 4 weeks follow up in office
• 6 weeks jogging and swimming
• 3 months sport training
• 6 months unrestricted activity