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Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.

ESP Block in Decompressive Laminectomy and Fusion

This case study represents an individual clinician experience with and methodology for using EXPAREL.

Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.

Please see Important Safety Information below and refer to the Full Prescribing Information.

Disclosure: Dr Gadsden is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
Jeff Gadsden, MD, FRCPC, FANZCA
Affiliation
Associate Professor of Anesthesiology, Duke University School of Medicine, Durham, NC
Surgical Case Performed
L3-L5 decompressive laminectomy and fusion
Inpatient or Outpatient Procedure
Inpatient
PATIENT CHARACTERISTICS
 
Gender
Female
Age
67 years
Patient History
and Characteristics
Patient presented with failed conservative management of degenerative lumbar spinal stenosis at both L3-L4 and L4-L5 levels, with spondylolisthesis of L4-L5. Patient had been taking oxycodone 20 mg PO daily for the last 9 months. Past medical history included hypertension, obesity, and hypothyroidism
PROCEDURAL DETAILS
 
Incision Size
7-cm midline lumbar incision
Preoperative Analgesics Used
20 mL (266 mg) EXPAREL admixed with 30 mL of 0.25% bupivacaine HCl
Intraoperative Analgesics Used
IV ketamine 0.5 mg/kg bolus followed by 2 mcg/kg/min; IV dexamethasone 10 mg; IV fentanyl prn
Dose of EXPAREL and
Total Volume Used
50ml
IV=intravenous; PO=by mouth; prn=as needed.

The recommended dose of EXPAREL for infiltration in adults is based on the size of the surgical site, the volume required to cover the area, and individual patient factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg. The recommended dose of EXPAREL for patients aged 6 to <17 years old is 4 mg/kg, up to a maximum of 266 mg. The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal is 133 mg. The recommended dose of EXPAREL in adults for adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) of 0.5% bupivacaine HCl, for a total volume of 20 mL.

EXPAREL can be administered unexpanded (20 mL) or expanded to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL [ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.

Bupivacaine HCl (which is approved for use in patients aged 12 and older) may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should be used with caution, including monitoring for neurological and cardiovascular effects related to local anesthetic systemic toxicity. Other than with bupivacaine, EXPAREL should not be admixed with other drugs prior to administration.

Figure-1A

FIGURE 1A. Erector spinae muscle group

Figure-1B

FIGURE 1B. Transducer and needle entry position for the ESP block at L4

  • ESP blocks were performed in the preoperative block area. For this procedure, Dr Gadsden prepared 2 syringes of injectate, each containing 10 mL (133 mg) of EXPAREL® (bupivacaine liposome injectable suspension) and 15 mL (37.5 mg) 0.25% bupivacaine HCl
  • The patient was positioned laterally with hips flexed, and midazolam 2 mg IV was administered for sedation
  • A curvilinear ultrasound probe was placed in a parasagittal orientation and the transverse process of L4 identified underneath the erector spinae muscle group

FIGURE 2. Sonoanatomy prior to needle insertion

  • A 21-gauge, 100-mm needle was advanced from the cephalad aspect of the probe until contact was made with the transverse process
Figure-2

FIGURE 3. Needle contacting L4 transverse process

  • Small boluses (1 mL) of saline were injected to confirm needle position underneath the deep fascia of the muscle, and the needle redirected to ensure the tip was not intramuscular. Once satisfied with needle position, 25 mL of the local anesthetic solution was slowly administered
Figure-3

FIGURE 4. Pool of local anesthetic “lifting” the erector spinae muscle group off the transverse process

  • The correct injection plane was confirmed by observing cephalocaudal spread and a lifting of the muscle off the transverse process
  • The block was then repeated on the contralateral side with 25 mL of the local anesthetic solution
Figure-4

TIPS

  • The ESP block can be performed with the patient seated or in the lateral or prone position. Due to the nature of the surgical procedure and the potential disruption of fascial planes, ESP blocks for spine cases are best done preoperatively
  • The ESP block should be performed at the midpoint of the expected surgical area (eg, for an L3-L5 laminectomy, depositing the local anesthetic at L4 provides coverage both cephalad and caudad). Dr Gadsden always consults with the surgeon ahead of time to confirm the surgical levels and approach
  • Dr Gadsden always uses normal saline to hydrolocate the needle tip to ensure that the local anesthetic will be deposited deep into the erector spinae muscle group, not intramuscularly

ESP Block in Decompressive Laminectomy and FusionPerformed by: Dr Gadsden

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Important Notice

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

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