Is Erector Spinae Plane Block Useful in Preventing the Transition from Acute to Chronic Pain After Multiple Rib Fractures?

Dear Editor,

We read with interest the excellent case report by Kulmar et al. (1) on the use of continuous erector spinae plane (ESP) block in a patient with multiple rib fractures, and we applaud the authors for the case management and presentation.

We would like to contribute to the discussion by suggesting a potential role of ESP block, which has not been investigated to date, in rib fractures, i.e. the prevention of acute to chronic pain transition (ATCPT). In post-traumatic patients, ATCPT is a well-known issue, particularly in patients of orthopaedic trauma, burn, central nerve injuries and chest trauma. With chest trauma, the prevalence of chronic pain can range from 22% to 59% (2, 3).

Chronic pain after chest trauma is strongly linked to permanent disability, and it has a substantial financial and social burden (2, 3). The principal risk factor for ATCPT is the presence of severe acute pain; therefore, prompt treatment of this acute pain is the cornerstone in ATCPT prevention. Many strategies have been studied to reduce acute pain scores, and these strategies include epidural analgesia and paravertebral nerve block (3). Moreover, over the past few years, the use of fascial plane blocks in this area has gained attention. Indeed, some authors used serratus anterior plane (SAP) and ESP blocks to reduce acute pain in rib fractures, and these blocks have a better safety profile with a reduction in possible side effects than epidural or paravertebral analgesia (3).

In particular, ESP block provides analgesia to anterior and posterior hemithoraces; thus, it is particularly suitable for patients with rib fractures compared with other fascial plane blocks such as SAP block (1, 3, 4). The effect of ESP block is due to the action of the local anaesthetic on the spinal nerves, and this could be particularly useful for ATPCT because through the same pathway, ESP block may prevent central sensitisation or revert it when established (4).

The study by Kulmar et al. (1) underlines how continuous ESP block can safely and markedly reduce acute pain in multiple rib fractures; therefore, this is a good starting point to prevent ATPCT. However, other studies on ESP block in different settings show that its neuromodulatory effect on the spinal nerves could play a further role in this area (4). So far, the potential role of ESP block in preventing ATPCT has not been studied, but we have several reasons to study it, and we are eager to perform studies on this topic in the near future.