Background & Aims
Thoracic outlet syndrome (TOS) is an uncommon compression syndrome of the subclavian vessels or the brachial plexus that presents with pain, motor weakness, swelling, vasoactive and sensory changes in the affected limb1,2. The origin of TOS can be neurogenic, vascular or a combination of both. Treatment often requires thoracic outlet decompression surgery (TODS). We aimed to assess the efficacy of regional analgesia, specifically erector spinae plane nerve block catheters3,4,5 in pediatric patients undergoing TODS over a 14-year period.
Methods
After IRB approval, we did a retrospective chart review of pediatric patients (<18y) who un-derwent thoracic outlet decompression surgery at a tertiary children’s hospital, between March 2010 and January 2024. We blindly matched regional analgesia group (RAg) pa-tients with no intervention (Cg) historical controls (1:2)5. We compared baseline patient characteristics (age, weight, ASA-PS, TOS type/laterality, TODS metrics). Outcomes as-sessed were postoperative recovery criteria (nausea and vomiting (PONV), pruritis, consti-pation, time to floor discharge), hospital length of stay (LoS), pain scores in the first hours, and oral morphine equivalent (OMEs) use in the first 48 hours after surgery,4,5.
Results
A total of 35 patients were identified who had regional analgesia for TODS, most within the last 4 years. There were no significant demographic or TODS differences between the 2 groups. Blocks took 19.9±7.8 minutes to complete. Pain scores were decreased in the RAg patients between 3 to 24h postoperative. Opioid analgesia administered to the RAg in 24h were less than a third compared to those administered to the control group (Cg). PONV in the Cg were more prevalent in the first 48h compared to the RAg (p=0.006).
Conclusions
Continuous Erector Spinae Plane nerve block catheters for pediatric patients undergoing thoracic outlet decompression surgery (TODS) decreased pain scores, oral morphine equivalent (OME) analgesic use, and certain opiate adverse effects compared to pediatric historical cohort who did not have regional analgesia.
References
1.Ransom EF, Minton HL, Young BL, He JK, Ponce BA, McGwin G, Meyer RD, Brabston EW 3rd. Intermediate and Long-term Outcomes Following Surgical Decompression of Neurogenic Thoracic Outlet Syndrome in an Adolescent Patient Population. Hand (N Y). 2022 Jan;17(1):43-49. Epub 2020 Feb 10. PMID: 32036706; PMCID: PMC8721805.
2.Matos JM, Gonzalez L, Kfoury E, Echeverria A, Bechara CF, Lin PH. Outcomes following operative management of thoracic outlet syndrome in the pediatric patients. Vascular. 2018 Aug;26(4):410-417. Epub 2018 Jan 4. PMID: 29301465.
3.Guffey R, Abuirqeba AA, Wolfson M, Fingerman ME, Liu Q, Ohman JW, Thompson RW. Erector Spinae Plane Block versus Continuous Perineural Local Anesthetic Infusion for Postoperative Pain Control After Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A Matched Case-Control Comparison. Ann Vasc Surg. 2021 Nov;77:236-242. Epub 2021 Aug 26. PMID: 34455047.
4.Goeteyn J, van den Broek R, Bouwman A, Pesser N, van Nuenen B, van Sambeek M, Houterman S, Teijink J, Versyck B. Interfascial Plane Blocks Reduce Postoperative Pain and Morphine Consumption in Thoracic Outlet Decompression. Ann Vasc Surg. 2020 Jul;66:301-308. Epub 2019 Dec 16. PMID: 31857230.
5.Roy N, Brown ML, Parra MF, Sleeper LA, Alrayashi W, Nasr VG, Eklund SE, Cravero JP, Del Nido PJ, Brusseau R. Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021 Jul;35(7):2082-2087. Epub 2020 Oct 12. PMID: 33139160.