- Design
- systematic review and meta-analysis of 10 studies
- Population
- patients undergoing thoracic surgery or with chest wall trauma receiving erector spinae plane or intercostal nerve block
- Primary outcome
- postoperative pain scores and morphine equivalent consumption at 24 and 48 hours
- Effect
- pain lower with erector spinae block at 1 h, 24 h and 48 h; no difference in opioid use, stay or time under analgesia
A meta-analysis screened 2,141 records and pooled 10 studies comparing erector spinae plane block with intercostal nerve block after thoracic surgery or chest wall trauma, using pain scores at 1, 24 and 48 hours and morphine equivalents at 24 and 48 hours.
Pain scores favoured the erector spinae block at every timepoint: 1 hour (P < 0.00001), 24 hours (P < 0.00001) and 48 hours (P = 0.0008). Nothing else separated the techniques. Opioid consumption was no different at 24 hours (P = 0.10) or 48 hours (P = 0.20), nor was length of stay (P = 0.06) or time spent under analgesia (P = 0.33).
A pain score difference without an opioid difference is worth thinking about rather than quoting. It may mean the analgesia was genuinely better and patients simply did not need to ask for less morphine, since dosing in these studies followed protocol and demand rather than a nociceptive target. Or it may mean the score difference was small enough not to matter. Either way the practical case for the erector spinae block rests on where it sits relative to the pleura and the neuraxis - a safer needle path in an anticoagulated or coagulopathic chest trauma patient - more than on these numbers. Both techniques work; choose on anatomy, operator familiarity and what else the patient is on.
- Choose between the blocks on needle-path safety and operator familiarity, not on pooled pain scores
- Prefer the erector spinae approach where anticoagulation or coagulopathy makes an intercostal needle unattractive
- Do not promise an opioid-sparing effect - the pooled data did not show one
- Keep multimodal non-opioid analgesia running regardless of which block is used
- Reassess at 24 hours: single-shot blocks in this analysis were still separating at 48 hours, but not by much
Why it matters
The case for these blocks is usually made on opioid sparing, and this pooled analysis did not find any.
Don't overread it
Ten heterogeneous studies pooled across elective thoracic surgery and chest wall trauma; better pain scores without an opioid difference is a weaker finding than it looks.
The statistics, in plain English
The analysis reports P values without pooled effect sizes for pain, so we know the difference was unlikely to be chance but not how large it was - and a statistically significant difference on a 10-point scale can be a fraction of a point, which no patient notices. Non-significant opioid results with only 10 studies may reflect too few patients rather than genuine equivalence. Length of stay at P = 0.06 is the clearest example of a result that should not be described either way.
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