Erector spinae plane block for neuropathic pain management in cardiac surgery via sternotomy: systematic review and meta-analysis

Dantas, Gustavo Meneses; Araújo, David Duarte de; Pastor, João Alberto; Neves, Matheus Andrade; Zeferino, Suely Pereira; Galas, Filomena Regina Barbosa Gomes

doi:10.63231/2595-0118.20250033-pt

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REVIEW ARTICLE • BrJP 8 • 2025 • https://doi.org/10.63231/2595-0118.20250033-en linkcopy

Erector spinae plane block for neuropathic pain management in cardiac surgery via sternotomy: systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES Neuropathic pain after cardiac surgeries, particularly following sternotomy, is challenging to manage with opioids due to side effects and limited efficacy. The Erector Spinae Plane Block (ESPB), introduced in 2016, offers promising analgesia by reducing postoperative pain and opioid use. However, further trials are needed to validate its efficacy and safety. The objective of this study was evaluate the efficacy of the ESPB compared to conventional analgesia in controlling postoperative pain and reducing opioid consumption in cardiac surgeries.

CONTENTS This systematic review and meta-analysis adhered to PRISMA guidelines. A comprehensive literature search was conducted in PubMed, SCOPUS, Cochrane, EMBASE, and Web of Science. Eligible studies included clinical trials examining the use of ESPB in cardiac surgeries. A total of 8 clinical studies met the inclusion criteria. Data analysis was performed using Review Manager (RevMan), with heterogeneity assessed by the I² index. ESPB significantly reduced Intensive Care Unit (ICU stay (-27.10 hours, 95% CI: -27.21, -26.99) and intraoperative fentanyl consumption (-17.16 mg morphine-equivalent, 95% CI: -17.43, -16.88). Pain scores also showed notable reductions, particularly at the 4th hour post-extubation (-1.51, 95% CI: -1.98, -1.05) and the 6th hour (-0.67, 95% CI: -1.10, -0.25). Mean arterial pressure and heart rate showed no significant differences between the groups.

CONCLUSION ESPB shows promise in reducing postoperative pain, fentanyl use, extubation time and ICU stay in cardiac surgery. However, due to study heterogeneity, further randomized controlled trials are necessary to establish consistent recommendations.

Keywords:
Analgesia; Cardiac surgery; Erector spinae plane bloc; ERAS (Enhanced Recovery After Surgery); Perioperative,; Systematic review

Highlights

This systematic review and meta-analysis evaluated the effectiveness of the erector spinae plane block (ESPB) in cardiac surgeries with sternotomy, focusing on postoperative pain control and opioid reduction

ESPB significantly reduced pain scores at 4, 6, and 12 hours post-extubation, intraoperative fentanyl use, extubation time, and ICU stay

Despite promising results, the quality of evidence was moderate to low, and current data do not support the routine use of ESPB; further high-quality randomized trials are needed

References	Athar et al. ^¹⁰	Bhat et al. ^¹¹	Krishna et al. ^¹³	Nagaraja et al. ^¹⁴
Titles	A Randomized Double-Blind Controlled Trial to Assess the Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Cardiac Surgery	To Evaluate the Analgesic Effectiveness of Bilateral Erector Spinae Plane Block Versus Thoracic Epidural Analgesia in Open Cardiac Surgeries Approached Through Midline Sternotomy	Bilateral Erector Spinae Plane Block for Acute Post-Surgical Pain in Adult Cardiac Surgical Patients: A Randomized Controlled Trial	Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery
Study Type	Prospective, randomized, double-blind, single-center clinical trial.	RCT, single-center	RCT, prospective, single-center	Prospective RCT, single-center
Year of Publication	2021	2024	2019	2018
Pain Scale	VAS	VAS	NRS	NRS
Population	30 patients (18-60 y/o, BMI 19-30 kg/m²), both genders, underwent elective cardiac surgeries (single-vessel CABG or valve replacement) under GA.	74 adults undergoing open cardiac surgery with median sternotomy	106 adults undergoing elective cardiac surgery with CPB	50 patients undergoing elective cardiac surgery
Intervention Group	The intervention group (Group E) received bilateral ESPB with 20 mL of 0.25% levobupivacaine per side.	ESP block, bilateral	53 patients: bilateral ESP block with 0.375% ropivacaine 3 mg/kg at T6	Group B: ESP block, bilateral
Control Group	The control group (Group C) received a sham block with 20 mL of normal saline per side.	Thoracic epidural (TEA)	53 patients: IV paracetamol (1 g q6h) + tramadol (50 mg q8h) post-operative	Group A: Continuous TEA
Conclusion	ESPB reduced postop analgesic needs, improved pain control vs. sham block. ESPB group: lower analgesic use, longer time to rescue analgesia, better Ramsay sedation scores post-extubation. No significant difference in PONV or other complications.	ESP is an effective and safe alternative to TEA in open cardiac surgery, showing trends toward lower analgesic needs, better safety profile, faster recovery, and fewer complications (e.g., arrhythmias) compared to TEA.	ESP block showed better pain control, less analgesic use, and fewer side effects compared to IV paracetamol + tramadol.	ESP is a viable alternative to TEA for perioperative analgesia in cardiac surgery, with similar VAS scores at 12h post-extubation and lower at 48h. ESP showed better outcomes in recovery, vent weaning, and ICU stay.

References	Güven et al. ^¹⁵	Kodali et al. ^¹⁶	Öğür et al. ^¹⁷	Wasfy et al. ^¹⁸
Titles	Postoperative analgesic effectiveness of bilateral erector spinae plane block for adult cardiac surgery: a randomized controlled trial	A Comparative Study of Bilateral Erector Spinae Block Versus Intravenous Dexmedetomidine for Perioperative Pain Management in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting - A Single-Blind Randomized Controlled Trial	Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery	Bilateral continuous erector spinae block versus multimodal intravenous analgesia in coronary bypass surgery
Study Type	RCT, single-center	RCT, single-blind, single-center	Prospective, randomized, controlled trial, single-center	Prospective, randomized, controlled trial, single-center
Year of Publication	2022	2023	2022	2021
Pain Scale	VAS	NRS	VAS	VAS
Population	66 patients undergoing various cardiac surgeries (e.g., CABG, ASD repair, valve replacement)	158 patients undergoing off-pump CABG	40 patients undergoing thoracic surgery	60 patients undergoing CABG with sternotomy
Intervention Group	Bilateral ESP block guided by ultrasound	Group E: ESP block	ESP block guided by ultrasound	Continuous bilateral ESP block during CABG
Control Group	No ESP block; GA only	Group D: IV dexmedetomidine	Standard care with NSAIDs, no ESP block	IV analgesia (opioids + standard protocol)
Conclusion	Bilateral ESP significantly reduced opioid use and improved pain scores in the first 8 hours post-op compared to GA alone. ESP also shortened ICU stay, reduced nausea/vomiting, and had a low complication rate, making it a safe and effective option in cardiac surgeries.	ESP provided better postop pain relief, lower fentanyl use, and less rescue analgesia vs. IV dexmedetomidine. ESP also led to shorter ICU stay and delayed need for rescue analgesia. Both methods reduced pain, but ESP resulted in lower opioid use, improving postop pain management.	ESP block effectively reduced postop pain, lowered opioid use, and improved recovery outcomes. ESP was associated with better pain control and fewer complications compared to standard care, making it a strong alternative for postop pain management.	Continuous bilateral ESP during CABG effectively reduced postop pain, opioid use, and improved recovery outcomes, leading to shorter ICU stay and better respiratory function. ESP may be a superior option for reducing opioids and enhancing recovery.

Studes	Domain 1: Randomization	Domain 2: Deviations from Interventions	Domain 3: Missing Outcome Data	Domain 4: Outcome Measurement	Domain 5: Selection of Reported Results	Overall RoB
Athar et al. ^¹¹	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk
Bhat et al. ^¹²	Low risk	Some concerns	Low risk	Some concerns	Low risk	Some concerns
Güven et al. ^¹⁴	Some concerns	Low risk	Low risk	Low risk	Low risk	Some concerns
Kodali et al. ^¹⁵	Low risk	Some concerns	Low risk	Some concerns	Low risk	Some concerns
Krishna et al. ^¹⁶	Low risk	Some concerns	Low risk	Some concerns	Low risk	Some concerns
Nagaraja et al. ^¹⁷	Some concerns	High risk	Low risk	High risk	Low risk	High risk
Oğur et al. ^¹⁸	Some concerns	High risk	Low risk	High risk	Low risk	High risk
Wasfy et al. ^¹⁹	Low risk	High risk	Low risk	Some concerns	Low risk	Some concerns

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[1] Summary of the main characteristics of the clinical trials included in the meta-analysis, including design, interventions, control groups, pain scales, and outcomes.