Comparison of thoracic epidural anesthesia with an erector spinae plane infusion for post-esophagectomy analgesia: a pragmatic retrospective cohort study

Introduction

Background

Esophageal cancer is the seventh most common cancer worldwide. Approximately 27,000 new cases of esophageal cancer were diagnosed in the United States in 2024, with a projected five-year survival rate of only 22% (1). Although new treatment strategies such as checkpoint inhibitors such as pembrolizumab, nivolumab, ipilimumab and tislelizumab have been approved to treat esophageal cancers, the mainstay of therapy still involves surgical resection with lymph node dissection and radiation (2). Minimally invasive and hybrid surgical approaches have reduced major pulmonary morbidity, most likely as a result of less postoperative pain, diaphragmatic splinting and thus less basal lung atelectasis (3). Nevertheless, postoperative pain control is imperative to reduce pulmonary complications and to maximize patient comfort following esophagectomy (4).

Effective pain management following esophagectomy may also reduce the conversion from acute to chronic pain. Regional anesthesia including thoracic epidural analgesia (TEA) and paravertebral analgesia have been traditionally used in combination with intravenous (IV) opioid analgesia. The ESP block is a regional anesthesia technique where local anesthetic is injected into the fascial plane deep to the erector spinae muscle, targeting the dorsal and ventral rami of spinal nerves (5). Since the description of the use of ESP analgesia for use in treating thoracic neuropathic pain (6), this method has been reported to be useful in thoracic, abdominal and extremity surgery (7,8).

Rationale and knowledge gap

A 2023 review on postoperative analgesia following esophagectomy concluded that evidence on the effectiveness of ESP analgesia is limited in this context (9). The review also noted that no comparison studies between TEA and ESP analgesia for esophagectomy had been reported. This represents a knowledge gap in determining if the ESP represents a comparable clinical replacement for TEA analgesia following esophagectomy.

Objective

The numbers of esophagectomy procedures performed at a single institution (Rush University Medical Center) limits the practicality of undertaking a randomized clinical trial. To address this knowledge gap, the objective of this study was to perform a quasi-experimental design study of retrospective data from a 9-year period to compare the analgesic effectiveness of these methods. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1542/rc) (10).

Methods

This single institution retrospective cohort quasi-experimental design pragmatic study was conducted at Rush University Medical Center in Chicago, Illinois. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Institutional Review Board (IRB) of Rush University Medical Center (ORA:2108024-IRB01, approval date 12/6/2024, Principal Investigator R.J.M.) and individual consent for this retrospective analysis was waived.

The study included the medical records of adult (>18 years) patients undergoing and an esophagectomy procedure (CPT 42117, 43107, or 43112) at Rush University Medical Center between 1/1/2016 through 10/31/2024. Excluded were patients that received a perioperative analgesia technique other than TEA or an erector spinae plane (ESP) infusion.

The following were abstracted from the electronic health record: clinical characteristics [age, sex, height, and body mass index (BMI)], race (White, African American, Asian), ethnicity (non-Hispanic, Hispanic), American Society of Anesthesiology (ASA) physical status, and co-morbidities (diabetes mellites, current smoker, history of major depressive illness). The Charlson co-morbidity index as well as the Cambridge co-morbidity score were calculated from information contained in the medical record (11,12). Procedural data included the surgical approach (Ivor-Lewis or McKeown), type of primary regional analgesia (TEA or ESP), and duration of surgery. Outcome data included pain assessment using the Defense and Veterans Pain Rating Scale (DVPRS), a 0 to 10 scale assessing pain intensity where 0 equals no pain and 10 equals worst pain imaginable. Pain assessments were recorded from the time of post-anesthesia care unit entry through 72 h of hospitalization. Opioid and local anesthetic drugs including those used in the regional anesthesia as well as those administered by patient-controlled analgesia or nursing staff were recorded. Intrathecal and epidural opioids were counted as IV at a 1:1 ratio. Opioids were converted to IV morphine milligram equivalents (MME) using the Center for Disease Control Clinical Practice guidelines (13). The time of return of bowel function (stool passage) and length of stay as well as the incidence of infection and re-admission within the first 30 days were collected.

Study data were collected and managed using the Research Electronic Data Capture (REDCap) electronic data capture tools hosted at Rush University Medical Center (14,15). REDCap is a secure, web-based application designed to support data capture for research studies, providing: (I) an intuitive interface for validated data entry; (II) audit trails for tracking data manipulation and export procedures; (III) automated export procedures for seamless data downloads to common statistical packages; and (IV) procedures for importing data from external sources.

The primary outcome was the area under the pain by time curve for 72 h postoperatively (AUC_0–72h) determined using trapezoid integration. Secondary outcomes were average DVPRS pain at rest over 72 h, and opioid consumption in MME. Exploratory outcomes included length of stay, time to return of bowel function, and 30-day infection and readmission rates. All available cases were used in the analysis and no formal sample size estimate was performed. Based on Institutional data we estimated approximately 100 cases would be available for inclusion in the study.

Statistical analyses

The distributions of subject characteristics, operative data and the primary and secondary outcomes were evaluated using the Shapiro-Wilks test and examined graphically using q-q plots. Data for which the assumption of normality was not rejected were included in the analyses as interval and presented using a mean ± standard deviation (SD), counts were handled as ordinal or nominal and presented as count (% of group). All data elements were complete for all subjects.

The balance between the TEA and ESP analgesia groups among clinical characteristics, ASA physical status, co-morbidities, surgical approach and duration of the procedure was assessed using a balance table (16). To adjust for imbalance between the treatment groups, a propensity score (PS) weight analysis was performed (17). PS scores were predicted for TEA and ESP group membership for each case from the clinical characteristics, co-morbidities, procedure type and operation duration variables using logistic regression (LR). Graphical assessment of PSs overlap for violation of the positivity assumption is shown in Figure 1. Based on the moderate degree of PS overlap with areas of non-overlap near PS scores of 0 and 1, entropy rather than inverse probability of treatment weighting was applied (18,19). The titling function for entropy weighting was calculated as –[PS * ln(PS) + (1 − PS) * ln(1 − PS)]. The effective sample size (ESS), or the number of observations from a simple random sample that yields an estimate with sampling variation equal to the sampling variation obtained from the weighted comparison observations was determined for the TEA and ESP groups.

Figure 1 Histogram of PS for study group membership generated by logistic regression model. PS show moderate overlap with some area of non-overlap at low PS values in the ESP analgesia group and high propensity scores in the TEA group. The 2 sample Kolmogorov-Smirnov statistic of the distributions is 0.471 (P=0.979). ESP, erector spinae plane; PS, propensity scores.

Analyses of the primary, secondary and exploratory data were performed on unweighted unadjusted data, unweighted adjusted as well as PS weighted and adjusted data using a generalized linear model adjusted for the year of surgery. The difference in the estimated marginal means and 95% confidence intervals (CIs) of the differences are reported as a measure of the effect size. A clinically important difference in the primary and secondary outcomes was set at an average DVPRS of 0.5, an AUC_0–72h of 36 score*h and an IV MME difference of 30 MME over the 72 h period (20).

Repeated measurement data for DVPRS pain assessments on postoperative days 0, 1, 2 and 3 as well as opioid consumption intraoperatively and on postoperative days 0, 1, 2 and 3 were evaluated using generalized estimating equations with subject ID as the subject variable, day as the repeated variable, and group, day and year of surgery as factors. The link function was gaussian, the covariance matrix was robust, and the working correlation matrix was autoregressive type 1 [AR(1)]. Unweighted PS weighted analyses were performed. Pairwise comparisons of estimates and 95% CIs with Bonferroni adjustment are presented as measures of effect size.

Data were analyzed using RStudio version 2025.09.0 Build 387, Posit Software, PBC, and R version 4.5.1, release date 13 June 2025 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

Ninety-nine hybrid esophagectomy procedures were identified and 79 (80%) were included in the analysis. Excluded cases include 6 patients that had a transhiatal approach, 2 that had only partial resections and 12 did not receive regional analgesia. Forty-four patients received TEA and 35 ESP anesthesia. TEA analgesia solutions were a base solution of 0.1% bupivacaine with fentanyl 5 mg/mL while ESP utilized either 1–2% lidocaine or 0.2% ropivacaine. Seventy were performed using the Ivor-Lewis (2-hole) and 19 using the McKeown (3-hole approach). The number of patients receiving TEA or ESP block analgesia following esophagectomy surgery per year of the study is shown in Figure 2.

Figure 2 Histogram of number of esophageal procedures by year, stratified by thoracic epidural or ESP analgesia. ESP, erector spinae plane.

The balance in clinical characteristics, co-morbidities, surgical approach and duration of the procedure are shown in Table 1. Prior to PS weighting the maximum ES difference for a single variable was 0.525 and a mean ES of all variables 0.177; after PS weighting these were reduced to 0.102 and 0.026, respectively (Figure 3). The ESS of the entropy-weighted cohort was 27 for the TEA group and 27 for the ESP group.

Figure 3 Love plot of the ASD of the unweighted and entropy-weighted cohorts. The mean ASD of the unweighted sample 0.177 is shown by the short-long-short dashed line and the mean ASD of the entropy-weighted sample 0.026 by the dot-dot-dashed line. The upper limit of the desired ASD is 0.1, shown by the solid line. ASA, American Society of Anesthesiologists; ASD, absolute standardized differences; BMI, body mass index; Hx, history; PS, propensity scores.

The median [1^st, 3^rd quartile] number of DVPRS assessments used in calculating the AUC_0–72h and the average pain over 72 h was 31 [27, 37] in the TEA and 34 [27, 41] in the ESP group (P=0.45). Primary and secondary outcomes are shown in Table 2. In the weighted analysis the average DVPRS over 72 h was 2.9 (95% CI: 2.2 to 3.6) in the TEA and 3.9 (95% CI: 3.4 to 4.6) in the ESP group, difference −1.0 (95% CI: −1.9 to −0.2, P=0.02). In addition, the mean AUC_0–72h was 61 score*h (95% CI: −6 to 128, P=0.07) greater in the ESP group; and total MME consumption was 34 MME (95% CI: −6 to 74 MME, P=0.09) greater in the ESP compared with the TEA group. The return of bowel function was shorter by 17 h (95% CI: 2 to 31, P=0.02) in the ESP group in the unweighted analysis but reduced to 7 h in the entropy-weighted comparison. In weighted comparisons there were no differences in any exploratory outcomes such as infections within 30 days of surgery and 30-day readmission rates.

Average pain assessments from the day of surgery through day 3 postoperative are shown in Figure 4. The combined TEA and ESP groups reported greater pain on postoperative day 1 compared to day 0 [difference in estimated marginal means 0.90 (95% CI: 0.13 to 1.7, P=0.01)] and lower pain on postoperative day 3 compared to postoperative day 1 [difference 0.91 (95% CI: −1.59 to −0.13, P=0.01)] but there were no group (TEA vs. ESP) (P=0.14), or group by day differences (P=0.29).

Figure 4 Box plots of the average DVPRS pain scores on day of surgery (0), and postoperative days 1 to 3 following esophagectomy. The solid horizontal line in the box is the median, the short-dashed line is the mean, the box represents the 25^th to 75^th percentiles, the whiskers are the 10^th and 90^th percentiles and the solid circles are the 5^th and 95^th percentiles. DVPRS, Defense and Veterans Pain Rating Scale; ESP, erector spinae plane.

Opioid consumption showed different response patterns from day of surgery to postoperative day 3 between the groups (Figure 5). In the TEA group, MME’s were decreased from day 0 by 22.3 MME (95% CI: 3.8 to 40.8, P=0.005), 22.3 MME (95% CI: 1.8 to 42.7, P=0.01) and 20.5 MME (95% CI: 4.6 to 36.6, P<0.002) on days 1, 2 and 3, respectively. In the ESP group, MMEs were not different on day 1 or day 2 compared to day 0 [difference 1.3 MME (95% CI: −16.3 to 19.0, P>0.99), 13.8 MME (95% CI: −7.9 to 35.6, P>0.99)], but only decrease from day 0 on day 3, 20.5 MME (95% CI: 2.2 to 38.8, P=0.01) MME. There were no differences in MME consumption between the groups on any day.

Figure 5 Box plots of the IV MME consumption on day of surgery (0), and postoperative days 1 to 3 following esophagectomy. The solid horizontal line in the box is the median, the short-dashed line is the mean, the box represents the 25^th to 75^th percentiles, the whiskers are the 10^th and 90^th percentiles and the solid circles are the 5^th and 95^th percentiles. ^†, different from day 0, P<0.05 in the TEA group; ^‡, different from day 0, P<0.05 in the ESP group. ESP, erector spinae plane; IV, intravenous; MME, morphine milligram equivalents; TEA, thoracic epidural analgesia.

No significant adverse events related to the TEA or ESP treatment occurred in any patient. Catheter-related complications, leaking and inadvertent removal occurred in 2 of 35 (6%) ESP and in 4 of 44 (10%) TEA patients (P=0.89).

Discussion

Key findings

The important finding of this study was the improved average DVPRS scores in the unweighted/adjusted and weighted/adjusted analyses in the TEA compared with the ESP group. In addition, both the pain AUC_0–72h, and MME consumption favored TEA compared to ESP also suggests improved analgesia in the TEA group. The observed differences in the average DVPRS scores, the AUC_0–72h and MME consumption were greater than the minimally clinically important differences suggesting that ESP analgesia may not provide clinically equivalent analgesia to that provided by TEA. ESP analgesia resulted in both a significant reduction in time to first bowel movement in the unweighted analysis and a clinically important difference of 7 h in the weighted analysis.

Strengths and limitations

The results of this study should be interpreted in context of its strengths and limitations. The strengths of our study are the direct comparison of subjects that received TEA versus ESP analgesia following hybrid esophagectomy. Surgeries were performed by 1 of 2 thoracic surgeons using a hybrid approach with a video assisted thoracoscopy combined with an abdominal laparoscopic combined with a cervical anastomosis when a 3-hole approach was used. Robotic assistance was used in some cases after 2020. Patients went from the operating room to the intensive care unit until stable and are discharged to the hospital ward. Anesthesia management during the period was relatively unchanged except for the switch from TEA to ESP for the regional component of the multimodal analgesia. Regional anesthesia catheter placement for these surgeries was performed by a member of the regional anesthesia team who placed the catheters and along with the acute pain service managed postoperative pain. General anesthesia was used intraoperatively and in addition to regional analgesia postoperative pain management included patient controlled IV analgesia. Rescue analgesics were administered intravenously to control breakthrough pain. Patients were generally nil per os (NPO) during the study period. Nevertheless, changes in procedures and protocol unaccounted for in this study could have influenced our findings.

Using statistical methods, we were able to balance the characteristics of groups and reduce potential bias due to group imbalance. TEA and ESP analgesia were provided in 8 of the 9 years of the study, and we did account for the year of surgery in our statistical analysis. We also included all opioid administered including that from the TEA solution. Nevertheless, our sample is small, and the time-period of the study is quite large, and group allocation was not randomly assigned. Based on the observed effect sizes differences between the groups in our study, Cohen’s d of 0.3 to 0.4, samples of 100 to 176 subjects per group would be required to demonstrate statistically significant differences in the primary and secondary outcomes studied at a power of 0.8 and an alpha of 0.05.

Comparisons with similar research

Pain management following esophagectomy can be challenging as both the Ivor Lewis and McKeown approaches involve both a thoracic and an abdominal incision and either approach may require substantial dissection around the esophagus (21). TEA has demonstrated superior analgesia compared to patient controlled intravenous analgesia and has been shown to have positive effects on postoperative pulmonary morbidity, faster recovery, earlier restitution of bowel function and a reduced systemic stress response due to sympathetic blockade (22). TEA has also been shown to reduce pro-inflammatory cytokines post-esophagectomy (23).

ESP block has become the regional analgesia block of choice for patients undergoing video assisted thoracoscopic surgery (24). ESP has demonstrated superior analgesia, lower perioperative analgesic requirements, better patient satisfaction, and less respiratory muscle strength impairment than intercostal nerve blocks in patients undergoing mini-thoracotomy (25). However, in a study comparing IV opioid analgesia with ESP and TEA in video assisted or thoracotomy surgeries, ESP was superior to IV opioid analgesia but required increase in rescue analgesia compared to TEA (26). ESP analgesia has also show to be non-inferior in terms of postoperative recovery following video-assisted thoracoscopic surgery (27). Case reports have suggested that bilateral ESP infusions have been reported to provide adequate analgesia following esophagectomy (28). Although no randomized clinical trials have compared TEA with ESP following esophagectomy, ESP has been demonstrated to be comparable to TEA in clinical trials for cardiac surgery (29), coronary artery bypass (30), traumatic flail chest (31), and the Nuss procedure (32).

Explanations of findings

Although we found only a statistical difference in average DVPRS scores over 72 h, the differences in average DVPRS over 72 h, pain AUC_0–72h and opioid consumption in MME were all greater in the ESP group than the minimally clinically important pain threshold difference compared to TEA analgesia. This suggests that the analgesia provided by ESP may not be clinically equivalent to that provided by TEA, but that our study had insufficient sample to observe statistically significant differences.

Implications and actions needed

ESP may represent an alternative regional analgesia technique following esophagectomy and may reduce serious complications associated with TEA; however, it likely offers somewhat reduced analgesia compared to TEA. Additional studies evaluating both short term as well as longer term outcomes as well as modification to the methods of delivery, such as programmed intermittent bolus delivery are needed before ESP analgesia can be considered the regional technique of choice following esophagectomy. Attributing changes in longer term outcomes is challenging as many of these patients go directly to oncology to begin chemotherapy and radiation treatments. These factors make evaluating chronic pain in this group difficult to study.

Conclusions

Our findings suggest that ESP may represent an alternative regional analgesia technique following esophagectomy and may reduce serious complications associated with TEA; however, it likely offers somewhat reduced analgesia compared to TEA.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1542/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1542/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1542/prf

Funding: The study was funded by the Department of Anesthesiology funds.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1542/coif). R.J.M. is a member of the editorial board for Pain, Anesthesia & Analgesia and the International Journal of Obstetric Anesthesia. These are all unpaid positions. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Institutional Review Board (IRB) of Rush University Medical Center (ORA:2108024-IRB01, approval date 12/6/2024, Principal Investigator R.J.M.) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. American Cancer Society. Cancer Facts & Figures 2024. Atlanta: American Cancer Society. 2024. [last accessed July 3, 2025]. Available online: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2024/2024-cancer-facts-and-figures-acs.pdf
2. Pancholi NJ. New Treatment Strategies for Esophageal Cancer. 2025. [last accessed 7/8/2025]. Available online: https://www.aacr.org/blog/2025/04/22/new-treatment-strategies-for-esophageal-cancer/
3. Mariette C, Markar SR, Dabakuyo-Yonli TS, et al. Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer. N Engl J Med 2019;380:152-62. [Crossref] [PubMed]
4. Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906-11; discussion 911-2. [Crossref] [PubMed]
5. Yang JH, Sun Y, Yang YR, et al. The Analgesic Mechanism and Recent Clinical Application of Erector Spinae Plane Block: A Narrative Review. J Pain Res 2024;17:3047-62. [Crossref] [PubMed]
6. Forero M, Adhikary SD, Lopez H, et al. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med 2016;41:621-7. [Crossref] [PubMed]
7. Tsui BCH, Fonseca A, Munshey F, et al. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth 2019;53:29-34. [Crossref] [PubMed]
8. Scimia P, Basso Ricci E, Droghetti A, et al. The Ultrasound-Guided Continuous Erector Spinae Plane Block for Postoperative Analgesia in Video-Assisted Thoracoscopic Lobectomy. Reg Anesth Pain Med 2017;42:537. [Crossref] [PubMed]
9. Feenstra ML, van Berge Henegouwen MI, Hollmann MW, et al. Analgesia in esophagectomy: a narrative review. J Thorac Dis 2023;15:5099-111. [Crossref] [PubMed]
10. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Epidemiology 2007;18:800-4. [Crossref] [PubMed]
11. Chang CM, Yin WY, Wei CK, et al. Adjusted Age-Adjusted Charlson Comorbidity Index Score as a Risk Measure of Perioperative Mortality before Cancer Surgery. PLoS One 2016;11:e0148076. [Crossref] [PubMed]
12. Payne RA, Mendonca SC, Elliott MN, et al. Development and validation of the Cambridge Multimorbidity Score. CMAJ 2020;192:E107-14. [Crossref] [PubMed]
13. Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022;71:1-95. [Crossref] [PubMed]
14. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81. [Crossref] [PubMed]
15. Harris PA, Taylor R, Minor BLThe REDCap consortium, et al. Building an international community of software platform partners. J Biomed Inform 2019;95:103208. [Crossref] [PubMed]
16. Ridgeway G, McCaffery D, Morral A, et al. Toolkit for Weighting and Analysis of Nonequivalent Groups: A guide to the twang package. Available online: https://cran.r-project.org/web/packages/twang/vignettes/twang.pdf
17. Olmos A, Govindasamy P. A Practical Guide for Using Propensity Score Weighting in R. Practical Assessment, Research and Evaluation. 2015;20:
18. Zhou Y, Matsouaka RA, Thomas L. Propensity score weighting under limited overlap and model misspecification. Stat Methods Med Res 2020;29:3721-56. [Crossref] [PubMed]
19. Li Y, Li L. Propensity score analysis methods with balancing constraints: A Monte Carlo study. Stat Methods Med Res 2021;30:1119-42. [Crossref] [PubMed]
20. Myles PS, Myles DB, Galagher W, et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth 2017;118:424-9. [Crossref] [PubMed]
21. Deana C, Vetrugno L, Bignami E, et al. Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint. J Thorac Dis 2021;13:6037-51. [Crossref] [PubMed]
22. Rosner AK, van der Sluis PC, Meyer L, et al. Pain management after robot-assisted minimally invasive esophagectomy. Heliyon 2023;9:e13842. [Crossref] [PubMed]
23. Fares KM, Mohamed SA, Hamza HM, et al. Effect of thoracic epidural analgesia on pro-inflammatory cytokines in patients subjected to protective lung ventilation during Ivor Lewis esophagectomy. Pain Physician 2014;17:305-15.
24. Chaudhary O, Matyal R, Sharkey A. Erector Spinae Plane Block-Block of Choice for Video-Assisted Thoracic Surgery? Ann Thorac Surg 2021;112:1037-8. [Crossref] [PubMed]
25. Fiorelli S, Leopizzi G, Menna C, et al. Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020;34:2421-9. [Crossref] [PubMed]
26. Zapletal B, Bsuchner P, Begic M, et al. Effectiveness and Safety of Erector Spinae Plane Block vs. Conventional Pain Treatment Strategies in Thoracic Surgery. J Clin Med 2025;14:2870. [Crossref] [PubMed]
27. van den Broek RJC, Postema JMC, Koopman JSHA, et al. Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracoscopic surgery: a prospective randomized open-label non-inferiority trial. Reg Anesth Pain Med 2025;50:11-9. [Crossref] [PubMed]
28. De Cassai A, Tonetti T, Galligioni H, et al. Erector spinae plane block as a multiple catheter technique for open esophagectomy: a case report. Braz J Anesthesiol 2019;69:95-8. [Crossref] [PubMed]
29. Bhat HA, Khan T, Puri A, et al. To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy. J Anesth Analg Crit Care 2024;4:17. [Crossref] [PubMed]
30. Sharma V, Atluri H. Comparison of Continuous Thoracic Epidural Analgesia Versus Bilateral Erector Spinae Plane Block for Pain Management in Coronary Bypass Surgery. Cureus 2024;16:e67149. [Crossref] [PubMed]
31. Mostafa SF, Eid GM. Ultrasound guided erector spinae plane block versus thoracic epidural analgesia in traumatic flail chest, a prospective randomized trial. J Anaesthesiol Clin Pharmacol 2023;39:250-7. [Crossref] [PubMed]
32. Ren Y, Zheng T, Hua L, et al. The Effect of Ultrasound-Guided Erector Spinae Plane Block versus Thoracic Epidural Block on Postoperative Analgesia After Nuss Surgery in Paediatric Patients: Study Protocol of a Randomized Non-Inferiority Design Trial. J Pain Res 2021;14:3047-55. [Crossref] [PubMed]