A 19-year-old female (50 kg; 160 cm) was admitted in the palliative care unit of our department with complaints of severe burning and stretching pain in the right flank region. Her pain scores were 10/10 on the Numeric Rating Scale (NRS), where 0 means no pain and 10 means worst possible pain. The patient was a postoperative case of desmoid tumor for which resection was done 2 years back []. Skin on the right side flank region develops pain, thickness, and tenderness from the past 6 months. The patient received medical treatment (morphine, nonsteroidal anti-inflammatory drugs [ibuprofen and paracetamol], and gabapentin), but the pain did not improve. Hence, we decided to perform lumbar ESP block.\nUnder all aseptic precautions, a linear ultrasound probe was placed longitudinally at the level of transverse process of L2. The skin was infiltrated with 2 ml of 1% lignocaine. The 10-cm Stimuplex needle (Stimuplex® A, B. Braun Melsungen AG, Germany) was inserted by the in-plane approach to touch the surface of transverse process of L2 []. A total of 20 ml of 0.375% ropivacaine and 40 mg triamcinolone was injected into the target plane between the erector spinae muscles and the transverse process. The patient had adequate pain relief (3/10 on NRS) 10 min after the block and had extensive sensory blockade from dermatome T10 to L5. NRS was noted for 24 h after the procedure []. The patient was discharged with oral medicines tapered. The patient was still pain-free without consumption of any oral analgesics at follow-up after 8 weeks.
Case 1: A 38-year-old male (weight 75 kg, ASA status III) was scheduled for right total hip arthroplasty (THA) due to severe bilateral rigid and sore hip joints. He had a history of ankylosing spondylitis for more than 18 years. Despite a long term usage of sulfasalazine and “painkiller”, the patient developed a rigid kyphotic and scoliotic deformity. An overall physical examination revealed rheumatoid arthritis involved most articles in the body resulting in limited movement and swelling of interphalangeal joints, metacarpophalangeal joints, elbow joints, shoulder joints, and ankle joints, with rigid bilateral hip and knee joints preventing any walk. The airway assessment revealed a Mallampati class III, interincisor distance of 3 cm, and rigid neck incapable of any movement. X-ray of his cervical, thoracic and lumbar vertebrae and pelvis revealed a loss of physiological curvature of the vertebral column, kyphosis, hyperplasia at the edge of the vertebrae, “bamboo” like bony bridge, blurred facet joints, and calcification of ligament, a fusion of both sacroiliac joints, rough articular face and narrowed articular cavity and hyperplasia of both hip joints (Fig. ). After administration, he received immunosuppressive therapy, with prednisone 20 mg per day, and methotrexate 10 mg once per week, and anti-TNF therapy with etanercept (TNF receptor fusion protein) 25 mg i.h. twice per week, and anticoagulation therapy with low-molecular-weight heparin 4000 U per day.