Our patient, a 52-year-old male (165 cm, 90 kg), was a known case of chronic lymphocytic leukemia (CLL, Rai Stage II). He had received two cycles of bendamustine and rituximab-based chemotherapy in two consecutive months. He developed herpes zoster infection in the following month and was started on oral acyclovir after consultation with a dermatologist. One week later, he visited our pain clinic and complained of severe pain on the right side of his lower back []. The pain was burning in nature and was associated with allodynia and restricted mobility. A diagnosis of PNH was made, and he was started on gabapentin in view of neuropathic nature of pain. The dermatomal distribution of the pain was from T11 to S1. The pain was affecting the quality of life of the patient and the pharmacological therapy was inadequate.\nWe decided to perform a right-sided ESPB in prone position for acute pain relief of the patient. A high-frequency linear ultrasound probe was placed in longitudinal orientation, about 3 cm lateral to the spinous process of the third lumbar vertebra. The interfacial plane below the erector spinae muscle was identified, and 0.25% bupivacaine and triamcinolone 40 mg (total volume 30 ml) were injected []. Patient's NRS score was decreased from 8/10 to 3/10 30 min after the block procedure. Later on, the ESPB was performed two times for 2 weeks and provided effective analgesia for the PHN. The patient reported a decline in pain score and analgesics consumption in follow-up clinics.
An 86-year-old female patient weighing 82 kg with 1-week-old right femoral neck fracture was scheduled for internal fixation or hemiarthroplasty. Medical history was significant for hearing loss, cerebrovascular event 7 years ago and severe aortic stenosis. Physical examination and laboratory tests were positive for Grade IV murmur on the aortic area and high serum creatinine (2.33 mg/dl). Peripheral arterial blood gases without O2 support were as follows: pH: 7.40, PaCO2: 38.3 mmHg PaO2: 66.7 mmHg and O2 saturation: 90%. Posterior-anterior chest X-ray showed right hilar widening, elevated left hemidiaphragm and an area of atelectasis/mass in the left basal segment. Initial electrocardiogram (ECG) revealed atrial fibrillation-flutter and a follow-up ECG demonstrated sinus rhythm. Patient was classified as being American Society of Anesthesiology Class 4. The patient and family were informed of the high risk of morbidity and mortality and written informed consent was obtained. After considering all comorbidities, general or spinal/epidural anaesthesia was considered to be of considerable risk. Therefore, a combination of peripheral nerve blocks was considered as alternatives. Premedication of 1 mg midazolam was performed. Invasive arterial pressure monitoring added to standard monitorisation plan.\nPatient was placed in the left lateral decubitus position. After aseptic precautions and skin preparation, the fourth lumbar vertebral spinous process was identified, and a low-frequency convex transducer was placed 4 cm lateral to the midline on the parasagittal plane. The transverse process and erector spinae muscles were visualised. A 10 cm 22G needle was advanced using the out-of-plane technique. After contact with the transverse process, local anaesthetic (0.5% bupivacaine 20 ml, 2% lidocaine 8 ml and 12 ml isotonic saline) was administered. Thereafter, the transducer was placed in the transverse plane on the flank of the patient cranial to the iliac crest. The fourth lumbar vertebral transverse process, erector spinae psoas and quadratus lumborum muscles were identified. A 15 cm 22G needle was inserted on the posterior corner of the convex probe. Twenty millilitres of local anaesthetic (0.5% bupivacaine 10 ml, 2% lidocaine 4 ml and 6 ml isotonic NaCl) was administered between the quadratus lumborum and psoas muscles. This ratio of LA was chosen considering toxic levels of each component and is customised for this patient.\nFollowing blocks, the patient was placed in the supine position. After 20 min, pinprick test revealed sensory block between T10 and L4 dermatomes. The patient was able to move her feet; however, there was no movement of the hip joint. The patient had no pain. There was no sensorial or motor block on the contralateral side, possibly excluding the presence of epidural spread. Surgery commenced at 35th min following nerve block. Partial hip prosthesis was performed in 2 h. Twenty-five micrograms of fentanyl was administered once for arterial line placement and once because of the slight increase in blood pressure, making the total administered dose 50 mcg. Interventions involving the medial aspect of the femur, innervated by the obturator nerve, led to mild pain and increments of 10 mg of intravenous ketamine was given totalling 40 mg. Post-operative analgesia plan included paracetamol that was administered every 8 h. Examination at postoperative 12th h revealed no pain at rest or on movement. Numeric Rating Scale was ≤2/10 for the first 16 post-operative hours during which time rescue analgesia was not required.