Sacral multifidus plane block for high-risk patients undergoing perianal surgery: two case reports

Erector spinae plane block has emerged as an effective analgesic technique. Sacral multifidus plane block (SMPB), a more appropriate term than sacral erector spinae plane block, is used to provide analgesia or anesthesia during various surgeries. However, SMPB has not been reported in high-risk patients. We describe the use of SMPB as an anesthetic technique for high-risk patients requiring anticoagulation or antiplatelet therapy during perianal surgery. SMPB was performed during perianal surgery in two patients: an advanced-age woman with severe aortic stenosis and heart failure and a man with heart failure and a history of sudden cardiac arrest. With the patient in the jackknife position, 10 mL of 0.25% ropivacaine was administered at the S2 and S4 levels after confirming both sacral intermediate crests. After confirming the absence of perineal pain, the surgery was successfully completed under sedation. Neither patient required additional analgesics on the day of surgery. Based on the absence of pain during the perioperative period, SMPB appears to provide effective anesthesia during perianal surgery in high-risk patients. However, further investigations are needed to confirm the mechanism of SMPB.

Multimorbidity; Regional anesthesia; Ropivacaine; Dexmedetomidine

[1] Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). Italian Journal of Cardiology. 2023; 24: e1–e102. (In Italian)

[2] Yap E, Wei J, Webb C, Ng K, Behrends M. Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study. Regional Anesthesia & Pain Medicine. 2022; 47: 294–300.

[3] Sostaric M. Perioperative preparation of cardiac patients in regional anesthesia. Acta Clinica Croatica. 2022; 61: 84–89.

[4] Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Canadian Journal of Anesthesia. 2021; 68: 387–408.

[5] Tulgar S, Senturk O, Thomas DT, Deveci U, Ozer Z. A new technique for sensory blockage of posterior branches of sacral nerves: ultrasound guided sacral erector spinae plane block. Journal of Clinical Anesthesia. 2019; 57: 129–130.

[6] Kukreja P, Deichmann P, Selph JP, Hebbard J, Kalagara H. Sacral erector spinae plane block for gender reassignment surgery. Cureus. 2020; 12: e7665.

[7] Sawyer K, Ceballos B, Kukreja P, Kalagara H. A novel sacral erector spinae block reduces opioid use after gender-affirming vaginoplasty. Journal of Sexual Medicine. 2022; 19: S91.

[8] Mermer A, Simsek G, Mermer HA, Tire Y, Kozanhan B. Effect of sacral erector spinae plane block on post-hemorrhoidectomy pain: a randomized controlled trial. Medicine. 2023; 102: e35168.

[9] Kaya C, Dost B, Tulgar S. Sacral erector spinae plane block provides surgical anesthesia in ambulatory anorectal surgery: two case reports. Cureus. 2021; 13: e12598.

[10] Unal M, Baydar H, Guler S, Sonmez A, Gumus M, Tulgar S. Sacral erector spinae plane block as the main anesthetic method for parasacral reconstructive surgeries: a single-center retrospective cohort feasibility study. Cureus. 2023; 15: e37347.

[11] Hamilton DL. The erector spinae plane block: time for clarity over anatomical nomenclature. Journal of Clinical Anesthesia. 2020; 62: 109699.

[12] Piraccini E, Taddei S. Sacral multifidus plane block: the correct name for sacral erector spinae plane block. Journal of Clinical Anesthesia. 2020; 63: 109754.

[13] Lee HJ, Cho Y, Joo H, Jeon JY, Jang YE, Kim JT. Comparative study of verbal rating scale and numerical rating scale to assess postoperative pain intensity in the post anesthesia care unit: a prospective observational cohort study. Medicine. 2021; 100: e24314.

[14] Rajabi M, Hosseinpour M, Jalalvand F, Afshar M, Moosavi G, Behdad S. Ischiorectal block with bupivacaine for post hemorrhoidectomy pain. The Korean Journal of Pain. 2012; 25: 89–93.

[15] Kilicaslan A, Goger E, Karakus F, Reisli R. Bilevel-bilateral sacral erector spinae plane block for chronic pain management: a case report and short literature review. Selcuk Medical Journal. 2020; 1: 65–69.

[16] Diwan S, Garud R, Sancheti P. Deciphering the mechanism of continuous sacral erector spinae block: a cadaveric study. Turkish Journal of Anaesthesiology And Reanimation. 2022; 50: 471–473.

[17] Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clinical Pharmacokinetics. 2017; 56: 893–913.