Erector Spinae Plane Block for Acute Pain Management of Pancreatic Cancer at the Emergency Department

Erector Spinae Plane Block for Acute Pain Management of Pancreatic Cancer at the Emergency Department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Erector Spinae Plane Block for Acute Pain Management of Pancreatic Cancer at the Emergency Department Osman Adi, Chan Pei Fong, Azma Haryaty Ahmad, Muhamad Rasydan Abd Ghani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7350964/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Nov, 2025 Read the published version in The Ultrasound Journal → Version 1 posted You are reading this latest preprint version Abstract Pancreatic cancer is often associated with severe and refractory pain due to tumour invasion of surrounding neural structures and visceral organs. Conventional pain management strategies, including opioids, are often insufficient and associated with significant side effects. The erector spinae plane block (ESPB) is an interfascial regional anaesthesia technique that has shown promise in managing thoracic and abdominal pain. This case series describe the use of ESPB in four pancreatic cancer patients with refractory pain. All patients reported significant pain relief and reduced opioid requirements following the procedure. This article highlights the potential role of ESPB as an adjunctive therapy for acute pain management in pancreatic cancer in emergency department with discussion on its technical aspect, mechanism, and clinical implication. Acute pain in emergency department Pancreatic cancer Regional anesthesia Erector spinae plane block Figures Figure 1 Figure 2 Introduction Pancreatic cancer is the seventh leading cause of cancer death worldwide with a 5-year survival rate of less than 10% (1). Pain is a very prominent feature of this condition, due to tumour invasion of surrounding structures, neural plexus and visceral organs, with 80% of the patients affected as the disease progresses (2). Pain is often severe, localized to the epigastrium, and radiates to the back, significantly impairing quality of life. Conventional pain management relies heavily on opioids, which are associated with side effects such as sedation, constipation, and tolerance (3). The erector spinae plane block (ESPB) is an interfascial plane block (4) that has gained popularity for its efficacy in pain management (5). Multiple case reports had described the use of regional anaesthesia in the emergency department for analgesia in rib fractures (6), abdominal pain (7), severe burns (8) and orthopaedic procedure (9). To our knowledge, limited studies had been conducted for ESB in pancreatic cancer patients at the emergency department (10). This case series explore the use of ESPB in four pancreatic cancer patients with acute and refractory pain at the emergency department. Case Series Case 1: A 62-year-old male with stage IV pancreatic adenocarcinoma presented with severe epigastric and back pain, rated 9/10 on the numeric rating scale (NRS), despite on high-dose opioids (morphine equivalent daily dose [MEDD] of 120 mg) and adjuvant gabapentin. Physical examination revealed tenderness in the epigastrium and mid-back. An ultrasound-guided ESPB was performed at the T8 level bilaterally using 20 mL of 0.25% levobupivacaine on each side. The needle was advanced in-plane to the transverse process, and local anaesthesia spread was observed real time with ultrasound. Within 30 minutes, the patient reported a reduction in pain score to 1/10. Opioid requirements decreased by 50% (MEDD of 60 mg) over the next 24 hours, and the patient reported improved sleep and mobility. No complications were observed [ Table 1]. Case 2: A 58-year-old female with locally advanced pancreatic cancer experienced intractable abdominal pain (NRS 9/10) radiating to the back. She was on a MEDD of 150 mg and reported inadequate pain control. Bilateral ESPB at T9 was performed using 20 mL of 0.25% levobupivacaine on each side. Her pain score decreased to 1/10 within 45 minutes, and the patient remained comfortable for 15 hours. Opioid use was reduced by 60% (MEDD of 60 mg), and the patient reported improved appetite and mood [ Table 1]. Case 3: A 70-year-old male with metastatic pancreatic cancer was awaiting admission at the emergency department for ascending cholangitis. He complaint of unbearable right hypochondrium pain (NRS 9/10). He underwent unilateral ESPB at T8 on the affected side using 25 mL of 0.25% levobupivacaine. Pain scores decreased to 0/10, and opioid requirement was reduced by 50% (MEDD from 120 mg to 60 mg) over the next 10 hours [ Table 1].The patient reported no adverse effects and expressed satisfaction with the treatment. Case 4: A 65-year old Malay female with a late-stage pancreatic carcinoma under palliative care presented with unbearable upper back pain (NRS 9/10). While waiting for ward admission, she received bilateral ESPB at T8 using 20 mL of 0.25% 0.25% levobupivacaine on each side without any complications. Pain scores dropped to 1/10, and the patient reported sustained pain relief for 12 hours [ Table 1].Opioid use was reduced by 70% (MEDD from 80 mg to 24 mg), and the patient passed away peacefully the next day. Discussion This case series demonstrated the feasibility of ESPB in managing pain in pancreatic cancer patients at the emergency department. All four patients experienced significant pain relief, reduced opioid requirements, and satisfaction following the procedure. The reduction in opioid requirements is particularly significant, as it minimizes the side effects associated with high-dose opioids, such as sedation, constipation, and respiratory depression ( 11 ). The pathophysiology of pain in pancreatic malignancy is complex. Visceral pain can occur due to pancreatic duct obstruction and the surrounding viscera inflammation. Cancer extension into the peritoneum and bones cause somatic pain. Neuropathic pain occurs due to nerve plexus invasion by metastasis from the pancreatic malignancy. The pain signals enter the celiac nerve plexus at the level of T12-L1 vertebra and synapse through the splanchnic nerves via the T5-T12 dorsal root ganglia (123). The choice of T7-T10 levels for ESPB in these cases was based on the anatomical location of pancreatic pain, which often involves the upper abdomen and mid-back. ESPB can be performed to relieve the visceral, somatic and neuropathic pain caused by pancreatic cancer. By injecting local anaesthesia deep to the erector spinae muscle at the tip transverse process, three mechanisms of action are proposed. First, somatic anaesthesia is provided due to the spread to dorsal rami; which supply the posterior wall, and ventral rami; which supply the anterolateral wall ( 4 ). Second, spread to the paravertebral space gives visceral coverage through the rami communicantes which transmit sympathetic nerves ( 11 ). Third, the drug can also spread through the fascial plane cephalad caudally up to 9 dermatomal levels with the median value of 3.4ml volume per desired vertebral level (135). Traditionally, when pain is uncontrollable in pancreatic cancer, patients may be offered second line pain intervention that is more invasive. This include neuroaxial analgesia such as intrathecal or epidural, sympathetic block such as celiac plexus neurolysis, peripheral nerve blocks and interruption of pain pathway with percutaneous cordotomy ( 14 ). Neuroaxial analgesia are limited by its of complications such as pneumothorax, and contraindications such as coagulopathy ( 12 ). Other peripheral nerve blocks such as rectus sheath block and transverse abdominis block provide primary somatic analgesia compare to ESPB, which also provide visceral coverage ( 15 ). ESPB is relatively easy to perform under ultrasound guidance and has a favourable safety profile ( 16 ). In fact, ESPB has been recognized as one of the Plan A blocks, a set of basic regional blocks that can be performed by non-experts ( 17 ). Although some minor complications had been reported such as motor block and hypotension ( 18 ), the complication rate estimate was found to be less than two cases per 10,000 patients which is consistent with other thoracic fascial plane blocks ( 19 ). The use of ESPB in chronic cancer pain is still not popular. This is because, the pain relief is short term, unless a catheter is inserted to provide longer analgesia. Furthermore, performing ESPB in a cancer patient may be challenging due to distorted neuroanatomy and difficult positioning ( 20 ). However, providing a temporary pain relief via ESPB is still worthwhile due to the lack of monitoring for high dose of opioids for breakthrough pain in a busy emergency department. While ESPB appears to be a promising intervention, further studies are needed to establish its safety, efficacy, and optimal technique in pancreatic cancer patients. Randomized controlled trials comparing ESPB to conventional pain management strategies are warranted. Additionally, the long-term outcomes and potential role of continuous ESPB via catheter placement should be explored. Conclusion Erector spinae plane block is a promising adjunctive therapy for pain management in pancreatic cancer patients. It provides significant pain relief, and reduces opioid requirements. The procedure is technically straightforward and has a favourable safety profile. Larger studies are needed to confirm these findings and establish ESPB as a standard component of multimodal pain management in pancreatic cancer. Declarations Author Contribution DeclarationsEthics approval and consent to participate The study was approved by Medical Research and Ethics Committee of Malaysia Ministry of Health was granted and obtained from the patient's parents before enrolment in the studyConsent for publicationConsent for publication was obtained and with permission from Director of Health , Ministry of Health , Malaysia.Availability of data and materials The materials are available from the corresponding author on reasonable request.Competing interests The authors declare that they have no competing interests. Funding information Authors received no funding for this study from any institution/ individual. Authors' contributionAO, CPF, AHA , SF ,& MRAG was involved in the initial conception and drafting of the manuscript. All authors contributed to the image interpretation, writing and revision of the manuscript.AcknowledgementsThe authors would like to thank Ipoh Emergency Critical Care Society (IECCS), Clinical Research Centre (CRC) HRPB, Ipoh, for their support and assistance and Director General of Health , Ministry of Health , Malaysia for his permission to publish this article. Acknowledgement The authors would like to thank Ipoh Emergency Critical Care Society (IECCS), Clinical Research Centre (CRC) HRPB, Ipoh, for their support and assistance and Director General of Health , Ministry of Health , Malaysia for his permission to publish this article. References Hu JX, Zhao CF, Chen WB, Liu QC, Li QW, Lin YY, Gao F. Pancreatic cancer: A review of epidemiology, trend, and risk factors. World J Gastroenterol. 2021 Jul 21;27(27):4298-4321. doi: 10.3748/wjg.v27.i27.4298. PMID: 34366606; PMCID: PMC8316912 Koulouris AI, Banim P, Hart AR. Pain in Patients with Pancreatic Cancer: Prevalence, Mechanisms, Management and Future Developments. Dig Dis Sci. 2017 Apr;62(4):861-870. doi: 10.1007/s10620-017-4488-z. Epub 2017 Feb 22. PMID: 28229252 Cui Y, Wang Y, Yang J, et al. The Effect of Single-Shot Erector Spinae Plane Block (ESPB) on Opioid Consumption for Various Surgeries: A Meta-Analysis of Randomized Controlled Trials. J Pain Res. 2022;15:683-699. Published 2022 Mar 6. doi:10.2147/JPR.S346809 Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016 Sep-Oct;41(5):621-7. doi: 10.1097/AAP.0000000000000451. PMID: 27501016. Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2021;68:110063. doi:10.1016/j.jclinane.2020.110063 Surdhar I, Jelic T. The erector spinae plane block for acute pain management in emergency department patients with rib fractures. CJEM. 2022 Jan;24(1):50-54. doi: 10.1007/s43678-021-00203-x. Epub 2021 Oct 20. PMID: 34669173 Gopinath B, Mathew R, Bhoi S, Nayaka R, Muvalia G. Erector spinae plane block for pain control in patients with pancreatitis in the emergency department. Turk J Emerg Med. 2021;21(3):129-132. Published 2021 Jul 7. doi:10.4103/2452-2473.320806 Ueshima H, Otake H. Continuous erector spinae plane block for pain management of an extensive burn [published correction appears in Am J Emerg Med. 2021 Sep;47:353. doi: 10.1016/j.ajem.2021.06.047.]. Am J Emerg Med. 2018;36(11):2130.e1-2130.e2. doi:10.1016/j.ajem.2018.07.014 Beh ZY, Osman A, Fathil S, Karmakar MK. Ultrasound guided interscalene brachial plexus block with low dose sedation - Technique of choice for reducing shoulder dislocation. Am J Emerg Med. 2018;36(4):717-718. doi:10.1016/j.ajem.2018.01.013 Aydın T, Balaban O, Demir L. Ultrasound-guided erector spinae plane block for pain management in pancreatic cancer: A case report. Pankreas kanserinde ağrı tedavisi için ultrason eşliğinde erektor spina plan bloğu: Olgu sunumu. Agri. 2019;31(4):218-219. doi:10.14744/agri.2019.09815 Abdelhamid K, ElHawary H, Turner JP. The Use of the Erector Spinae Plane Block to Decrease Pain and Opioid Consumption in the Emergency Department: A Literature Review. J Emerg Med. 2020 Apr;58(4):603-609. doi: 10.1016/j.jemermed.2020.02.022. Epub 2020 Mar 31. PMID: 32245689. Lahoud MJ, Kourie HR, Antoun J, El Osta L, Ghosn M. Road map for pain management in pancreatic cancer: A review. World J Gastrointest Oncol. 2016 Aug 15;8(8):599-606. doi: 10.4251/wjgo.v8.i8.599. PMID: 27574552; PMCID: PMC4980650. De Cassai A, Tonetti T. Local anesthetic spread during erector spinae plane block. J Clin Anesth. 2018 Aug;48:60-61. doi: 10.1016/j.jclinane.2018.05.003. Epub 2018 May 10. PMID: 29753992. Kurita GP, Sjøgren P, Klepstad P, Mercadante S. Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects. Cancers (Basel). 2019;11(4):443. Published 2019 Mar 29. doi:10.3390/cancers11040443 Kwon HM, Kim DH, Jeong SM, et al. Does Erector Spinae Plane Block Have a Visceral Analgesic Effect?: A Randomized Controlled Trial. Sci Rep. 2020;10(1):8389. Published 2020 May 21. doi:10.1038/s41598-020-65172-0 Kot P, Rodriguez P, Granell M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209-220. doi:10.4097/kja.d.19.00012 Altıparmak B, Korkmaz Toker M, Uysal Aİ, Gümüş Demirbilek S. Bi-level erector spinae plane block for the control of severe back pain related to vertebral metastasis. BMJ Case Rep. 2019 Jun 20;12(6):e228129. doi: 10.1136/bcr-2018-228129. PMID: 31227568; PMCID: PMC6605916. Pawa A, King C, Thang C, White L. Erector spinae plane block: the ultimate 'plan A' block?. Br J Anaesth. 2023;130(5):497-502. doi:10.1016/j.bja.2023.01.012 De Cassai A, Geraldini F, Carere A, Sergi M, Munari M. Complications Rate Estimation After Thoracic Erector Spinae Plane Block. J Cardiothorac Vasc Anesth. 2021;35(10):3142-3143. doi:10.1053/j.jvca.2021.02.043 Chambers WA. Nerve blocks in palliative care. Br J Anaesth. 2008;101(1):95-100. doi:10.1093/bja/aen105 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Nov, 2025 Read the published version in The Ultrasound Journal → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7350964","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":503669711,"identity":"5c5afcc5-a6a5-4efd-b51c-f9b47e670baa","order_by":0,"name":"Osman Adi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBADxjb2BiBlYEGKFp4DIC0SJGhpkEgA0URo4ec/nfi5gMFOtk/y+dUNPwokGPjbuxPwapGckbtZegZDsnGbdE7ZzR6gwyTOnN2AV4vBDd4N0jwMzIlALWk3eIBaDCRyCWg5f3bzbx6G+sQ2yTNpN/8QpeVA7jagLYcT2yTYj90myhagX7ZZ8xgcN27jyWG7LWMgwUPQL/z8Zzff5qmolp3ffvzZzTd/bOT423vxa4E6D0TwQEgilMMB+wNSVI+CUTAKRsEIAgAU0UH+sufN8QAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Osman","middleName":"","lastName":"Adi","suffix":""},{"id":503669712,"identity":"faac7baf-fefe-405a-8457-d7e05c5982af","order_by":1,"name":"Chan Pei Fong","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Chan","middleName":"Pei","lastName":"Fong","suffix":""},{"id":503669713,"identity":"1c0d32e3-4176-4a2d-92e7-0abf2193f495","order_by":2,"name":"Azma Haryaty Ahmad","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Azma","middleName":"Haryaty","lastName":"Ahmad","suffix":""},{"id":503669714,"identity":"83de36b8-e009-4a6a-8750-639d2eeeea19","order_by":3,"name":"Muhamad Rasydan Abd Ghani","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Muhamad","middleName":"Rasydan Abd","lastName":"Ghani","suffix":""},{"id":503669715,"identity":"b1555e71-63a8-4d0e-825c-41d6f72dab22","order_by":4,"name":"Shahridan Fathil","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Shahridan","middleName":"","lastName":"Fathil","suffix":""}],"badges":[],"createdAt":"2025-08-12 03:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7350964/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7350964/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13089-025-00461-1","type":"published","date":"2025-11-04T15:56:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89656117,"identity":"483fe03b-4f71-4788-90e1-a9e4a18971b0","added_by":"auto","created_at":"2025-08-22 10:27:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":245290,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound image showing the needle advancing into the T8 transverse process.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7350964/v1/bd0e4caf5fb5fe3bf434e5a9.jpg"},{"id":89657562,"identity":"184de775-68a8-41a1-b09d-fc6ccbda963b","added_by":"auto","created_at":"2025-08-22 10:35:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":336517,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of local anaesthesia spread in the erector spinae plane.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7350964/v1/68b85471cd0f61e9c34a91d2.jpg"},{"id":95563930,"identity":"6c787ccc-4f14-4352-a180-9477390070d9","added_by":"auto","created_at":"2025-11-10 16:04:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":900548,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7350964/v1/a9cdd65d-9bab-4ef6-933d-386a3ab436df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Erector Spinae Plane Block for Acute Pain Management of Pancreatic Cancer at the Emergency Department","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePancreatic cancer is the seventh leading cause of cancer death worldwide with a 5-year survival rate of less than 10% (1). Pain is a very prominent feature of this condition, due to tumour invasion of surrounding structures, neural plexus and visceral organs, with 80% of the patients affected as the disease progresses (2). \u0026nbsp;Pain is often severe, localized to the epigastrium, and radiates to the back, significantly impairing quality of life. Conventional pain management relies heavily on opioids, which are associated with side effects such as sedation, constipation, and tolerance (3).\u003c/p\u003e\n\u003cp\u003eThe erector spinae plane block (ESPB) is an interfascial plane block (4) that has gained popularity for its efficacy in pain management (5). Multiple case reports had described the use of regional anaesthesia in the emergency department for analgesia in rib fractures (6), abdominal pain (7), severe burns (8) and orthopaedic procedure (9).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo our knowledge, limited studies had been conducted for ESB in pancreatic cancer patients at the emergency department (10). This case series explore the use of ESPB in four pancreatic cancer patients with acute and refractory pain at the emergency department.\u003c/p\u003e"},{"header":"Case Series","content":"\u003cp\u003e\u003cstrong\u003eCase 1:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A 62-year-old male with stage IV pancreatic adenocarcinoma presented with severe epigastric and back pain, rated 9/10 on the numeric rating scale (NRS), despite on high-dose opioids (morphine equivalent daily dose [MEDD] of 120 mg) and adjuvant gabapentin. Physical examination revealed tenderness in the epigastrium and mid-back. An ultrasound-guided ESPB was performed at the T8 level bilaterally using 20 mL of 0.25% levobupivacaine on each side. The needle was advanced in-plane to the transverse process, and local anaesthesia spread was observed real time with ultrasound. Within 30 minutes, the patient reported a reduction in pain score to 1/10. Opioid requirements decreased by 50% (MEDD of 60 mg) over the next 24 hours, and the patient reported improved sleep and mobility. No complications were observed [ Table 1].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 2:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 58-year-old female with locally advanced pancreatic cancer experienced intractable abdominal pain (NRS 9/10) radiating to the back. She was on a MEDD of 150 mg and reported inadequate pain control. Bilateral ESPB at T9 was performed using 20 mL of 0.25% levobupivacaine on each side. Her pain score decreased to 1/10 within 45 minutes, and the patient remained comfortable for 15 hours. Opioid use was reduced by 60% (MEDD of 60 mg), and the patient reported improved appetite and mood [ Table 1].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 3:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A 70-year-old male with metastatic pancreatic cancer was awaiting admission at the emergency department for ascending cholangitis. He complaint of unbearable right hypochondrium pain (NRS 9/10). He underwent unilateral ESPB at T8 on the affected side using 25 mL of 0.25% levobupivacaine. Pain scores decreased to 0/10, and opioid requirement was reduced by 50% (MEDD from 120 mg to 60 mg) over the next 10 hours [ Table 1].The patient reported no adverse effects and expressed satisfaction with the treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 4:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 65-year old Malay female with a late-stage pancreatic carcinoma under palliative care presented with unbearable upper back pain (NRS 9/10). While waiting for ward admission, she received bilateral ESPB at T8 using 20 mL of 0.25% 0.25% levobupivacaine on each side without any complications. Pain scores dropped to 1/10, and the patient reported sustained pain relief for 12 hours [ Table 1].Opioid use was reduced by 70% (MEDD from 80 mg to 24 mg), and the patient passed away peacefully the next day.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis case series demonstrated the feasibility of ESPB in managing pain in pancreatic cancer patients at the emergency department. All four patients experienced significant pain relief, reduced opioid requirements, and satisfaction following the procedure. The reduction in opioid requirements is particularly significant, as it minimizes the side effects associated with high-dose opioids, such as sedation, constipation, and respiratory depression (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe pathophysiology of pain in pancreatic malignancy is complex. Visceral pain can occur due to pancreatic duct obstruction and the surrounding viscera inflammation. Cancer extension into the peritoneum and bones cause somatic pain. Neuropathic pain occurs due to nerve plexus invasion by metastasis from the pancreatic malignancy. The pain signals enter the celiac nerve plexus at the level of T12-L1 vertebra and synapse through the splanchnic nerves via the T5-T12 dorsal root ganglia (123). The choice of T7-T10 levels for ESPB in these cases was based on the anatomical location of pancreatic pain, which often involves the upper abdomen and mid-back.\u003c/p\u003e\u003cp\u003eESPB can be performed to relieve the visceral, somatic and neuropathic pain caused by pancreatic cancer. By injecting local anaesthesia deep to the erector spinae muscle at the tip transverse process, three mechanisms of action are proposed. First, somatic anaesthesia is provided due to the spread to dorsal rami; which supply the posterior wall, and ventral rami; which supply the anterolateral wall (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Second, spread to the paravertebral space gives visceral coverage through the rami communicantes which transmit sympathetic nerves (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Third, the drug can also spread through the fascial plane cephalad caudally up to 9 dermatomal levels with the median value of 3.4ml volume per desired vertebral level (135).\u003c/p\u003e\u003cp\u003eTraditionally, when pain is uncontrollable in pancreatic cancer, patients may be offered second line pain intervention that is more invasive. This include neuroaxial analgesia such as intrathecal or epidural, sympathetic block such as celiac plexus neurolysis, peripheral nerve blocks and interruption of pain pathway with percutaneous cordotomy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Neuroaxial analgesia are limited by its of complications such as pneumothorax, and contraindications such as coagulopathy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Other peripheral nerve blocks such as rectus sheath block and transverse abdominis block provide primary somatic analgesia compare to ESPB, which also provide visceral coverage (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eESPB is relatively easy to perform under ultrasound guidance and has a favourable safety profile (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In fact, ESPB has been recognized as one of the Plan A blocks, a set of basic regional blocks that can be performed by non-experts (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Although some minor complications had been reported such as motor block and hypotension (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), the complication rate estimate was found to be less than two cases per 10,000 patients which is consistent with other thoracic fascial plane blocks (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe use of ESPB in chronic cancer pain is still not popular. This is because, the pain relief is short term, unless a catheter is inserted to provide longer analgesia. Furthermore, performing ESPB in a cancer patient may be challenging due to distorted neuroanatomy and difficult positioning (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, providing a temporary pain relief via ESPB is still worthwhile due to the lack of monitoring for high dose of opioids for breakthrough pain in a busy emergency department.\u003c/p\u003e\u003cp\u003eWhile ESPB appears to be a promising intervention, further studies are needed to establish its safety, efficacy, and optimal technique in pancreatic cancer patients. Randomized controlled trials comparing ESPB to conventional pain management strategies are warranted. Additionally, the long-term outcomes and potential role of continuous ESPB via catheter placement should be explored.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eErector spinae plane block is a promising adjunctive therapy for pain management in pancreatic cancer patients. It provides significant pain relief, and reduces opioid requirements. The procedure is technically straightforward and has a favourable safety profile. Larger studies are needed to confirm these findings and establish ESPB as a standard component of multimodal pain management in pancreatic cancer.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDeclarationsEthics approval and consent to participate The study was approved by Medical Research and Ethics Committee of Malaysia Ministry of Health was granted and obtained from the patient's parents before enrolment in the studyConsent for publicationConsent for publication was obtained and with permission from Director of Health , Ministry of Health , Malaysia.Availability of data and materials The materials are available from the corresponding author on reasonable request.Competing interests The authors declare that they have no competing interests. Funding information Authors received no funding for this study from any institution/ individual. Authors' contributionAO, CPF, AHA , SF ,\u0026amp; MRAG was involved in the initial conception and drafting of the manuscript. All authors contributed to the image interpretation, writing and revision of the manuscript.AcknowledgementsThe authors would like to thank Ipoh Emergency Critical Care Society (IECCS), Clinical Research Centre (CRC) HRPB, Ipoh, for their support and assistance and Director General of Health , Ministry of Health , Malaysia for his permission to publish this article.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Ipoh Emergency Critical Care Society (IECCS), Clinical Research Centre (CRC) HRPB, Ipoh, for their support and assistance and Director General of Health , Ministry of Health , Malaysia for his permission to publish this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHu JX, Zhao CF, Chen WB, Liu QC, Li QW, Lin YY, Gao F. 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PMID: 27501016.\u003c/li\u003e\n\u003cli\u003eSaadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2021;68:110063. doi:10.1016/j.jclinane.2020.110063\u003c/li\u003e\n\u003cli\u003eSurdhar I, Jelic T. The erector spinae plane block for acute pain management in emergency department patients with rib fractures. CJEM. 2022 Jan;24(1):50-54. doi: 10.1007/s43678-021-00203-x. Epub 2021 Oct 20. PMID: 34669173\u003c/li\u003e\n\u003cli\u003eGopinath B, Mathew R, Bhoi S, Nayaka R, Muvalia G. Erector spinae plane block for pain control in patients with pancreatitis in the emergency department. Turk J Emerg Med. 2021;21(3):129-132. Published 2021 Jul 7. doi:10.4103/2452-2473.320806\u003c/li\u003e\n\u003cli\u003eUeshima H, Otake H. 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Br J Anaesth. 2023;130(5):497-502. doi:10.1016/j.bja.2023.01.012\u003c/li\u003e\n\u003cli\u003eDe Cassai A, Geraldini F, Carere A, Sergi M, Munari M. Complications Rate Estimation After Thoracic Erector Spinae Plane Block. J Cardiothorac Vasc Anesth. 2021;35(10):3142-3143. doi:10.1053/j.jvca.2021.02.043\u003c/li\u003e\n\u003cli\u003eChambers WA. Nerve blocks in palliative care. Br J Anaesth. 2008;101(1):95-100. doi:10.1093/bja/aen105\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute pain in emergency department, Pancreatic cancer, Regional anesthesia, Erector spinae plane block","lastPublishedDoi":"10.21203/rs.3.rs-7350964/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7350964/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePancreatic cancer is often associated with severe and refractory pain due to tumour invasion of surrounding neural structures and visceral organs. Conventional pain management strategies, including opioids, are often insufficient and associated with significant side effects. The erector spinae plane block (ESPB) is an interfascial regional anaesthesia technique that has shown promise in managing thoracic and abdominal pain. This case series describe the use of ESPB in four pancreatic cancer patients with refractory pain. All patients reported significant pain relief and reduced opioid requirements following the procedure. This article highlights the potential role of ESPB as an adjunctive therapy for acute pain management in pancreatic cancer in emergency department with discussion on its technical aspect, mechanism, and clinical implication.\u003c/p\u003e","manuscriptTitle":"Erector Spinae Plane Block for Acute Pain Management of Pancreatic Cancer at the Emergency Department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 10:27:42","doi":"10.21203/rs.3.rs-7350964/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d14e5fe-60ad-40be-8e5b-9e5221944452","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T15:59:11+00:00","versionOfRecord":{"articleIdentity":"rs-7350964","link":"https://doi.org/10.1186/s13089-025-00461-1","journal":{"identity":"the-ultrasound-journal","isVorOnly":false,"title":"The Ultrasound Journal"},"publishedOn":"2025-11-04 15:56:56","publishedOnDateReadable":"November 4th, 2025"},"versionCreatedAt":"2025-08-22 10:27:42","video":"","vorDoi":"10.1186/s13089-025-00461-1","vorDoiUrl":"https://doi.org/10.1186/s13089-025-00461-1","workflowStages":[]},"version":"v1","identity":"rs-7350964","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7350964","identity":"rs-7350964","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}