Erector Spinae Plane Block versus Intercostal Nerve Blocks in Uniportal Videoscopic-assisted Thoracic Surgery: A Multicenter, Double-blind, Prospective Randomized Placebo-controlled Trial

Background: Although intercostal nerve blocks are sometimes approached with caution due to concerns about potentially high local anesthetic uptake, they remain a valuable tool in specific clinical situations. On the other hand, the erector spinae plane block is currently often favored for its broader coverage and versatility. The hypothesis was that the intercostal nerve block, applied directly by surgeons under direct vision in patients undergoing uniportal video-assisted thoracoscopic surgery, might offer superior analgesia and fewer complications compared to the erector spinae plane block. Methods: In this multicenter, double-blind, placebo-controlled randomized trial, 100 patients undergoing uniportal thoracoscopic surgery (wedge excision or lobectomy) within an enhanced recovery program received either a surgical intercostal nerve block under thoracoscopic guidance or an ultrasound-guided erector spinae plane block, followed by 30 ml ropivacaine 0.5% (n = 50) or saline (n = 50). The primary outcome measured was 12-h morphine consumption postextubation. Secondary outcomes included 24-h morphine use, pain severity, rescue analgesia need, postoperative complications, and length of stay. Plasma levels of local anesthetics were also assessed. Results: The intercostal nerve block group had significantly lower mean 12-h morphine consumption compared to the erector spinae plane block group (10.9 mg vs . 17.6 mg; P = 0.0015), as well as lower mean 24-h consumption (18.7 mg vs . 26.7 mg; P = 0.018). Intercostal blocks also led to lower pain scores in the first 2 h postoperatively and a reduced need for rescue analgesia (16% vs . 40%; P = 0.0033). No differences were found in patient satisfaction, complications, or length of stay. Notably, the erector spinae plane block group showed higher systemic absorption of local anesthetics. Conclusions: For uniportal thoracoscopic surgery, intercostal nerve block significantly reduces morphine consumption and systemic anesthetic absorption compared to erector spinae plane block.