Sequential use of erector spinae plane block and thoracic epidural analgesia as multimodal regional analgesia in bilateral rib fractures: a case report

Effective pain management is a cornerstone in the treatment of patients with multiple rib fractures, as inadequate analgesia can impair ventilation and increase the risk of pulmonary complications. Bilateral rib fractures, in particular, can significantly compromise respira-tory mechanics, leading to hypoventilation, atelectasis, and hypoxemia. Regional analgesic techniques play a crucial role in improving respiratory function while reducing reliance on opioids and their associated adverse effects. We report the case of a patient with multiple bilateral rib fractures following thoracic trauma who presented with severe pain and compromised respiratory function. Initial management with systemic analgesic proved inadequate. Multimodal regional analgesia was therefore initiated with a bilateral erector spinae plane block, resulting in rapid pain relief and improved oxygenation. Given the limited duration of analgesia provided by a single-shot erector spinae plane block, thoracic epidural analgesia was subsequently established via epidural catheter. Continuous low-dose epidural local anesthetic infusion ensured sustained analgesia, prevented pain recurrence, and supported ongoing improvement in respiratory function throughout the clinical course. This case highlights that a multimodal regional analgesic approach, combining an erector spinae plane block followed by thoracic epidural analgesia, may represent an effective and feasible strategy for optimizing pain control and respiratory outcomes in patients with bilateral rib fractures. Such an approach may also reduce the need for systemic opioid therapy while optimizing clinical outcomes and minimizing associated risks.