Reply to “Comment on:” Modified lumbar-sacral erector spinae plane block for the treatment of low back pain

Dear Editor, We read with great interest the commentary on the article “Comment on: “Modified lumbar-sacral erector spinae plane block for the treatment of low back pain” by Kurhekar P. et al.,[1] and we are grateful for a quick response to the points raised. Our technique represents a modification of the approach described by Tulgar et al.[2] We employed a double puncture strategy: one in the craniocaudal direction and the second in the caudocranial direction.[3] After reaching the target using the craniocaudal direction, the needle was advanced within the fascial plane to facilitate its opening, resulting in a caudal spread of the local anesthetic. Subsequently, the needle was withdrawn to the subcutaneous plane and redirected in the cranial direction. Once again, the needle was advanced within the fascial plane to facilitate opening in the cranial direction. This dual needling within the fascial planes facilitates the more effective expansion of the fascial plane itself, improves injectate diffusion, and, crucially, disrupts the connective septa.[4] Disruption of connective septa is a key point, as these contribute to the increased stiffness of the myofascial unit and limit the sliding of fascial planes, contributing to a vicious circle that limits mobility and worsens pain. For this reason, we suggest performing fascial plane blocks dynamically to optimize their effectiveness, especially in chronic pain management.[5] Regarding the combination of ropivacaine and dexamethasone, while it is correct that they have different pKa values and, in principle, may form aggregates, to date, there are no specific contraindications for their use and no definite clinical data indicate real risks in the patients. Moreover, several studies demonstrated that adding dexamethasone to local anesthetics significantly prolonged the analgesic effect of the regional anesthesia techniques.[6] In conclusion, we aimed to emphasize the importance of performing fascial plane blocks dynamically to optimize the targeting of the fascial planes and, accordingly, clinical outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.