Twelve patients (age: 22–68 years, male—8, female—4) who suffered from isolated fractures of the proximal humerus and shaft femur were to undergo open and open or close surgical fixation of the fractures of the humerus and femur respectively. The side of fractures and type of blocks are mentioned in Table 1. All patients were evaluated by specialists and optimized before surgery. None of them had brain injuries. They received intravenous paracetamol 1 g in the casualty and infusion every 8th h. Upon admission, of the 12, three patients suffering from multiple rib fractures (3 in number) and with rib fracture score (Fokin et al. 2018) of more than 7 received single bolus serratus anterior plane block (30 ml 0.2% ropivacaine and 30-μg clonidine).

After obtaining consent from the ethical committee, patients were recruited for the cervical and lumbar ESPB. Informed consent for a continuous cervical and lumbar ESPB is to be administered after general anesthesia, as an interventional pain management technique for postoperative pain relief was obtained. They were also notified in the event of pain persisting with these techniques; intravenous fentanyl as a rescue analgesic would be infused. General anesthesia was induced with a standard protocol (fentanyl, propofol, cis-atracurium, sevoflurane). Electrocardiogram, oxygen saturation, non-invasive arterial blood pressure, and end-tidal carbon dioxide were monitored intraoperatively.

The lumbar ESPB was administered at the level of the L3 transverse process (TP) identified in the parasagittal plane. An 18-G Tuohy needle was inserted from cephalad to caudal, and the tip of the needle was positioned deep to the erector spinae muscle and superficial to the tip of the L3 TP. After an initial injection of 15-ml 0.2% ropivacaine through the needle, a catheter was introduced, and the remaining 15-ml 0.2% ropivacaine was administered through the catheter (Fig. 1A).

A Lumbar ESP catheter at the level of L2 in the long axis in the non-dependant and operative side. The catheter is directed in-plane from the cephalad to the caudal. B Cervical ESP catheter at the level of T1 in the long axis in the non-dependant operative side. The catheter is directed in-plane from the caudal to the cephalad. C Subcutaneous tunnelling (SCT) of the L-ESPB catheter. D Dual ESPB (cervical—CESP and lumbar—LESP) catheter at the cervical and lumbar level. E Postoperative infusions (circled yellow) of cervical and lumbar catheters in the ICU

The first rib was identified, following which a linear probe was deployed in the parasagittal plane at the first costotransverse junction. An 18-G Tuohy needle was inserted in-plane from caudal to cephalad, and the tip was positioned deep to the erector spinae and superficial to the first costotransverse junction. Initially, 10-ml 0.2% ropivacaine was injected following which a catheter was introduced, and a further 10 ml was injected.

In both blocks, the catheter (20-G multi-hole catheter) was introduced not more than 4–5 cm (Fig. 1B) and was subcutaneously tunneled (Fig. 1C). The catheter sites were labeled as cervical and lumbar ESPB (Fig. 1D), and 0.1% ropivacaine at 6 ml/h was initiated for all patients (Fig. 1E). IV paracetamol 1 g was infused 30 min before surgical closure and 12 hourly thereafter. IV fentanyl 20 μg was used as a rescue analgesic if the visual analog scale (VAS) score persisted more than 4. Pain scores were monitored at 0, 6, 12, 24, and 48 h and were 1.75, 2.5, 1.83, 1.91, and 1.66, respectively.

Catheters were appropriately positioned in all patients at both cervical and lumbar levels. There were no additional requirements for IV fentanyl in the intraoperative period. Hemodynamics were stable throughout the intraoperative period. All patients were successfully extubated postoperatively. None of these patients required IV fentanyl in the postoperative period. Three patients who had MRFs demanded additional analgesics and received intramuscular diclofenac 75 mg 8 hourly. Both catheters were removed at the end of the infusion after 48 h.