68 year old man with rib pain after a fall

68 yo male with a past medical history of chronic back pain, DVT on dabigatran presents several days after a fall. Reports pain in his R posterior ribs.

Patient currently takes oxycodone, acetaminophen, gabapentin for chronic pain and is on clonazepam for anxiety. New rib pain is not controlled with his chronic home medication.

CT showed multiple contiguous rib fractures

Patient’s posterior rib fractures caused significant pain that was difficult to control with IV pain medication.

Do we continue administering parenteral opioids or are there better options to control this patient’s posterior rib pain?

Image at the left shows more lateral rib cage where rib and pleural are visible, while the image at right shows transverse process without rib or pleura. This is the target for the ESPB.

Injection of anesthetic just inferior to the erector spinae muscle plane

Real time ultrasound shows appropriate spread of anechoic anesthesia across the tissue plane deep to the erector spinae muscles and superficial to the transverse processes. 20mL of Ropivacaine was used and patient experienced almost complete resolution of his rib pain.