Comparison of two-level and single-level erector spinae plane block during video-assisted lobectomy: a prospective observational study

Background. Video-assisted thoracic surgery (VATS) is currently one of the minimally invasive methods that allows for faster recovery after thoracic surgery. Despite this, VATS can cause damage to the intercostal nerves, pleura, and muscle trauma, leading to acute pain. If this pain is not controlled in a timely and effective manner, it can affect the results of the surgery, worsen rehabilitation, and lead to chronic pain in the future. Postoperative pain not only causes anxiety and discomfort in patients, but also contributes to poor postoperative outcomes, including delayed mobilization, impaired respiratory physiology, increased opioid use, and prolonged hospital stay. Research and some clinical cases suggest the usefulness of erector spinae plane block (ESPB) for pain control during VATS. However, in this case, the local anesthetic is administered from a single injection site. We hypothesized that ESPB applied at two different levels in the same patient would result in a higher frequency and greater coverage of the surgical incision, as well as anesthetize the insertion of thoracoscopic trocars and the site of pleural drainage. The purpose of the study was to compare the effectiveness of intraoperative and postoperative analgesia in single-level (T5) and two-level (T4 + T6) erector spinae plane blocks in patients who underwent video-assisted lobectomy. Materials and methods. This study was conducted in a prospective design from March to November 2025 and included 30 patients who were divided into two groups depending on the ESPB technique used: in the first group, a single-level block was performed at the T5 level using a single injection, under ultrasound guidance, with 30 ml of 0.25% bupivacaine. In the second group, a two-level block was performed at the T4 and T6 levels using 15 ml of 0.25% bupivacaine for each level. Two groups of 15 patients were compared, they matched for age, gender, ASA, and body mass index. The assessment of results included: pain intensity on a visual analogue scale at rest and when coughing at 1, 2, 4, 12, 24, and 48 hours after surgery; opioid consumption (intraoperative fentanyl; morphine 0–24 and 24–48 hours); sleep quality on the first night using the Richards-Campbell Sleep Questionnaire; glucose levels during and after surgery; forced expiratory volume in one second (FEV1). Results. In our study, more effective intraoperative analgesia and analgesia in the early postoperative period were achieved in the group of two-level ESPB compared to the single-level ESPB group, as evidenced by lower visual analogue scale scores at rest and when coughing, less need for opioids, and higher sleep quality during the first 48 hours after surgery, as well as preservation of external respiratory function (higher FEV1 after 24 hours), potentially reducing the risk of postoperative respiratory complications. However, we believe that further large-scale multicenter studies on this topic are needed. Two-level ESPВ demonstra­ted a better analgesic effect due to the wider craniocaudal spread of the local anesthetic, which provided more complete coverage of the surgical access area. The data obtained are consistent with previous studies, which also noted the advantages of two-level techniques in thoracic surgery. Better analgesia contributed to the preservation of respiratory function and reduced the need for opioids. Conclusions. Two-level ESPB (T4 + T6) provides more effective postoperative analgesia and better preservation of FEV1compared to the single-level technique. This method can be recommended as an optimal component of multimodal analgesia after video-assisted lobectomy.