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Abstract
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Background and Aims Ewing’s sarcoma (ES) is a high-grade malignant bone tumor, peaking at the teenage years, predominantly in long bones. It is rarely located in the scapula, with 9 of the 15 cases published in the literature occurring in children. We describe here the analgesic plan and outcome for a case of total scapulectomy in a six-year-old female (after completion of the standard ES radio- and chemotherapy protocol), combining elements of regional anaesthesia as part of multi modal analgesia. Analgesic options for this operation are anatomically challenging and their outcomes have been sparingly described in the literature, mostly in adults.
Methods Intraoperatively we chose a combined neuraxial (T3/4 thoracic epidural) and peripheral (posterior tunneled interscalene) continuous catheter approach, as well as multiple opioid sparing techniques (ketamine and dexmedetomidine infusions). A superficial cervical block would not have added a major analgesic benefit to the catheters. The interscalene catheter became displaced during transport to the intensive care unit. We continued epidural treatment for 6 days, with parent-controlled boluses, supplemented with a continuous infusion of morphine, scheduled paracetamol, ketorolac and metamizole combined with gabapentin.
Results Satisfactory intraoperative analgesia was achieved with the combination of catheters using a single bolus of fentanyl at induction. The epidural boluses were reported effective by the patient and parents for breakthrough pain.
Surgical approach (preoperative view)
Location of peripheral and neuraxial continuous catheters
Scapulectomy (on left) and Brachial plexus post-scapulectomy (on right)
Conclusions The combination of neuraxial and regional analgesia was beneficial intraoperatively. Epidural patient controlled analgesia was effective in the early post-operative period, as part of multi-modal analgesia. This treatment enabled a rapid and calm recuperation considering the extent of the surgery.