2025/07/21 by Yongli Jin, Ruoyan Zheng · 1 voice · 1 citation
Decision Sciences · Medicine · #Reliability and Agreement in Measurement #Orthopedic Surgery and Rehabilitation
paper · pdf · doi:10.1111/anae.16720
openalex publication_date 2025/07/21 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/16
We read with interest the article by Hu et al. describing the analgesic efficacy of a continuous erector spinae plane block compared with a conventional opioid-based regimen after video-assisted thoracoscopic lung resection [1]. The authors are to be congratulated on completing a prospective, randomised non-inferiority study in a challenging surgical population. We would, however, like to raise several clinical points that we believe deserve further discussion. The primary endpoint was the cumulative area-under-the-curve (AUC) of cough pain scores over 48 h. The chosen non-inferiority margin (Δ = 11.86) appears to be based a 10th–20th of the mean AUC observed in a 20-patient pilot. While pragmatic, this approach is not anchored in a clearly defined minimal clinically important difference. A brief justification of Δ in terms of patient-centred benefit would strengthen confidence that statistical non-inferiority truly reflects clinical equivalence. As both patients and investigators were unblinded, the two key outcomes of the study, pain scores and QoR-15, are susceptible to expectation bias. The impressive between-group differences in QoR-15 (median +11 at 24 h, +10 at 48 h) might, therefore, partially reflect placebo or care-giver effects rather than a pharmacological advantage of the block. A short clarification of how bias was mitigated (e.g. independent data collectors or scripted interactions) would help readers interpret these patient-reported endpoints. Approximately 17% of participants underwent segmentectomy rather than lobectomy. Segmentectomy is typically associated with shorter operating times and reduced nociceptive input [2]. A supplementary analysis restricted to lobectomies would confirm that the non-inferiority conclusion remains robust for the more painful procedure. The reduction in 30-day pulmonary complications (13% vs. 29%) is compelling. However, pulmonary outcomes were secondary and adjudicated in an unblinded fashion. The authors rightly call for confirmatory trials; we suggest labelling this finding explicitly as hypothesis-generating to avoid premature changes in practice. Total ropivacaine exposure was around 775 mg over 48 h. Although within recognised limits, serum concentrations were not measured. Reporting whether any catheter-related systemic toxicity or early warning signs occurred would reassure clinicians considering high-dose erector spinae plane block protocols. Addressing the above points will strengthen the clinical impact of these findings and support their use in diverse thoracic enhanced recovery protocols. We hope these comments prompt further high-quality, blinded, multicentre trials on continuous fascial plane blocks in thoracic surgery.