Erector Spinae Plane Block Modulates Immune Function in Minimally Invasive Lung Surgery
Abstract
Minimally invasive lung surgery still triggers significant inflammatory and immunosuppressive responses. This retrospective cohort study (January 2021–December 2023) assessed whether erector spinae plane block (ESPB) improves perioperative immune/cytokine balance in lung cancer patients undergoing elective minimally invasive surgery (ESPB, n=58; control, n=65).
Compared with controls, the ESPB group demonstrated superior perioperative outcomes. Hemodynamics at incision were more stable (MAP: 103.24±9.85 vs 112.40±11.23 mm Hg, HR: 86.17±7.91 vs 94.74±9.05 beats/min), and opioid consumption was significantly lower (intraoperative sufentanil: 33.12±3.93 vs 36.75±5.08 μg). Postoperative pain scores were reduced (resting VAS at 1 hour: median 2 vs 4), comfort scores higher (BCS at 1 hour: median 2 vs 1), and patient-controlled analgesia use less frequent (total PCA demands at 48 hours: 18.55±5.14 vs 23.45±5.97).
Immunologically, the ESPB group showed significantly attenuated suppression of cellular immunity, with higher CD3+ (60.92±4.74% vs 56.53±3.27% at 48 hours), CD4+ (38.16±4.29% vs 34.18±4.06% at 48 hours), CD4+/CD8+ ratio (1.23±0.17 vs 1.02±0.23 at 48 hours), and NK cells (21.03±3.45% vs 18.27±2.78% at 48 hours). The cytokine response was also modulated favorably: the rise in proinflammatory IL-6 (26.82±4.65 vs 32.55±5.21 pg/mL at 24 hours) and TNF-α (54.86±7.12 vs 61.55±6.01 pg/mL at 24 hours) was lower, while the anti-inflammatory IL-10 was higher in the ESPB group (28.12±4.43 vs 24.55±5.44 pg/mL at 24 hours).
Clinically, the ESPB group experienced a lower incidence of postoperative dizziness (3.45% vs 13.85%), earlier ambulation (24.36±4.24 vs 27.55±5.17 hours), and a shorter hospital stay (15.16±1.83 vs 17.54±2.39 days).
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6. Hong Z, Cui B, Sheng Y, Lu Y, Bai X, Wu X, et al. Effects of da Vinci robot versus thoracoscopic surgery on body trauma and lymphocyte subsets in lung cancer patients: A propensity score matching study. J Surg Oncol. 2023;128(4):667-74.
7. Liang S, Yin X, Fu Y, Li X, Zhu J, Xu R. Comparison of inflammatory cytokine levels between single-port and three-port thoracoscopic lobectomy in the treatment of non-small-cell lung cancer. Biomed Res Int. 2022;2022:3240252.
8. Erus S, Öztürk AB, Albayrak Ö, İncir S, Kapdağlı MH, Cesur EE, et al. Immune profiling after minimally invasive lobectomy. Interact Cardiovasc Thorac Surg. 2021;32(2):291-7.
9. Xue W, Zhang Y, Zhang M, Huang Z. Changes in the immune index before and after surgery in urinary malignancy patients with AIDS. Sci Rep. 2025;15(1):11569.
10. Yang YW, Wu CH, Tsai HT, Chen YR, Chang YP, Han YY, et al. Dynamics of immune responses are inconsistent when trauma patients are grouped by injury severity score and clinical outcomes. Sci Rep. 2023;13(1):1391.
11. Jain A, Gyori BM, Hakim S, Jain A, Sun L, Petrova V, et al. Nociceptor-immune interactomes reveal insult-specific immune signatures of pain. Nat Immunol. 2024;25(7):1296-305.
12. Brinck ECV, Virtanen T, Mäkelä S, Soini V, Hynninen VV, Mulo J, et al. S-ketamine in patient-controlled analgesia reduces opioid consumption in a dose-dependent manner after major lumbar fusion surgery: A randomized, double-blind, placebo-controlled clinical trial. PLoS One. 2021;16(6):e0252626.
13. Carron M, Tamburini E, Linassi F, Pettenuzzo T, Boscolo A, Navalesi P. Efficacy of nonopioid analgesics and adjuvants in multimodal analgesia for reducing postoperative opioid consumption and complications in obesity: A systematic review and network meta-analysis. Br J Anaesth. 2024;133(6):1234-49.
14. Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for video-assisted thoracoscopic surgery: A systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;77(3):311-25.
15. Reysner T, Wieczorowska-Tobis K, Kowalski G, Grochowicka M, Pyszczorska M, Mularski A, et al. The influence of regional anesthesia on the systemic stress response. Reports. 2024;7(4).
16. Koo CH, Lee HT, Na HS, Ryu JH, Shin HJ. Efficacy of erector spinae plane block for analgesia in thoracic surgery: A systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2022;36(5):1387-95.
17. Ma J, Bi Y, Zhang Y, Zhu Y, Wu Y, Ye Y, et al. Erector spinae plane block for postoperative analgesia in spine surgery: A systematic review and meta-analysis. Eur Spine J. 2021;30(11):3137-49.
18. Sethuraman RM. Erector spinae plane block versus paravertebral block in breast surgeries. BMC Anesthesiol. 2022;22(1):408.
19. Viderman D, Aubakirova M, Abdildin YG. Erector spinae plane block in abdominal surgery: A meta-analysis. Front Med (Lausanne). 2022;9:812531.
20. Unal S, Baskan S, Guven Aytac B, Aytac I, Balci M. Should the erector spinae plane block be applied in the pain management of percutaneous nephrolithotomy? Cureus. 2022;14(2):e22554.
21. Cui Y, Wang Y, Yang J, Ran L, Zhang Q, Huang Q, et al. The effect of single-shot erector spinae plane block (ESPB) on opioid consumption for various surgeries: A meta-analysis of randomized controlled trials. J Pain Res. 2022;15:683-99.
22. Zeng L, Yu X, Yang T, Liao J, Ouyang Y. The effect of ultrasound-guided thoracic paravertebral nerve block combined with hydromorphone on postoperative analgesia and inflammatory response in thoracoscopic surgery: A randomized controlled trial. Front Med (Lausanne). 2025;12:1587477.
23. Khan JA, Albalkhi I, Garatli S, Migliore M. Recent advancements in minimally invasive surgery for early stage non-small cell lung cancer: A narrative review. J Clin Med. 2024;13(11).
24. Ashrafizadeh M. Cell death mechanisms in human cancers: Molecular pathways, therapy resistance and therapeutic perspective. J Cancer Biomol Ther. 2024;1(1):17-40.
25. Ren J. Advances in combination therapy for gastric cancer: Integrating targeted agents and immunotherapy. Adv Clin Pharmacol Ther. 2024;1(1):1-15.
26. De Cassai A, Geraldini F, Tulgar S, Ahiskalioglu A, Mariano ER, Dost B, et al. Opioid-free anesthesia in oncologic surgery: The rules of the game. J Anesth Analg Crit Care. 2022;2(1):8.
27. Liu Y, Gao Y, Lin T. Expression of interleukin-1 (IL-1), IL-6, and tumor necrosis factor-α (TNF-α) in non-small cell lung cancer and its relationship with the occurrence and prognosis of cancer pain. Ann Palliat Med. 2021;10(12):12759-66.
28. Chen S, Wang M, Lu T, Liu Y, Hong W, He X, et al. JMJD6 in tumor-associated macrophage regulates macrophage polarization and cancer progression via STAT3/IL-10 axis. Oncogene. 2023;42(37):2737-50.
29. Zhang L, Wei P, Wang H, Zhang Y, Wang H, Xu Y, et al. Effect of perioperative lidocaine application on inflammatory factors, immune function, and quality of early postoperative recovery in patients undergoing video-assisted thoracoscopic surgery: A randomized controlled trial. Eur J Med Res. 2025;30(1):1072.
30. Wang B, Hu S, Fu X, Li L. CD4(+) cytotoxic T lymphocytes in cancer immunity and immunotherapy. Adv Biol (Weinh). 2023;7(4):e2200169.
31. Paul A, Borkar A. Anaesthetic management for mastectomy in a male with unilateral gynecomastia: The utilization of thoracic segmental spinal anaesthesia and erector spinae plane block. Cureus. 2023;15(10):e47502.
32. Sanabria-Mazo JP, Colomer-Carbonell A, Carmona-Cervelló M, Feliu-Soler A, Borràs X, Grasa M, et al. Immune-inflammatory and hypothalamic-pituitary-adrenal axis biomarkers are altered in patients with non-specific low back pain: A systematic review. Front Immunol. 2022;13:945513.
33. Chen WC, Tsai HI, Kao FC, Tsai TT, Niu CC, Chen LH, et al. Effects of erector spinae plane block on intraoperative blood pressure variability, blood loss, and postoperative pain in transforaminal lumbar interbody fusion. Sci Rep. 2025;15(1):27721.
2. Jedlička V. Surgical treatment of lung cancer. Klin Onkol. 2021;34(Suppl 1):35-42.
3. Zheng L, Song P, Jiang Y, Fan X, Yang C, Zhang L, et al. Outcomes and quality of life after robot-assisted lobectomy/segmentectomy for lung cancer compared to video-assisted thoracoscopic surgery: Both three-port procedures performed by a single surgeon. J Thorac Dis. 2022;14(3):689-98.
4. Seitlinger J, Olland A, Guinard S, Massard G, Falcoz PE. Conversion from video-assisted thoracic surgery (VATS) to thoracotomy during major lung resection: How does it affect perioperative outcomes? Interact Cardiovasc Thorac Surg. 2021;32(1):55-63.
5. Ju S, Liu M, Wang B, Yu D, Zhang H, Zhang M, et al. Transcutaneous electrical acupoint stimulation improves pulmonary function by regulating oxidative stress during one-lung ventilation in patients with lung cancer undergoing thoracoscopic surgery: A randomized controlled trial. BMC Complement Med Ther. 2023;23(1):463.
6. Hong Z, Cui B, Sheng Y, Lu Y, Bai X, Wu X, et al. Effects of da Vinci robot versus thoracoscopic surgery on body trauma and lymphocyte subsets in lung cancer patients: A propensity score matching study. J Surg Oncol. 2023;128(4):667-74.
7. Liang S, Yin X, Fu Y, Li X, Zhu J, Xu R. Comparison of inflammatory cytokine levels between single-port and three-port thoracoscopic lobectomy in the treatment of non-small-cell lung cancer. Biomed Res Int. 2022;2022:3240252.
8. Erus S, Öztürk AB, Albayrak Ö, İncir S, Kapdağlı MH, Cesur EE, et al. Immune profiling after minimally invasive lobectomy. Interact Cardiovasc Thorac Surg. 2021;32(2):291-7.
9. Xue W, Zhang Y, Zhang M, Huang Z. Changes in the immune index before and after surgery in urinary malignancy patients with AIDS. Sci Rep. 2025;15(1):11569.
10. Yang YW, Wu CH, Tsai HT, Chen YR, Chang YP, Han YY, et al. Dynamics of immune responses are inconsistent when trauma patients are grouped by injury severity score and clinical outcomes. Sci Rep. 2023;13(1):1391.
11. Jain A, Gyori BM, Hakim S, Jain A, Sun L, Petrova V, et al. Nociceptor-immune interactomes reveal insult-specific immune signatures of pain. Nat Immunol. 2024;25(7):1296-305.
12. Brinck ECV, Virtanen T, Mäkelä S, Soini V, Hynninen VV, Mulo J, et al. S-ketamine in patient-controlled analgesia reduces opioid consumption in a dose-dependent manner after major lumbar fusion surgery: A randomized, double-blind, placebo-controlled clinical trial. PLoS One. 2021;16(6):e0252626.
13. Carron M, Tamburini E, Linassi F, Pettenuzzo T, Boscolo A, Navalesi P. Efficacy of nonopioid analgesics and adjuvants in multimodal analgesia for reducing postoperative opioid consumption and complications in obesity: A systematic review and network meta-analysis. Br J Anaesth. 2024;133(6):1234-49.
14. Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for video-assisted thoracoscopic surgery: A systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;77(3):311-25.
15. Reysner T, Wieczorowska-Tobis K, Kowalski G, Grochowicka M, Pyszczorska M, Mularski A, et al. The influence of regional anesthesia on the systemic stress response. Reports. 2024;7(4).
16. Koo CH, Lee HT, Na HS, Ryu JH, Shin HJ. Efficacy of erector spinae plane block for analgesia in thoracic surgery: A systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2022;36(5):1387-95.
17. Ma J, Bi Y, Zhang Y, Zhu Y, Wu Y, Ye Y, et al. Erector spinae plane block for postoperative analgesia in spine surgery: A systematic review and meta-analysis. Eur Spine J. 2021;30(11):3137-49.
18. Sethuraman RM. Erector spinae plane block versus paravertebral block in breast surgeries. BMC Anesthesiol. 2022;22(1):408.
19. Viderman D, Aubakirova M, Abdildin YG. Erector spinae plane block in abdominal surgery: A meta-analysis. Front Med (Lausanne). 2022;9:812531.
20. Unal S, Baskan S, Guven Aytac B, Aytac I, Balci M. Should the erector spinae plane block be applied in the pain management of percutaneous nephrolithotomy? Cureus. 2022;14(2):e22554.
21. Cui Y, Wang Y, Yang J, Ran L, Zhang Q, Huang Q, et al. The effect of single-shot erector spinae plane block (ESPB) on opioid consumption for various surgeries: A meta-analysis of randomized controlled trials. J Pain Res. 2022;15:683-99.
22. Zeng L, Yu X, Yang T, Liao J, Ouyang Y. The effect of ultrasound-guided thoracic paravertebral nerve block combined with hydromorphone on postoperative analgesia and inflammatory response in thoracoscopic surgery: A randomized controlled trial. Front Med (Lausanne). 2025;12:1587477.
23. Khan JA, Albalkhi I, Garatli S, Migliore M. Recent advancements in minimally invasive surgery for early stage non-small cell lung cancer: A narrative review. J Clin Med. 2024;13(11).
24. Ashrafizadeh M. Cell death mechanisms in human cancers: Molecular pathways, therapy resistance and therapeutic perspective. J Cancer Biomol Ther. 2024;1(1):17-40.
25. Ren J. Advances in combination therapy for gastric cancer: Integrating targeted agents and immunotherapy. Adv Clin Pharmacol Ther. 2024;1(1):1-15.
26. De Cassai A, Geraldini F, Tulgar S, Ahiskalioglu A, Mariano ER, Dost B, et al. Opioid-free anesthesia in oncologic surgery: The rules of the game. J Anesth Analg Crit Care. 2022;2(1):8.
27. Liu Y, Gao Y, Lin T. Expression of interleukin-1 (IL-1), IL-6, and tumor necrosis factor-α (TNF-α) in non-small cell lung cancer and its relationship with the occurrence and prognosis of cancer pain. Ann Palliat Med. 2021;10(12):12759-66.
28. Chen S, Wang M, Lu T, Liu Y, Hong W, He X, et al. JMJD6 in tumor-associated macrophage regulates macrophage polarization and cancer progression via STAT3/IL-10 axis. Oncogene. 2023;42(37):2737-50.
29. Zhang L, Wei P, Wang H, Zhang Y, Wang H, Xu Y, et al. Effect of perioperative lidocaine application on inflammatory factors, immune function, and quality of early postoperative recovery in patients undergoing video-assisted thoracoscopic surgery: A randomized controlled trial. Eur J Med Res. 2025;30(1):1072.
30. Wang B, Hu S, Fu X, Li L. CD4(+) cytotoxic T lymphocytes in cancer immunity and immunotherapy. Adv Biol (Weinh). 2023;7(4):e2200169.
31. Paul A, Borkar A. Anaesthetic management for mastectomy in a male with unilateral gynecomastia: The utilization of thoracic segmental spinal anaesthesia and erector spinae plane block. Cureus. 2023;15(10):e47502.
32. Sanabria-Mazo JP, Colomer-Carbonell A, Carmona-Cervelló M, Feliu-Soler A, Borràs X, Grasa M, et al. Immune-inflammatory and hypothalamic-pituitary-adrenal axis biomarkers are altered in patients with non-specific low back pain: A systematic review. Front Immunol. 2022;13:945513.
33. Chen WC, Tsai HI, Kao FC, Tsai TT, Niu CC, Chen LH, et al. Effects of erector spinae plane block on intraoperative blood pressure variability, blood loss, and postoperative pain in transforaminal lumbar interbody fusion. Sci Rep. 2025;15(1):27721.
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| Issue | Articles in Press | |
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| Cellular Cytokines Immunity Inflammation Nerve block Perioperative care | ||
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How to Cite
1.
Chen L, Chen D, Ruan Q, Zi H. Erector Spinae Plane Block Modulates Immune Function in Minimally Invasive Lung Surgery. Iran J Allergy Asthma Immunol. 2026;:1-16.
