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Dear Editor, A mass in the lumbosacral region near midline poses a challenge to perform neuraxial blocks in pediatric patients. In such situations, the peripheral nerve blocks may be used following surgical removal of the lump to provide optimal postoperative analgesia. Here, we describe pain management of a child following excision of a giant gluteal neurofibroma with site-specific anatomical landmark-guided regional anesthesia techniques. An 8-year-old boy (weight 18.7 kg, height 124 cm), American Society of Anaesthesiologists (ASA) physical grade I was admitted with complaints of pain and a lump in the left gluteal region for 8 months. On examination, a solitary, non-mobile, firm to hard swelling of 12 cm × 10 cm size was noted with smooth and welldefined margins. The overlying skin was mobile, and there was no rise in local temperature. Left hip range of motion was normal with no distal neurovascular deficit. His pain intensity was 8/10 on the numeric rating scale (NRS) score, and there was no clinical neurological deficit. Magnetic resonance imaging and core needle biopsy revealed the lump as a benign neural tumor, neurofibroma (Fig. 1a). Systemic examination, airway evaluation, and blood investigations were unremarkable. Excision of the lump was planned. The perioperative management plan was discussed with the parents, and informed written consent was obtained. The patient was premedicated with intravenous midazolam 2mg in the preoperative room. Once the patient was wheeled into the operating room, all standard ASA monitors were attached. General anesthesia was induced with intravenous propofol 40 mg, fentanyl 40 μg, and atracurium 10mg. His trachea was intubated with a 6.0mm cuffed endotracheal tube. Radial artery cannulation was performed after induction for arterial blood pressure monitoring. Anesthesia was maintained with nitrous oxide to oxygen (60:40), titrated desflurane, and controlled ventilation. Intraoperatively, intravenous fentanyl intermittent bolus of 0.5 μg/kg/h and paracetamol 15 mg/kg was administered for analgesia. Surgery was performed in the right lateral position and lasted for 3 h. The incision was extended from the left gluteal region to the lateral part of the upper thigh (Fig. 1b). The root of the mass appeared to arise through the sciatic notch encircling around the sciatic nerve, and it did not adhere to adjacent structures or blood vessels. The tumor was made free from its bed, and the whole mass was excised carefully, preserving the anatomic integrity of the sciatic nerve. Total blood loss was 600 ml, which was replaced by crystalloid and packed red cells. The peripheral nerve blocks were performed at the end of surgery before the reversal of the neuromuscular blockade. Left-sided anatomical landmark-guided lumbar erector spinae plane block (LESPB) was performed at the L4 transverse process level. Following strict aseptic precautions, a 21-G Tuohy needle was inserted 2.5 cm lateral to the spinous process where the L4 transverse process tip could be palpated (Fig. 1c). The needle was advanced perpendicular to the skin, and the transverse process was contacted at a depth of 1.5 cm from the skin. A volume of 15 ml of 0.2% ropivacaine and 2 mg dexamethasone was injected after negative aspiration for blood. Left-sided lateral femoral cutaneous nerve (LFCN) block was performed with 5ml of 0.2%

Incision congruent regional analgesia for postoperative pain management following a giant gluteal neurofibroma excision in a pediatric patient