Bilateral ultrasound-guided erector spinae plane block versus wound infiltration for postoperative analgesia in lumbar spinal fusion surgery: a randomized controlled trial

Ultrasound‑guided erector spinae plane block in posterior lumbar surgery (Review)

The erector spinae plane block (ESPB) is a novel fascial planar block technique, which is used to reduce postoperative pain in several surgical procedures, including breast, thoracic, spine and hip surgery. Due to its recognizable anatomy and low complication rate, the application of ESPB has been significantly increased. However, it is rarely used in clinical practice for postoperative analgesia after posterior lumbar spine surgery, while the choice of adjuvant drugs, block levels and drug doses remain controversial. Based on the current literature review, ropivacaine and dexmedetomidine could be considered as the best available drug combination. The present review aimed to analyze the currently available clinical evidence and summarize the benefits and challenges of ESPB in spinal surgery, thus providing novel insights into the application of ESPB in the postoperative management of posterior lumbar surgery.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Postoperative analgesic options after spine surgery: finding the optimal treatment strategies

INTRODUCTION

Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes.

AREAS COVERED

This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques.

EXPERT OPINION

Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.

Efficacy and Safety of Bilateral Ultrasound-Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

A meta-analysis of randomized controlled trials was conducted to assess efficacy and safety of bilateral ultrasound-guided erector spinae plane block (ESPB) for postoperative analgesia in patients receiving spine surgery.

METHODS

PubMed, Embase, and CENTRAL databases were searched by 2 reviewers independently to identify randomized controlled trials evaluating the efficacy of ultrasound-guided ESPB for pain management in patients undergoing spine surgery. For meta-analysis, mean difference (MD) and 95% confidence interval (CI) were selected for continuous data, and risk ratio (RR) and 95% CI were selected for dichotomous variables.

RESULTS

A total of 25 randomized controlled trials including 1917 patients (873 in ESPB group and 874 in control group) were eligible for inclusion. At rest, ESPB was associated with significantly lower pain intensity at 0, 2, 4, 6, 8, 12, 24, and 48 hours compared with the control group. During movement, ESPB was associated with significantly lower pain intensity at 0, 4, 6, 8, 12, 24, and 48 hours compared with the control group. Significantly reduced opioid consumption (MD = -6.29, 95% CI [-8.16, 4.41], P < 0.001), prolonged time for first rescue analgesia (MD = 7.51, 95% CI [3.47, 11.54], P < 0.001), fewer patients needing rescue analgesia (RR = 0.34, 95% CI [0.28, 0.43], P < 0.0001), improved patient satisfaction (MD = 1.34, 95% CI [0.88, 1.80], P < 0.001), and shorter length of hospital stay (MD = -0.38, [95% CI -0.50, -0.26], P < 0.001) were demonstrated after use of ESPB. Additionally, ESPB was associated with decreased risks of any adverse event (RR = 0.51, 95% CI [0.43, 0.60], P < 0.001) and postoperative nausea and vomiting events (RR = 0.39, 95% CI [0.31, 0.49], P < 0.001).

CONCLUSIONS

Ultrasound-guided ESPB is an effective adjunctive technique with good tolerability for multimodal analgesia in management of pain in patients undergoing spine surgery.

Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

Effect of Erector Spinae Plane Block in Terms of Analgesic Efficacy in Elderly Patients Undergoing Posterior Lumbar Spine Surgery: A Retrospective, Propensity-Score Matched Study

INTRODUCTION

For preoperative analgesia during a variety of operations, the erector spinae plane block (ESPB) has grown in popularity. However, its effectiveness in lumbar surgery is still unknown. The purpose of this study was to investigate the potential benefits of ESPB in enhancing analgesic efficacy in elderly individuals following posterior lumbar spine surgery.

METHODS

Patients aged 65 years or older who underwent elective posterior lumbar instrumented fusion (with or without decompression) at our institution between January 2019 and June 2022 were included. Demographic data, comorbidities, and results of preoperative screening were retrospectively collected. Propensity score matching (PSM) was performed in a ratio of 1:1 for control and ESPB groups. The primary outcome was opioid consumption at 24 h after surgery. Secondary outcomes was visual analog scale (VAS) pain scores at rest in the first 24 h. Additional secondary outcomes included number of patients requesting rescue analgesia, incidence of nausea and vomiting, time to the first request for analgesia via patient-controlled analgesia, and length of stay.

RESULTS

A total of 382 patients were included, of whom 119 received ESPB. The mean age of the study patients was 70.6 years old, and 254 (66.5%) were male. After PSM, each group comprised 115 patients. Patients in the ESPB group showed a significantly lower opioid consumption at 24 h after surgery. Compared with the control group, VAS pain scores at rest in the first 24 h, number of patient-controlled intravenous analgesia (PCIA) pump compressions, ratio of patients requesting rescue analgesia, incidence of nausea and vomiting, and length of stay were significantly reduced in the ESPB group. There were no significant differences between the two groups regarding safety outcomes.

CONCLUSIONS

ESPB reduces short-term opioid consumption while providing safe and effective analgesia in elderly patients undergoing posterior lumbar surgery.