Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series

The effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain control in idiopathic scoliosis patients undergoing posterior spine fusion surgery: study protocol of a randomized controlled trial

BACKGROUND

Posterior spinal fusion (PSF) for the correction of idiopathic scoliosis is associated with severe postoperative pain. Erector spinae plane block (ESPB) has been proposed to provide analgesia and reduce opioid consumption. We aimed to investigate the effect of bilateral ultrasound-guided single-shot ESPB on postoperative analgesia in pediatric patients undergoing PSF.

METHODS

This double-blinded, randomized controlled trial will enroll 74 AIS patients undergoing elective PSF. Participants will be assigned to the ESPB group or control group at a 1:1 ratio. Patients in the ESPB group will receive ultrasound-guided bilateral ESPB preoperatively, and patients in the control group received sham ESPB using normal saline. The primary joint endpoints are the area under the curve (AUC) of numerical rating scale (NRS) score and opioid consumption in postoperative 24 h. The secondary endpoints are numerical rating scale (NRS) score and opioid consumption at postoperative 0.5, 3, 6, 9, 12, 24, 36, and 48 h, rescue analgesia, recovery outcomes, and adverse events.

DISCUSSION

At present, studies investigating the effect of ESPB on pediatric patients are still needed. This study focuses on the effect of ESPB on pediatric patients undergoing PSF on postoperative pain control and intends to provide a new strategy of multimodal analgesia management for major spine surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300074505. Registered on August 8, 2023.

Surgical vs ultrasound-guided lumbar erector spinae plane block for pain management following lumbar spinal fusion surgery

PURPOSE

Spinal surgery is associated with severe diffuse pain in the postoperative period. Effective pain management plays an essential role in reducing morbidity and mortality. This study is designed to compare the ultrasound-guided erector spinae plane (ESP) block and surgical infiltrative ESP block for postoperative analgesia management after lumbar spinal fusion surgery.

METHODS

The patients who underwent two or three levels of posterior lumbar spinal fusion surgery were randomly allocated into one of three groups with 30 patients each (Group SE = Surgical ESP block; Group UE = ultrasound-guided ESP block; Group C = Controls). The primary aim was to compare postoperative opioid consumption, and the secondary aim was to evaluate postoperative dynamic and static pain scores and the incidence of opioid-related adverse effects.

RESULTS

There was a significant difference in terms of opioid consumption, rescue analgesia on demand, and both static and dynamic pain scores between groups at all time periods (p < 0.05). Group SE and Group UE had lower pain scores and consumed fewer opioids than the controls (p < 0.05). However, the Group UE had lower pain scores and opioid consumption than the Group SE. The sedation level of patients was significantly higher in the control group than in the other two groups. Also, nausea was more common in controls than in the other groups.

CONCLUSION

While both surgical and ultrasound-guided ESP blocks reduced opioid consumption compared to the controls, the patients who received ultrasound-guided ESP blocks experienced better postsurgical pain relief than those in the other groups (surgical ESP and controls).

Bilateral ultrasound-guided erector spinae plane block for postoperative pain relief in major traumatic spine surgery: A randomized controlled trial

Introduction

Spine fixation surgery for traumatic vertebral fractures is associated with severe pain and is often difficult to control. Traditionally systemic opioids have been the mainstay of analgesia for these procedures, which can lead to hyperalgesia, nausea, ileus, sedation, cognitive impairment, dependence, etc., limiting usage of opioids. The Erector spinae plane block (ESPB) is a novel ultrasound-guided procedure with easily identifiable sonoanatomy. We hypothesized that a multimodal approach involving ESPB to a conventional analgesic regimen with local infiltration for patients undergoing major traumatic spine surgeries might provide better perioperative analgesia and reduce the need for postoperative opioid requirements.

Material and Methods

A randomized control prospective trial was conducted on 34 ASA grade I -II patients aged 18 to 65 years who were scheduled to undergo elective posterior spine fixation surgery with ASIA B to E after traumatic spine fracture under general anesthesia. Patients were randomized to Group A which included patients who received general anesthesia with ESPB, and Group B, or the control group, included patients who received general anesthesia with systemic analgesics and postoperative local infiltration without ESPB. Intraoperative total fentanyl consumption, VAS score at 0, 3, 6, 12, 18, and 24 hours, time to activate patient-controlled analgesia (PCA) pump, total morphine consumption, and opioid-related side effects were monitored and compared in both groups.

Results

Postoperative PCA morphine consumption was significantly lower in group A patients who received ESPB than those in the control group (17.06 ± 9.59 vs 37.82 ± 9.88 P value = <0.0001). VAS scores at rest and movement at 0, 3, 6, 9, 12, 18, and 24 hours were significantly lower (P value = 0.05) in the ESPB group compared with the control group at all time points.

Conclusion

Bilateral ultrasound-guided Erector spinae plane block, when administered in traumatic spine patients undergoing spine fixation surgery, provides better analgesia with statistically decreased VAS scores and less postoperative opioid requirement.

Effect of Surgeon-Performed Thoracic Paravertebral Block on Postoperative Pain in Adolescent Idiopathic Scoliosis Surgery: A Prospective Randomized Controlled Trial

Posterior spinal fusion for adolescent idiopathic scoliosis (AIS) causes severe postoperative pain. Thoracic paravertebral block (PVB) provides excellent analgesia during various surgeries. We examined the effects of PVB on postoperative analgesia in children undergoing AIS surgery. In this study, 32 children scheduled for AIS surgery were randomly assigned to receive either PVB (PVB group) or no block (control group). The PVB group underwent surgeon-performed PVB with 0.5 mL/kg of adrenalized 0.2% ropivacaine on each side. The primary outcome was the pain score at rest at 6 h postoperatively. Secondary outcomes included pain scores both at rest and during movement and analgesic use for 48 h postoperatively. The postoperative resting pain scores at 6 h were comparable between the control and PVB groups (5.2 ± 2.0 and 5.1 ± 1.8, respectively), with no significant differences. However, at 1 h postoperatively, the control group showed significantly higher resting and mean moving pain scores than the PVB group (p < 0.05). The pain scores at other time points and analgesic use were comparable between the groups. Initial benefits of surgeon-performed bilateral PVB were observed but diminished at 6 h postoperatively. Future research using various anesthetics is needed to extend the effects of PVB.

Efficacy of Erector Spinae Plane (ESP) Block for Non-cardiac Thoracic and Upper Abdominal Surgery: A Single Institute Comparative Retrospective Case Series

Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022. All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD) 1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and required significantly more antiemetic pharmacotherapy (mean 1.4 antiemetics administered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24 hours (95% CI -9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral block techniques in thoracic and upper abdominal surgeries for perioperative pain management.

A comparison of the effects of thoracolumbar interfascial plane (TLIP) block and erector spinae plane (ESP) block in postoperative acute pain in spinal surgery

PURPOSE

Spinal surgeries are a very painful procedure. New regional techniques for postoperative pain management are being considered. The present study aimed to evaluate the hypothesis that the ultrasound-guided erector spinae plane (ESP) block would lead to lower opioid consumption compared to the thoracolumbar interfascial plane (TLIP) block after lumbar disk surgery. The study's primary objective was to compare postoperative total opioid consumption, and the secondary objective was to assess postoperative pain scores.

METHODS

Sixty-eight patients who underwent elective lumbar disk surgery were randomly assigned to either the ESP block group or the TLIP block group. The current pain status of the patients in both the ESP and TLIP block groups was assessed using the Numerical Rating Scale (NRS) at specific time intervals (30 min, 1, 6, 12 and 24 h) during the postoperative period. The number of times patients administered a bolus dose of patient-controlled analgesia, (PCA) within the first 24 h was recorded.

RESULTS

In the ESP group, the total opioid consumption in terms of morphine equivalents was found to be significantly lower (ESP group: 7.7 ± 7.0; TLIP group: 13.0 ± 10.1; p < 0.05). The NRS scores were similar between the groups at 30 min, 1, 6, and 12 h, but at 24 h, they were significantly lower in the ESP group. Moreover, the groups had no significant difference regarding observed side effects.

CONCLUSION

This study demonstrated the analgesic efficacy of both techniques, revealing that the ESP block provides more effective analgesia in patients undergoing lumbar disk surgery.

The efficacy of ultrasound-guided erector spinae plane block (ESPB) versus freehand ESPB in postoperative pain management after lumbar spinal fusion surgery: a randomized, non-inferiority trial

PURPOSE

Spine surgeries have experienced exponential growth over the past 2 decades. These surgeries are often accompanied by long and severe perioperative pain, presenting a significant management challenge. This study aims to assess and compare the efficacy of two techniques for postoperative pain (POP) management in lumbar spine surgeries: ultrasound-guided erector spinae plane block (ESPB) and intraoperative freehand ESPB.

METHODS

In this prospective randomized non-inferiority trial (Registration Number: IRCT20221107056427N1), adult patients who were candidates for lumbar spinal fusion surgery were randomly divided into two groups: ultrasound-guided ESPB (n = 29) and freehand ESPB (n = 29). The primary outcomes were the total amount of morphine consumed during the first 24 h following the surgery and the numerical rating scale (NRS) pain score at various time points within the first 24 h following the surgery. The secondary outcome was the fentanyl used during surgery.

RESULTS

Participants in the intraoperative freehand approach had considerably higher total morphine consumption in the first postoperative 24 h. The trend of NRS changes in both the ultrasound-guided ESPB group and the freehand ESPB group during the first 24 h after surgery showed a significant decrease. Still, there was no significant difference between the two groups. However, the first analgesic demand time was significantly shorter in the intraoperative freehand ESPB group compared to the ultrasound-guided approach.

CONCLUSION

According to our results, the ultrasound-guided approach of ESPB is more effective in POP management and opioid sparing in lumbar spinal fusion surgeries compared to the freehand approach. However, the data from this study are not sufficient to draw robust conclusions, and further randomized controlled trials with larger sample sizes are required to validate our results.

Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study

Background

Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy.

Objectives

This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches.

Materials and methods

Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05).

Results

Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015).

Conclusion

ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.

Comparative Study Between Dexmedetomidine with Bupivacaine and Bupivacaine Alone in Erector Spinae Plane Block for Postoperative Pain Control of Posterior Lumbosacral Spine Fixation Surgeries: A Randomized Controlled Trial

Background

As posterior lumbosacral spine fixation surgeries are common spine procedures done nowadays due to different causes and mostly accompanied with moderate-to-severe postoperative pain, so should find effective postoperative analgesia for these patients. This study aimed to observe analgesic effect of dexmedetomidine combined with bupivacaine versus bupivacaine alone for erector spinae plane block ESPB for postoperative pain control of posterior lumbosacral spine fixation surgeries.

Methods

Double-blind randomized controlled study including 90 patients who were randomly allocated into 3 groups (30 patients for each): Dexmedetomidine combined with bupivacaine (DB group), bupivacaine (B group), and saline (control) (S group). US-guided ESPB was performed preoperatively bilaterally in all patients of the 3 groups. All patients received intravenous patient-controlled postoperative analgesia with morphine and 1 gm intravenous paracetamol every 8 hours. Primary clinical outcomes were active (while mobilization) and passive (at rest) visual analog scale (VAS) pain score at first 24 hours measured every 2 hours, opioid consumption (number of PCA presses), and need for rescue analgesia. Other clinical outcomes included active and passive VAS pain score at second 24 hours, measured every 4 hours, opioid consumption, need for rescue analgesia, postoperative opioid side effects, and intraoperative dexmedetomidine side effects as bradycardia and hypotension.

Results

Active and passive VAS pain scores, postoperative opioid consumption, need for rescue analgesia, and postoperative opioid side effects were significantly lower in DB group when compared to other groups (B and S groups). There were no additional intraoperative dexmedetomidine side effects as bradycardia and hypotension. The estimated effect-size r was -0.58 and Cohen's d was -1.46.

Conclusion

Addition of dexmedetomidine to bupivacaine 0.25% in ESPB for postoperative pain control in patients of posterior lumbosacral spine fixation surgeries resulted in lower active and passive VAS pain scores, decreased postoperative opioid consumption, need for rescue analgesia and postoperative opioid side effects without additional intraoperative dexmedetomidine side effects.

Clinicaltrialsgov Identifier

NCT05590234.

Efficacy and Safety of Erector Spinae Plane Block Versus Thoracolumbar Interfascial Plane Block in Patients Undergoing Spine Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

As 2 novel peripheral nerve blocks, the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block can relieve postoperative pain in spinal surgery. This systematic review and meta-analysis aimed to determine the efficacy and safety of ESPB versus TLIP block in patients undergoing spine surgery.

METHODS

An extensive search of English online databases, including PubMed, Web of Sciences, Embase, Medline, and Cochrane Central Register of Controlled Trials, and Chinese online databases like Wanfang Data, CNKI, and CQVIP until March 31, 2023, with no language restrictions, was performed. This systematic review and meta-analysis are based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and have been registered on PROSPERO (International Prospective Register of Systematic Reviews) with registered ID: CRD42023420987.

RESULTS

Five studies involving 457 patients were eligible for inclusion in this study. Compared with TLIP block, ESPB had lower postoperative opioid consumption at postoperative 48 hours (standard mean difference =-1.31, 95% CI:-2.54 to -0.08, P =0.04, I2 =80%) and postoperative pain score at postoperative 24 hours (standard mean difference =-0.72, 95% CI=-1.43 to -0.02, P =0.04, I2 =95%) in patients undergoing spine surgery. Complications associated with ESPB and TLIP block were not reported in the included studies.

DISCUSSION

ESPB and TLIP block are 2 novel and effective block methods. Patients receiving ESPB had lower postoperative opioid consumption and postoperative pain scores compared with patients receiving TLIP block; there was no statistically significant difference's between the 2 groups in intraoperative opioid consumption, adverse events, and rescue analgesia.

Paravertebral Nerve Block for Procedural Pain in Percutaneous Vertebroplasty

OBJECTIVES

This study aimed to unidimensionally measure procedural pain at each percutaneous vertebroplasty (PVP) stage and evaluate the effectiveness of paravertebral nerve block (PVNB) in reducing procedural pain.

METHODS

A retrospective study of prospectively collected data was conducted on 66 patients who underwent PVP for osteoporotic vertebral compression fractures. The patients were divided into 2 groups: group A (fluoroscopic-guided PVNB; 5 cm 3 of 0.75% ropivacaine on each side) and group B (local anesthesia). To investigate procedural pain associated with PVP, the visual analog scale score was assessed at each surgical stage: before the incision (stage 1), transpedicular approach (stage 2), and polymethylmethacrylate cement injection (stage 3). After the procedure, patients were asked about their surgical experience and satisfaction using the Iowa Satisfaction with Anesthesia Scale. Periprocedural complications were also recorded.

RESULTS

A total of 63 patients (78.65 y of age) were finally enrolled: 30 from group A and 33 from group B. In both groups, a significant ≥2-point increase in procedural pain was observed during PVP compared with that during stage 1 ( P < 0.001). In stages 2 and 3, the pain intensity was significantly lower in group A ( P < 0.001). Upon discharge, the visual analog scale score improved in all groups; however, the Iowa Satisfaction with Anesthesia Scale score was significantly higher in group A ( P < 0.001). There was no difference in periprocedural complications between the two groups ( P = 0.743).

CONCLUSION

PVP causes significant procedural pain, and PVNB is a potentially effective modality for enhancing patient satisfaction and reducing procedural pain.

Erector Spinae Plane Block Reduces Immediate Postoperative Pain and Opioid Demand After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Matched cohort comparison.

OBJECTIVE

To determine perioperative outcomes of erector spinae plane (ESP) block for minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

There is a paucity of data on the impact of lumbar ESP block on perioperative outcomes and its safety in MI-TLIF.

MATERIALS AND METHODS

Patients who underwent 1-level MI-TLIF and received the ESP block (group E ) were included. An age and sex-matched control group was selected from a historical cohort that received the standard-of-care (group NE). The primary outcome of this study was 24-hour opioid consumption in morphine milligram equivalents. Secondary outcomes were pain severity measured by a numeric rating scale, opioid-related side effects, and hospital length of stay. Outcomes were compared between the two groups.

RESULTS

Ninety-eight and 55 patients were included in the E and NE groups, respectively. There were no significant differences between the two cohorts in patient demographics. Group E had lower 24-hour postoperative opioid consumption ( P = 0.117, not significant), reduced opioid consumption on a postoperative day (POD) 0 ( P = 0.016), and lower first pain scores postsurgery ( P < 0.001). Group E had lower intraoperative opioid requirements ( P < 0.001), and significantly lower average numeric rating scale pain scores on POD 0 ( P = 0.034). Group E reported fewer opioid-related side effects as compared with group NE, although this was not statistically significant. The average highest postoperative pain score within 3 hours postprocedurally was 6.9 and 7.7 in the E and NE cohorts, respectively ( P = 0.029). The median length of stay was comparable between groups with the majority of patients in both groups being discharged on POD 1.

CONCLUSIONS

In our retrospective matched cohort, ESP blocks resulted in reduced opioid consumption and decreased pain scores on POD 0 in patients undergoing MI-TLIF.

LEVEL OF EVIDENCE

Level 3.

Erector spinae plane block in spine surgeries: Single-level versus bi-level, single-shot versus continuous catheter technique

Erector spinae plane block (ESPB) is one of the commonly preferred regional anesthesia techniques in the recent past for various procedures including spine surgeries. The main advantages of ESPB are the ease of performing the technique and the lesser chance of complications. Many studies have proven that ESPB plays an important role in reducing perioperative opioid consumption, postoperative nausea and vomiting, as well as the length of stay in the hospital. Thus it has been adopted as one of the measures for the enhanced recovery after surgery (ERAS) protocol. Nevertheless, the role of bi-level ESPB and a continuous catheter technique are the major research gaps and thus require further research in this population. The details of these two methods are discussed elaborately here.

Assessment of Analgesic Efficacy of Bilateral Lumbar Erector Spinae Plane Block for Postoperative Pain following Lumbar Laminectomy: A Single-Blind, Randomized Clinical Trial

Background

The erector spinae plane (ESP) block is a novel approach to minimizing postoperative pain. We investigated the efficacy and side effects of the ultrasonography-guided bilateral ESP block in reducing pain in the first 24 hours after lumbar laminectomy.

Materials and Methods

We conducted a single-blind (statistical analyst and those responsible for recording patient information postoperation were unaware of the study groups) randomized clinical trial on 50 patients aged 18 to 65 with American Society of Anesthesiology (ASA) class I or II physical status scheduled for lumbar laminectomy surgery at Shahid Chamran Hospital, Shiraz, Iran. Patients were randomly allocated to the ESP block (26 participants) or control (24 participants) group. A bilateral ESP block was administered to patients in the first group before general anesthesia, which was provided identically to both groups. The postoperative time to the first request of analgesia, pain score, total opioid use, side effects, and patient satisfaction were compared between the groups.

Results

Compared with the control group, patients in the ESP block group had significantly more postoperative pain relief in the first hour and until 24 hours (P < 0.05). The total opioid consumption was lower in the ESP block group (P < 0.001). However, the ESP block led to a higher rate of urinary retention (P = 0.008).

Conclusion

The bilateral ESP block effectively reduces postoperative pain following lumbar laminectomy, minimizing the need for narcotics. Further research is needed to delineate ways to reduce urinary retention as its main complication. This trial is registered with IRCT20100127003213N6.

Enhancing post-operative analgesia following spinal cord stimulation implant: a comprehensive evaluation of the effectiveness of erector spinae plane block utilizing liposomal bupivacaine

Erector spinae plane block (ESPB) is an inter-fascial plane block that provides multi-dermatomal analgesia for treatment of acute pain and chronic neuropathic pain in the trunk. This retrospective case series describes a novel method of treating acute postoperative pain after spinal cord stimulation implant with erector spinae plane block using liposomal bupivacaine. Bilateral erector spinae plane block was administered at L1-L2 intervertebral level in 18 cases prior to performing spinal cord stimulation implant at one interspace above. This study reveals that the block provides effective analgesia as evidenced by low pain scores and less opioid consumption after surgery.

Erector spinae plane block for post-operative analgesia in thoracolumbar spine surgery: A randomised controlled trial

Background and Aims

Thoracolumbar spine surgery is one of the most painful surgical procedures. This study's primary objective was to evaluate the effect of erector spinae plane (ESP) block on post-operative cumulative morphine consumption at 24 h in patients undergoing thoracolumbar spine surgery.

Methods

Seventy adults posted for thoracolumbar spine surgery were randomised into the control group [Number of patients (n)=35], who received general anaesthesia without any nerve block, and the intervention group (n = 35), who received bilateral ultrasound (US)-guided ESP block at the level of spine surgery with 0.25% bupivacaine 20 mL after standard general anaesthesia. Along with intravenous patient-controlled analgesia morphine, post-operative analgesia was standardised for both groups. Total morphine consumption, visual analogue scale (VAS) score to evaluate pain, overall patient satisfaction, and any side effects were compared at 24 h. The statistical analysis was done using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL).

Results

Post-operative total morphine consumption at 24 h was significantly decreased in the intervention group compared to the control group [5.69 (1.549) versus 9.51 (1.634) mg; P < 0.001]. Post-operative VAS scores were also significantly decreased in the intervention group at rest (P < 0.001) and on movement (P < 0.001). Patient satisfaction scores were more favourable in the intervention group [3.8 (0.4) versus 3.2 (0.6); P < 0.001]. Post-operative nausea and vomiting were found more in the control group but were not significant (n = 14 versus 8; P = 0.127).

Conclusion

US-guided ESP block significantly reduces post-operative morphine consumption and improves analgesia and patient satisfaction without adverse effects in patients undergoing thoracolumbar spine surgery.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

Bilateral Bi-Level Erector Spinae Plane Blocks as a Part of Opioid-Sparing Multimodal Analgesia in Scoliosis Surgery: A Case Series of Six Pediatric Patients

Background and Aim: Postoperative pain after scoliosis surgery is severe and usually requires long-term intravenous opioid therapy. Local anesthetic options, such as wound infiltration, are limited and include neuraxial analgesia. However, they are rarely used due to side effects and inconsistent efficacy. We report an opioid-sparing multimodal analgesia regimen with bilateral erector spinae plane blocks. This case series evaluated the analgesic effect of the bilateral bi-level erector spinae plane blocks (ESP) in congenital and neurogenic scoliosis surgery. Patients and Methods: Six pediatric patients with congenital or neurogenic scoliosis underwent posterior spinal fusion involving 5 to 12 vertebral levels. Bilateral single-injection ESPB was performed at one or two levels before incision. Preoperatively, patients received intravenous dexamethasone. General anesthesia with endotracheal intubation and volume-controlled ventilation was performed via TIVA with remifentanil and propofol. During and after the procedure, the basic hemodynamic parameters, opioid consumption, pain scores (numerical rating scale/NRS), and possible block complications were monitored. Results: All the patients experienced minimal postoperative pain levels. In addition, on the first day after surgery, they had low opioid requirements with no side effects. Conclusions: ESPB in patients undergoing congenital and neurogenic scoliosis correction surgery seems to be an essential analgesic technique that may reduce both severities of pain and opioid consumption.

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis.

MATERIALS AND METHODS

The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective.

RESULTS

The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6).

CONCLUSIONS

TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

Continuous erector spinae plane catheters leading to unwanted neuraxial spread after spinal fusion surgery: a report of two cases from a terminated prospective randomized clinical trial

BACKGROUND

Erector spinae plane blocks are used to improve outcomes after spine surgery, but pain frequently outlasts the duration of single injection blocks. We hypothesized continuous erector spinae plane (cESP) catheters would provide superior analgesia. We terminated a prospective double-blinded randomized clinical trial (RCT) comparing outcomes after multilevel spine surgery among patients randomized to saline versus ropivacaine cESP catheters. We present two cases of undesired epidural spread of ropivacaine and discuss etiology, management, and future research directions.

CASE PRESENTATION

Nine out of 44 patients (planned) enrolled in the RCT; 6/9 were randomized to receive ropivacaine infusions via bilateral cESP catheters. Two patients underwent uncomplicated posterior lumbar fusion and were recovering well with minimal pain and opioid requirements through postoperative day 1. Both had new-onset urinary retention and bilateral lower extremity numbness, weakness and paresthesias (24 and 30 hours after infusion-start time, respectively). One patient underwent MRI, which was remarkable for an epidural fluid collection compressing the thecal sac. Infusions were stopped, cESP catheters were removed and symptoms fully resolved over the next 3-5 hours.

CONCLUSIONS

Unwanted neuraxial spread of local anesthetic from cESP catheters may be a unique consideration after spine surgery, accounted for by unpredictable local anesthetic distribution within disrupted surgical planes. Future studies are indicated to determine optimal catheter regimens together with guidance for extended monitoring in parallel with further studies of efficacy in spine surgery cohorts.

TRIAL REGISTRATION NUMBER

NCT05494125.

Utility of Erector Spinae Plane Blocks for Postoperative Pain Management and Opioid Reduction Following Lumbar Fusions

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to determine the utility of the erector spinae plane regional anesthesia (ESP) block in reducing opioid medication usage and postanesthesia care unit length of stay (PACU-LOS) for patients undergoing either a posterior or transforaminal lumbar interbody fusions (PLIF/TLIF).

SUMMARY OF BACKGROUND DATA

Posterior lumbar spine fusion is a common surgical procedure typically associated with significant postoperative pain. Poorly controlled postoperative pain can lead to a number of poor outcomes. Although opioids are a mainstay for pain control, they are associated with adverse effects and a risk of dependence. Therefore, multimodal pain control has become more prevalent in orthopedics and combines traditional opioid and nonopioid pain mediation with general anesthesia protocols and regional nerve blocks.

MATERIALS AND METHODS

A retrospective chart review was conducted for patients undergoing PLIFs or TLIFs between 2019 and 2021. Patients were placed into 2 groups, those receiving an ESP block and those that did not. T tests assuming unequal variances were used to assess differences in pain scores, opioid consumption, and PACU-LOS between groups.

RESULTS

The study group demonstrated a 35% reduction in opioid use ( P =0.016), a 16% reduction in pain with activity ( P =0.042), and a 9.7% reduction in pain at rest ( P =0.219) compared with the control group. There were no significant differences in PACU-LOS between groups ( P =0.314).

CONCLUSION

The use of an ESP block for patients undergoing PLIFs and TLIFs appears to be a safe and effective means to manage postoperative pain and reduce opioid consumption.

Onset Time of Lumbar Erector Spinae Plane Block Compared with Its Thoracic Counterpart: Case Reports

The erector spinae plane block (ESPB) at the level of the fifth thoracic vertebra (T5) is a novel technique, first published in 2016, which was found to be effective in both acute and chronic pain control. The mechanism of action and spread of local anesthetic of the ESPB at the lumbar region are thought to differ from those of the thoracic ESPB; however, the difference in onset time has never been evaluated. As for the onset of lumbar ESPBs, we presented three cases: two received lumbar ESPBs (one with chronic low back pain and one with acute postoperative hip pain), and the third one with chronic back pain received a thoracic ESPB. We administered 30 mL of 0.3% ropivacaine in all three patients, but the analgesic effect did not reach its maximum until 3 and 1.5 h, respectively, in the lumbar ESPB cases. On the contrary, the thoracic ESPB case experienced noticeable pain relief within 30 min. The onset time was considerably longer than that reported in earlier reports on ESPBs, and the lumbar ESPB achieved its peak effect much later than the thoracic ESPB using the same formula of local anesthetic. While the delayed-onset lumbar ESPB may have some drawbacks for treating acute postoperative pain, it still could produce significant analgesia, once it took effect, when given to patients suffering from hip surgery with large incisions and intractable low back pain. The current data suggested that the onset time of a lumbar ESPB may be delayed compared with its thoracic counterpart. Therefore, the local anesthetic formula and injection timing should be adjusted for a lumbar ESPB when applied in the perioperative period to make the onset of the analgesic effect coincide with the immediate postoperative pain. Without this concept in mind, clinicians may consider a lumbar ESPB to be ineffective before it takes effect, and consequently treat the patients inadequately with this technique. Future randomized controlled trials should be designed according to our observations to compare lumbar ESPB with its thoracic counterpart regarding onset time.

Contrast Spread After Erector Spinae Plane Block at the Fourth Lumbar Vertebrae: A Cadaveric Study

INTRODUCTION

In recent years, the erector spinae plane block (ESPB) has seen widespread use to treat acute and chronic pain in the regions of the thoracic spine. While limited data suggest its increasing utilization for pain management distal to the thoracic, abdomen and trunk, the anesthetic spread and analgesic mechanism of ESPB at the level of the lumbar spine has not been fully described or understood.

METHODS

This is an observational anatomic cadaveric study to assess the distribution of solution following an ESPB block performed at the fourth lumbar vertebrae (L4) using ultrasound guidance to evaluate the spread of a 20 ml solution consisting of local anesthetic and methylene blue. The study was performed in an anatomy lab in a large academic medical center. Following injection of local anesthetic with contrast dye, cadaveric dissection was performed to better understand the extent of contrast dye and to determine the degree of staining to further predict analgesic potential. We reviewed the findings of other ESPB cadaveric studies currently available for comparison.

RESULTS

Following cadaveric dissection in an anatomy lab, the contrast dye was observed in the ESP space, and staining was found most cranially at L2 and extending caudally underneath the sacrum. Evaluating the depth of its spread, we found it to be confined to the posterior compartment of the spine sparing the nerve roots bilaterally, which is consistent with the only other cadaveric study of ESPB performed at L4.

CONCLUSION

Our results demonstrate the clinical utility of lumbar ESPB where posterior confinement of local anesthesia is preferred. However, further investigation is needed to determine the efficacy of ESPB in lower extremity analgesia which is predicated on ventral nerve root involvement.

Efficacy of Postoperative Analgesia by Erector Spinal Plane Block after Lumbar Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background. In recent years, erector spinae plane block (ESPB) has been increasingly used as a new regional block technique for postoperative analgesia; however, little is known on its benefits. Therefore, we performed a systematic review and meta-analysis to investigate the efficacy and safety of ESPB in lumbar spine surgery. Methods. Databases including PubMed, Embase, Cochrane Library, and Web of Science were systematically searched for randomized controlled trials (RCTs) comparing ESPB with no block in lumbar spine surgery until September 30, 2021. The primary outcome was opioid consumption after surgery. The Cochrane Collaboration’s tool for assessing the risk of bias was used to evaluate the quality of included studies. Results. Fifteen RCTs involving 980 patients were included in the study. Opioid consumption 24 hours after surgery was significantly lower in the ESPB group standardized mean difference ( $\text{SMD}=-2.27$ , 95% confidence interval (95% CI) (-3.21, -1.32); $p<0.01$ ). ESPB reduced pain scores at rest and on movement within 48 hours after surgery and the incidence of the postoperative rescue analgesia ( $\text{RR}=0.32$ , 95% CI (0.31, 0.80); $p=0.02$ ), while it significantly prolonged time to first rescue analgesia ( $\text{SMD}=4.87$ , 95% CI (2.84, 6.90); $p<0.01$ ). Moreover, significantly better patient satisfaction was associated with ESPB ( $\text{SMD}=1.89$ , 95% CI (1.03, 2.74); $p<0.01$ ). Conclusion. EPSB provides effective and safe postoperative analgesia after lumbar spine surgery.

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial

INTRODUCTION

Erector spinae plane block has been proposed to reduce opioid use and improve pain relief with controversial results. This randomized clinical study aimed to assess the efficacy of erector spinae plane block in major spine surgery including multimodal and 'Enhance Recovery After Surgery' programs.

METHOD

After institutional review board approval, adult patients undergoing elective lumbar spine surgery with standardized general anesthesia, rehabilitation and multimodal analgesia protocols were randomly allocated to receive bilateral ultrasound-guided block with saline versus ropivacaine (3.75 mg/mL). Before surgery, a bilateral erector spinae plane block was performed at lumbar level (third vertebrae) with 20 mL of solution for each side. The primary outcome was morphine consumption after 24 hours. Secondary outcomes included pain scores and side effects, from postanesthesia care unit to discharge, and questionnaires at 3 months on pain and quality of life (EQ-5D).

RESULTS

From November 2019 to July 2021, 50 patients were enrolled with similar characteristics and surgery for each group. After the first 24 hours, there was no statistical difference regarding cumulative intravenous morphine consumption between ropivacaine and saline groups: 7.3 mg (3.7-19) vs 12.5 mg (3.5-26) (p=0.51). Over the five postoperative days, opioid sparing, pain scores and side effects were similar between groups. At 3 months, pain relief, incidence of chronic pain and EQ-5D were similar between groups.

DISCUSSION

Erector spinae plane block used in conjunction with 'Enhance Recovery After Surgery' and multimodal analgesia protocols provides limited reduction in opioid consumption and no long-term benefits.

TRIAL REGISTRATION NUMBER

EudraCT 2019-001678-26.

Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review

BACKGROUND

Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery.

METHODS

This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy.

RESULTS

Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017.

CONCLUSIONS

Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.

Dexmedetomidine combined with ropivacaine for erector spinae plane block after posterior lumbar spine surgery: a randomized controlled trial

Purpose

Due to lumbar spinal surgery is frequently accompanied with moderate-to-severe postoperative pain, it is necessary to find an effective postoperative analgesia for patients with this surgery. This study aimed to observe the analgesic effect of dexmedetomidine combined with ropivacaine erector spinae plane block (ESPB) used in posterior lumbar spine surgery.

Methods

In this clinical trial, patients undergoing posterior lumbar spine surgery were recruited and randomly divided into two groups: intervention and control. The intervention group (Group E) received 0.375% ropivacaine with 1 µg/kg dexmedetomidine in a total of 20 ml for ESPB; the control group (Group C) received 20 ml ropivacaine 0.375% for ESPB. US-guided ESPB was performed preoperatively in all patients. Demographics, anesthesia time, surgery time, and ASA grade from the participants were recorded at baseline. The primary clinical outcome measures were 2-, 4-, 8-, 12-, 24-and 48-h visual analog scale (VAS) pain scores after surgery at rest and movement state. Other end points included opioid consumption, number of PCIA presses, flurbiprofen-axetil consumption, quality of recovery and pain management after surgery.

Results

One hundred twenty patients were enrolled in the study (mean [SD] ages: Group E, 54.77 [8.61] years old; Group C,56.40 [7.87] years old; P = 0.280). The mean anesthesia time was 152.55 (15.37) min in Group E and 152.60 (16.47) min in Group C (P = 0.986). Additionally, the surgery time was 141.70 (15.71) min in Group E compared to 141.48 (17.13) min in Group C (P = 0.943). In addition, we found that the VAS pain scores in the resting state during the postoperative period at 8–48 h were lower in Group E than in Group C. However, the VAS pain scores in the active state were lower in Group E at 12–48 h (P < 0.05). More importantly, the consumption of opioids and flurbiprofen-axetil after surgery was also lower in Group E (P < 0.05). Subsequently, we administered questionnaires on the quality of recovery and pain management after surgery that were positively correlated with the postoperative analgesic effect. It was worth affirming that the QoR-15 scores and APS-POQ-R questionnaire results were different between the two groups, further confirming that the combination of drugs not only could obtain an ideal analgesic effect but also had no obvious adverse reactions (P < 0.05).

Conclusions

All the findings suggested that dexmedetomidine could significantly relieve postoperative pain and reduce the consumption of opioids in patients undergoing posterior lumbar spine surgery without obvious adverse reactions as a local anesthetic adjuvant. Further studies with larger sample sizes and different drug dosages may be useful in understanding the potential clinical benefits of dexmedetomidine.

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases

Purpose

Presumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery.

Patients and Methods

We included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018–July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration).

Results

We did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed.

Conclusion

Ultrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

Erector Spinae Plane Block as an Alternative Analgesic Technique in Patients Scheduled for Open Renal Surgery: A Randomized Controlled Study

BACKGROUND: Renal surgeries are accompanied by a moderate to a high degree of intra and postoperative pain. Ultra-sound guided erector spinae plane block (ESPB) represents an alternative method for analgesia in such surgeries as it provides cutaneous and visceral sensory blockade that covers the origin of renal and ureteric pain. Furthermore, it allows the anesthesiologist to limit the use of perioperative opioids and avoiding its possible complications. The use of the ultrasound provides higher safety profile and lower incidence of complication in the block performance. AIM: In this study, the ultrasound-guided ESPB was investigated as an alternative method to decrease the use of perioperative opioids. METHODS: The study was designed to be randomized controlled study. 46 patients undergoing open renal surgeries were included and divided into two groups: The ESPB (E) group and the control (C) group. Each group contained 23 patients. After induction of general anesthesia, all patients received ultrasound guided ESPB. Patients of the E group received 25 ml of bupivacaine 0.25% while patients of the C group received 25 ml of normal saline. For all patients; perioperative opioid consumption, 1st analgesic requirement postoperatively, and post-operative numerical rating scale (NRS) for post-operative pain assessment were recorded and analyzed. RESULTS: As regard the general descriptive data and the duration of surgery, the E and the C groups showed no statistical variations (p ≥ 0.05). The ESPB significantly prolonged the time to the firstly required analgesic medication. The median value was “300 min” in the E group compared to “30 min” the C group” with a highly significant p-value (p < 0.001). The median value of the total morphine consumption in the first 24th h postoperatively was significantly reduced in the E group “9 mg” compared to the C group “18 mg” with p-value (p < 0.001) regarding the median value of the intraoperative fentanyl consumption. Patients of the E group consumed 80 mg of fentanyl compared to 180 mg in the C group with p < 0.001. The NRS showed that the E group had lower degrees of postoperative pain throughout most of the first 24th h postoperatively. This was shown by lower NRS median values in the E group at NRS: 0, 1, and 2 with highly significant p-value (p < 0.001) compared to C group. At NRS (3); there was no statistical significance between the E group and the C group (p > 0.05). Afterward, all the time points showed lower median values of NRS in the E group relative to the C group with a highly significant p-value (p < 0.001) except for the 24th h postoperatively (NRS: 6) which had a p-value (p < 0.05). Furthermore, there were no recorded complications in the two groups. CONCLUSION: Ultrasound-guided erector spinae block prolonged the time of first analgesic requirement by the patient and reduced perioperative opioid consumption. Furthermore, it decreased pain scores in the first 24 h after open renal surgeries and it proved to be a good alternative analgesic technique in open renal surgery.

Bilateral Radioscopically-Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Randomized Clinical Trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare two perioperative pain management procedures: a radioscopically-guided erector spinae plane (ESP) block versus the standard wound infiltration technique with local anaesthetics, in patients undergoing lumbosacral spine surgery.

METHODS

A randomized, double-blind clinical trial was performed, in which adults at our hospital undergoing lumbosacral surgery without fixation were randomly assigned to receive either the standard wound infiltration technique, employing long-term anaesthetics, or a radioscopically-guided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilised due to wound pain, length of hospitalisation, and complications were recorded.

RESULTS

Over the first seven postoperative hours, pain relief was superior in the ESP block group among patients who underwent discectomies or one-level decompression (p<0.0001). Using an ESP block also was statistically superior at decreasing all postoperative variables recorded in patients scheduled for multi-level decompression: VAS pain severity over the first seven hours after the procedure (p=0,0004); number of patients with wound pain 1 (p=0.049), 7 (p<0.0001) and 24 hours (p=0.007) after surgery; length of hospitalisation (p=0.0007), number of patients immobilised for wound pain (p=0.0004) and rescue morphine consumption (p<0.0001).

CONCLUSION

The ESP block is a safe procedure which seems to outperform the infiltration wound technique for postoperative pain management in patients undergoing open spinal surgery. Future studies are needed to verify its effectiveness for arthrodesis/fixation and minimally-invasive procedures, and for chronic spine pain relief.

Erector Spinae Plane Blocks With Liposomal Bupivacaine for Pediatric Scoliosis Surgery

Pain management in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion can be challenging. Various analgesic techniques are currently used, including enhanced recovery after surgery principles, spinal opioids or continuous epidural infusion, intravenous methadone, or surgical site infiltration of local anesthetic. Another recently developed technique, ultrasound-guided erector spinae plane blockade (ESPB), has been used successfully in spine surgery and may offer advantages because of its ease of placement, excellent safety profile, and opioid sparing qualities. Liposomal bupivacaine is a long-acting local anesthetic that was recently approved for infiltration and fascial plane blocks in pediatric patients of ages 6 years and older. This medication may prove to be beneficial when administered through ESPB in patients with AIS undergoing posterior spinal fusion because it can provide prolonged analgesia after a single injection. Here, we present a case report of two such patients, and we compare outcomes with a retrospective cohort of 13 patients with AIS who received IV methadone instead of ESPB. ESPB patients seemed to have less opioid use and shorter length of stay but higher pain scores, although the sample size is too small for meaningful statistical analysis. Future prospective trials are needed to see if differences in outcomes truly exist.

Novel use of erector spinae plane block in laparoscopic surgery

Background and Aims:

Methods:

Results:

Conclusion:

Comparison of Two Ultrasound-guided Plane Blocks for Pain and Postoperative Opioid Requirement in Lumbar Spine Fusion Surgery: A Prospective, Randomized, and Controlled Clinical Trial

INTRODUCTION

The erector spinae plane (ESP) block and thoracolumbar interfascial plane (TLIP) block were two novel plane blocks. The purpose of this study was to investigate TLIP block and ESP block on the effect of analgesic and opioid consumption in lumbar spine fusion surgery in the perioperative period.

METHODS

Three hundred and four patients who suffered lumbar spine fusion were included and randomly divided into three groups: a control group (n = 102), an ESP block group (n = 100), and a TLIP block group (n = 102). We recorded the numerical rating scale (NRS) pain at movement and static during the postoperative 48 h, opioid consumption, additional analgesic requirement, frequency of patient-controlled analgesia (PCA) compressions, Bruggemann Comfort Scale (BCS) score, side effects, duration of hospital stay, and the life quality score (LQS) after operation at 6 months.

RESULTS

The patients in the ESP block group have better analgesia during 12-48 h postoperative time at static state, a lower frequency of PCA compressions at 24-48 h after surgery, and the opioid consumption in the PCA (sufentanil) were less than those in the TLIP block group (P < 0.05). However, the BCS and LQS scores were no different between the two plane block groups after surgery at 6 months. There was no difference in hospital stay and the incidence of side effect among the three groups.

CONCLUSIONS

Our results found that patients who suffered ESP block have better analgesic effects and less pain scores in static states and less frequency of PCA compression and opioid analgesic consumption compared with those that suffered TLIP block.

TRIAL REGISTRATION

ChiCTR1800019639.

Efficacy of erector spinae plane block on postoperative pain in patients undergoing lumbar spine surgery

BACKGROUND

Major lumbar spine surgery causes severe pain in the postoperative period. There are few studies regarding the effect of erector spinae plane block (ESPB) effect on lumbar surgery and its effect is still controversial. Therefore, the study aimed to investigate the effect of ultrasound-guided low thoracic ESPB on opioid consumption and postoperative pain score.

MATERIAL AND METHODS

Seventy-eight patients undergoing elective open lumbar spine surgery were randomized into two groups. In ESPB group (n = 35) received ultrasound-guided ESPB and in the control group (n = 35), there was no block. Postoperative opioid consumption as morphine equivalent dose, numerical rating scale, mobilization time, discharge time and side effects, bolus deliveries, rescue analgesia doses were evaluated.

RESULTS

Total opioid consumption as morphine equivalent was higher in the control group than the ESPB group (p = 0.000). Compare with the control group, the numeric rating scale scores were lower in the ESPB group at the 6th, 12th, and 24th hours (p < 0.05). The patient-controlled analgesia button pressing number in the postoperative 24-h period was lower in the ESPB group (p = 0.000). In the postoperative 24-h period, the need for paracetamol in the ESPB group was lower and the difference between the groups was statistically significant (p = 0.008). Rescue analgesia (diclofenac) doses were higher in the control group (p < 0.05). There was no statistically significant difference in terms of side effects and mobilization times.

CONCLUSION

ESPB is adequate for postoperative analgesia in patients undergoing lumbar spine surgery and can reduce opioid consumption compared with standard analgesia.

Impact of ultrasound-guided erector spinae plane block on outcomes after lumbar spinal fusion: a retrospective propensity score matched study of 242 patients

BACKGROUND

We evaluated the impact of bilateral ultrasound-guided erector spinae plane blocks on pain and opioid-related outcomes within a standardized care pathway for lumbar fusion.

METHODS

A retrospective propensity score matched cohort study. Clinical data were extracted from the electronic medical records of patients who underwent lumbar fusion (January 2019-July 2020). Propensity score matching based on common confounders was used to match patients who received or did not receive blocks in a 1:1 ratio. Primary outcomes were Numeric Rating Scale pain scores (0-10) and opioid consumption (morphine equivalent dose) in the first 24 hours after surgery (median (IQR)). Secondary outcomes included length of stay and opioid-related side effects.

RESULTS

Of 1846 patients identified, 242 were matched and analyzed. Total 24-hour opioid consumption was significantly lower in the erector spinae plane block group (30 mg (0, 144); without-blocks: 45 mg (0, 225); p=0.03). There were no significant differences in pain scores in the postanesthesia care unit (with blocks: 4 (0, 9); without blocks: 4 (0,8); p=0.984) or on the nursing floor (with blocks: 4 (0,8); without blocks: 4 (0,8); p=0.134). Total length of stay was 5 hours shorter in the block group (76 hours (21, 411); without blocks: 81 (25, 268); p=0.001). Fewer patients who received blocks required postoperative antiemetic administration (with blocks: n=77 (64%); without blocks: n=97 (80%); p=0.006).

CONCLUSIONS

Erector spinae plane blocks were associated with clinically irrelevant reductions in 24-hour opioid consumption and no improvement in pain scores after lumbar fusion. The routine use of these blocks in the setting of a comprehensive care pathway for lumbar fusion may not be warranted.

Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study

BACKGROUND CONTEXT

Postoperative experience plays a vital role in patient recovery and does not depend on the type and quality of the surgical procedure alone. Non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Most recently evolved among these are the regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae (ESP) block.

PURPOSE

To assess the efficacy of ultrasound-guided (US) ESP block for postoperative analgesia after a single level lumbar spine fusion surgery compared with conventional (opioid-based) multimodal postoperative analgesia.

STUDY DESIGN

A prospective, randomized, controlled, and double-blinded clinical trial.

PATIENT SAMPLE

A 100 consecutive patients requiring single-level lumbar spinal fusion procedure were randomized into two groups- block (multimodal analgesia with US-ESP) and control (only multimodal analgesia) groups.

OUTCOME MEASURES

Demographic and surgical data, intra-operative blood loss, duration of surgery, total opioid consumption (TOC) and amount of muscle relaxants used were assessed. Postoperatively, the Numeric pain Rating Scale(NRS), Modified Observer's assessment of Alertness and/or Sedation Scale (MOASS) and Patient satisfaction scores were recorded every 2 hours for the first 6 hours followed by every 6 hours for 24 hours. Continuous variables were analyzed using Student's t-test, and categorical variables were analyzed using either the Chi-square test or Fisher's exact test. p-value < .05 was considered statistically significant.

METHODS

Patients in both groups underwent the identical protocol for pre-emptive analgesia and induction of anesthesia. Patients in the block group received the US-ESP block after induction and positioning, followed by the multimodal analgesia, while the control group received only the multimodal analgesia.

RESULTS

Both groups had identical demographic backgrounds and surgical profile. TOC for 24 hours following induction was significantly lower in the block group than the control group (105.0 ± 15.15 vs 158.00 ± 23.38mcg; p < .001). The total muscle relaxant consumption during surgery was also significantly less in the block group than the control group (51.90 ± 3.17 vs 57.70 ± 5.90; p < .001). The intra-operative blood loss was significantly less (p < .001) in the block group (303.00 ± 86.55 ml) than the control group (437.00 ± 116.85 ml). Compared to the block group, the control group's pain score (NRS) was significantly higher in the first 48 hours following surgery. The MOASS score was significantly lower in the control group (4.46 ± 0.50 vs 3.82 ± 0.82; p < .001) in the immediate postoperative period. The satisfaction score was significantly higher in the block group than the control group (9.52 ± 0.65 vs 8.22 ± 0.79; p < .001).

CONCLUSION

The employed US-ESP block for single-level lumbar fusion surgery is an effective component of multimodal analgesia for reducing blood loss, total opioid consumption, and related side effects with a significant reduction of postoperative pain and higher patient satisfaction.

The Efficacy of Intraoperative Freehand Erector Spinae Plane Block in Lumbar Spondylolisthesis: A Randomized Controlled Study

STUDY DESIGN

Prospective randomized comparative (controlled) study.

OBJECTIVE

Management of the severe postoperative back pain followed the major spinal surgeries remains a challenge. The search is going on to find simple, efficient, and reliable perioperative analgesia with low side effects. We aimed to investigate the efficacy of intraoperative freehand erector spinae plane block (ESBP) after spinal surgeries.

SUMMARY OF BACKGROUND DATA

A few case reports and randomized controlled studies demonstrated the analgesic efficacy of ESPB in spinal surgeries. Up-to-date, no randomized controlled studies investigated the effectiveness of ESPB on spinal instrumentation surgeries.

METHODS

We randomly divided 56 consecutive adult patients who underwent posterior spinal instrumentation and fusion for spondylolisthesis into two groups. The study (ESPB) group (n = 28) received intraoperative freehand bilateral ESPB with a 20-mL mixture solution of 0.25% bupivacaine and 1.0% lidocaine equally divided into all operating levels. In the control group (n = 28), 20 mL physiological saline was injected. Postoperatively, we ordered 1 g paracetamol thrice/day, besides patient-controlled analgesia pumps with morphine. We performed a postoperative evaluation with a visual analog scale (VAS), morphine consumption, ESPB-related adverse effects, and postoperative length of hospital stay (PLOS).

RESULTS

Morphine consumption was significantly higher in the controls within the first postoperative 24-hour 44.75 ± 12.3 mg versus 33.75 ± 6.81 mg in the ESPB participants (P < 0.001). Except for postoperative 24th-hour VAS (P = 0.127), all postoperative VAS scores recorded at all time-points were significantly higher in the controls (P < 0.05). In control individuals, the first analgesic demand time was shorter, and PLOS was longer (P < 0.001). Patient satisfaction was significantly higher in the ESPB group. We observed no significant difference regarding postoperative complications.

CONCLUSION

Intraoperative ESPB as a part of multimodal analgesia was effective. For posterior instrumented patients with spondylolisthesis, it can relieve postoperative backache and reduce opioid consumption.Level of Evidence: 1.

Erector Spinae Plane Block in the Emergency Department for Upper Extremity: A Case Report

Introduction

The erector spinae plane block (ESPB) has been described as an effective analgesic modality in the emergency department (ED) for thoracic pain. It has not previously been described to treat ED patients with pain in the upper extremity.

Case Report

We present a case of a 52-year-old female who presented to the ED with an acute exacerbation of her chronic radicular left arm pain originating after a fall she sustained one year prior. After a variety of analgesic modalities failed to control her pain, an ESPB was used to successfully treat her pain and facilitate discharge from the ED.

Conclusion

A significant portion of patients who present to the ED have underlying chronic pain; however, opioids are a potentially dangerous and ineffective modality to treat chronic pain. In addition to avoiding opiates, the ESPB has the advantage of preserving motor function, thus avoiding the complications associated with brachial plexus blockade.

Anatomic and radiological correlation of injectate spread from first thoracic costotransverse junction in cervical erector spinae plane

Introduction

Cervical erector spinae plane block (ESPB) provides postoperative pain relief when administered at the level of first thoracic costotransverse junction (CTJ) for surgeries on the proximal shoulder and cervical spine. We propose to describe the spread of 20 ml radiocontrast - dye solution administered at this level from caudad to cephalad direction in a fresh frozen cadaveric model through imaging and cross-sections.

Methods

An observational study with four thoracic to cervical ESP blocks at the level of first thoracic CTJ level on two fresh cadavers (total 4 specimens) was conducted using 20 ml of radiocontrast- methylene blue combination (10 ml through the needle and 10 ml through the catheter). Both cadavers were subjected to computed tomography (CT) scan. An anatomist and radiologist, respectively, analyzed cross-sections of cadavers and CT contrasted images.

Results

The spread was assessed in axial, sagittal, and coronal at the levels of C4, C5, C6, C7and T1. The medial limit was articular processes in both cadavers. The lateral limits were the outer border of the middle scalene muscle in cadaver 1 and posterior to the sternocleidomastoid muscle in cadaver 2. Contrast spread was visualized on the superior and anterior aspect of anterior scalene muscle in cadaver 2. An epidural spread was observed at the level of C5-6 and C6-7 in axial and coronal planes in cadaver 1.

Conclusions

The cervical ESPB administered at the first thoracic CTJ with injections directed cephalad has a consistent action on the dorsal spinal nerves of thoracic and cervical area, and spreads in the paravertebral space dorsal to the ventral cervical roots.

Erector spinae plane block for chronic low back pain analgesia: A case series

BACKGROUND

Chronic low back pain (CLBP) is a frequent condition, poorly managed with conventional treatments. The ultrasound-guided erector spinae plane block has increasingly been used in the management of acute and chronic pain. We aimed to determine this technique's analgesic efficacy in patients with moderate to severe CLBP.

METHODS

Ten consecutively selected patients: adults, regularly followed in our Pain Clinic with moderate/severe long-term CLBP refractory to pharmacological treatment, VAS > 4. Prospective data collection: before the intervention -demographical data, past medical history, current pain therapies, VAS pain level, Brief Pain Inventory- Short Form and Neuropathic Pain Questionnaire; 30 min after - VAS and satisfaction level; 24 and 72 h, 7 days and 1 month after - complications and pain level.

RESULTS

Majority of females (90%), mean age of 70.3 years-old. All had primary musculoskeletal CLBP. 90% experienced severe pain (VAS >= 7) in the last 24 h. Half presented neuropathic characteristics. Patients were very satisfied with the technique (mean: 8.75) with immediate pain relief (VAS mean: 2.3). 24 and 72 h, 7 days and 1 month after the treatment VAS means were 3.2, 3.1, 3.8 and 6.2. We report a 20.8 days duration mean. No short or long-term complications.

DISCUSSION AND CONCLUSIONS

Ultrasound-guided erector spinae plane block has preliminary advantages in CLBP: easily performed with low complications risk, immediate discharge home with absence of motor block, 100% efficacy at short and medium-terms. Even though pain's relief was shorter than a month, it is a useful tool allowing patients' well-being, physical rehabilitation and exercise during this period.

Bilateral Ultrasound-guided Erector Spinae Plane Block for Postoperative Analgesia in Lumbar Spine Surgery: A Randomized Control Trial

BACKGROUND

Major lumbar spine surgery causes severe postoperative pain. The primary objective of this randomized controlled study was to compare the effect of ultrasound (US)-guided erector spinae plane (ESP) block on 24-hour postoperative cumulative opioid requirements with standard (opioid-based) analgesia. Postoperative pain control and patient satisfaction were also assessed.

MATERIALS AND METHODS

Adults scheduled for elective lumbar spine surgery under general anesthesia were randomly assigned to the following (and they are): Control group-no preoperative ESP block, or ESP block group-preoperative bilateral US-guided ESP block. Both groups received standard general anesthesia during surgery. Postoperative pain score, number of patients requiring rescue analgesia, and total morphine consumption during the first 24 postoperative hours were recorded. Patient satisfaction was assessed 24 hours after surgery.

RESULTS

Postoperative morphine consumption was significantly lower in patients in the ESP group compared with those in the control group (1.4±1.5 vs. 7.2±2.0 mg, respectively; P<0.001). All patients in the control group required supplemental morphine compared with only 9 (45%) in the ESP block group (P=0.002). Pain scores immediately after surgery (P=0.002) and at 6 hours after surgery (P=0.040) were lower in the ESP block group compared with the control group. Patient satisfaction scores were more favorable in the block group (P<0.0001).

CONCLUSIONS

US-guided ESP block reduces postoperative opioid requirement and improves patient satisfaction compared with standard analgesia in lumbar spine surgery patients.

Erector spinae plane block at lower thoracic level for analgesia in lumbar spine surgery: A randomized controlled trial

BACKGROUND

Patients undergoing lumbar spine surgery usually suffer severe pain in the postoperative period. The erector spinae plane block (ESPB), first published in 2016, can anesthetize the ventral and dorsal rami of thoracic nerves and produce an extensive multi-dermatomal sensory block.

AIM

To assess whether bilateral ultrasound-guided ESPB at a lower thoracic level could improve pain control and quality of recovery in patients undergoing lumbar spine surgery.

METHODS

A total of 60 patients aged 18-80 years scheduled to undergo lumbar spine surgery with general anesthesia were randomly assigned to two groups: ESPB group (preoperative bilateral ultrasound-guided ESPB at T10 vertebral level) and control group (no preoperative ESPB). Both groups received standard general anesthesia. The main indicator was the duration to the first patient controlled intravenous analgesia (PCIA) bolus.

RESULTS

In the ESPB group, the duration to the first PCIA bolus was significantly longer than that in the control group (h) [8.0 (4.5, 17.0) vs 1.0 (0.5, 6), P < 0.01], and resting and coughing numerical rating scale (NRS) scores at 48 h post operation were significantly lower than those in the control group (P < 0.05). There was no significant difference between the two groups regarding resting and coughing NRS scores at 24 h post operation. Sufentanil consumption during the operation was significantly lower in the ESPB group than in the control group (P < 0.01), while there was no significant difference between the two groups regarding morphine consumption at 24 or 48 h post operation. In the ESPB group, Modified Observer’s Assessment of Alertness/Sedation score within 20 min after extubation was higher and duration in the post-anesthesia care unit was shorter than those in the control group (P < 0.01).

CONCLUSION

In patients undergoing lumbar spine surgery, ultrasound-guided ESPB at a lower thoracic level improves the analgesic effect, reduces opioid consumption, and improves postoperative recovery.

Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Cervical and Thoracic Spine Surgeries - A Case Series

Erector spinae plane (ESP) block is a recently introduced regional technique for pain management. However, its usefulness for perioperative analgesia in cervical and thoracic spine surgeries is underutilized. In this case series, we reviewed the case records of seven patients who received ultrasound-guided ESP block for perioperative analgesia for cervical and thoracic spine surgeries during a two-month period. We evaluated the performance of the ESP block with regards to intraoperative nociception and hemodynamics, postoperative pain, and need of rescue analgesia in these patients. The median age of our patients was 28 years (range 5-74 years) and the duration of surgery was 300 minutes (range 240-540 minutes). The surgical pleth index, a marker of intraoperative nociception, was below the threshold of 50 at most time-points during the surgery. Similarly, intraoperative hemodynamic parameters (HR and BP) were stable throughout the surgery. Postoperative pain control was good during the initial 48 after surgery with median NRS score of 2 at rest and 4 with movement. The ESP block results in good intraoperative and postoperative analgesia and also provides hemodynamic stability and opioid-sparing effect for cervical and thoracic spine surgeries.

Awake Spinal Fusion

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Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints.

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ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia.

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The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Regional Anesthesia for Spine Surgery

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4-22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0-3 [0-5]) in the control group vs. 1 (0-1 [0-4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.