The Effect of the Modified Thoracolumbar Interfacial Nerve Plane Block on Postoperative Analgesia and Healing Quality in Patients Undergoing Lumbar Disk Surgery: A Prospective, Randomized Study

Regional Anesthesia Techniques in Modern Neuroanesthesia Practice: A Narrative Review of the Clinical Evidence

Neurosurgical procedures are often associated with significant postoperative pain that is both underrecognized and undertreated. Given the potentially undesirable side effects associated with general anesthesia and with various pharmacological analgesic regimens, regional anesthetic techniques have gained in popularity as alternatives for providing both anesthesia and analgesia for the neurosurgical patient. The aim of this narrative review is to present an overview of the regional techniques that have been incorporated and continue to be incorporated into modern neuroanesthesia practice, presenting in a comprehensive way the evidence, where available, in support of such practice for the neurosurgical patient.

Analgesic efficacy of classical thoracolumbar interfascial plane block versus modified thoracolumbar interfascial plane block in patients undergoing lumbar disc surgeries: A comparative, randomised controlled trial

Background and Aims

We compared classical (medial) and modified (lateral) thoracolumbar interfascial plane block (TLIP) with only general anaesthesia (GA) using multimodal analgesia in patients undergoing lumbar disc surgeries.

Methods

In this study, 100 patients aged 18-70 years were randomised to Group cTLIP (conventional TLIP block with 20 mL of 0.25% ropivacaine with GA), Group mTLIP (modified TLIP block with 20 mL of 0.25% ropivacaine with GA), and Group C (only GA using multimodal analgesia). The primary outcome was to assess the total peri-operative opioid consumption in the first 24 h. The secondary outcomes were to assess pain score upon arriving in the post-anaesthesia care unit, time to first analgesic need after surgery, post-operative opioid consumption in 24 h, and incidence of nausea and vomiting.

Results

The total peri-operative opioid consumption in Group cTLIP (507.58 (258.55) μg) and Group mTLIP (491.67 (165.39) μg) was significantly lower than that in Group C (1225.4 (237.03) μg); (P < 0.001). However, it was comparable between groups cTLIP and mTLIP (P = 0.767). Pain score was comparable in groups cTLIP and mTLIP. It was significantly lower than Group C (P = 0.001). Rescue analgesia was needed in all (100%) patients of Group C but in only 15.2% of patients of the cTLIP and mTLIP groups. No patient in groups cTLIP and mTLIP complained of nausea and vomiting in the first 24 h, whereas it was significantly higher (61.8%) in Group C (P = 0.001).

Conclusion

The analgesic effect of the modified TLIP block was not superior to the conventional TLIP block. Both techniques provided the same intra-operative and post-operative analgesia for lumbar disc surgeries.

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.

The efficacy of thoracolumbar interfascial plane block for lumbar spinal surgeries: a systematic review and meta-analysis

BACKGROUND

The intent of this meta-analysis was to examine the efficacy of thoracolumbar interfascial plane block (TLIP) for pain control after lumbar spinal surgery.

METHODS

Randomized controlled trials (RCTs) published on PubMed, CENTRAL, Scopus, Embase, and Web of Science databases up to February 10, 2023, comparing TLIP with no or sham block or wound infiltration for lumbar spinal surgeries were included. Pain scores, total analgesic consumption, and postoperative nausea and vomiting (PONV) were analyzed.

RESULTS

Seventeen RCTs were eligible. Comparing TLIP with no block or sham block, the meta-analysis showed a significant decrease of pain scores at rest and movement at 2 h, 8 h, 12 h, and 24 h. Pooled analysis of four studies showed a significant difference in pain scores at rest between TLIP and wound infiltration group at 8 h but not at 2 h, 12 h, and 24 h. Total analgesic consumption was significantly reduced with TLIP block as compared to no block/sham block and wound infiltration. TLIP block also significantly reduced PONV. GRADE assessment of the evidence was moderate.

CONCLUSION

Moderate quality evidence indicates that TLIP blocks are effective in pain control after lumbar spinal surgeries. TLIP reduces pain scores at rest and movement for up to 24 h, reduces total analgesic consumption, and the incidence of PONV. However, evidence of its efficacy as compared to wound infiltration of local anesthetics is scarce. Results should be interpreted with caution owing low to moderate quality of the primary studies and marked heterogeneity.

Ultrasound-Guided Modified Thoracolumbar Fascial Plane Block in Tianji Robot-Assisted Lumbar Internal Fixation: A Prospective, Randomized, and Non-Inferiority Study

Purpose

Ultrasound-guided modified thoracolumbar fascial plane block (MTLIP) has been reported effective for postoperative pain control following lumbar surgery. Although trauma of the Tianji robot-assisted lumbar internal fixation is reduced, the degree of pain cannot be ignored.MTLIP may improve operation efficiency and reduce puncture complications.This study aimed to explore whether MTLIP is not inferior to thoracolumbar fascial plane block (TLIP) in the treatment of lumbar internal fixation.

Methods

This prospective double-blinded, non-inferiority randomized trial enrolled patients underwent Tianji robot-assisted lumbar internal fixation between April and August 2022 to either MTLIP or TLIP. The primary outcome was an effective dermatomal block area after 30 min. Secondary outcomes included the numeric rating scale (NRS) scores, nerve block operation time, puncture times, image clarity, patient satisfaction, intraoperative opioid consumption, complications/adverse reactions, and Oswestry Disability Index (ODI).

Results

Sixty participants were randomized to MTLIP (n=30) and TLIP (n=30). The effective dermatomal block area 30 min after block was non-inferior in the MTLIP group (283.6 ± 62.6 cm²) compared with the TLIP group (261.4±53.2 cm²) (P=0.145; estimated mean difference: -22.17, 95% CI: -52.19, 7.85; smaller than the non-inferiority margin of 39.5). Compared with TLIP, MTLIP showed shorter operation time, smaller puncture times, and better target definition and satisfaction scores (all P<0.001). Sufentanil amount, remifentanil amount, PCIA sufentanil dosage, parecoxib amount, NRS scores (increased with time in the two groups but without inter-group differences), and complications were not significantly different between the two groups (all P>0.05).

Conclusion

This non-inferiority trial supports the hypothesis that MTLIP yields a non-inferior effective dermatomal block area compared with TLIP for Tianji robot-assisted lumbar internal fixation.

Clinical Trials Registration

Chinese Clinical Trial Registry (ChiCTR2200058687);.

Investigation of the analgesic efficacy of ultrasound-guided thoracolumbar interfacial plane block in vertebral surgery: A prospective randomized clinical study

OBJECTIVES

To investigate the effect of thoracolumbar interfacial plane block (TLIP) on analgesic consumption and pain score in vertebral surgery.

METHODS

All patients (64 patients undergoing vertebral surgery) were randomly allocated as Group T (patients with block, n=32) and Group C (patients without block, n=32). After surgery, patient-controlled analgesia using tramadol was administered to all patients. Pain intensity was evaluated with visual analogue scale (VAS; recovery room at 1, 2, 6, 12, and 24 hours postoperative), and as rescue analgesia, morphine was administered to patients with VAS scores of >4. In this study, total tramadol consumption, the number of patients requiring morphine, VAS score, and Quality of Recovery-40 of all patients questionnaire was evaluated.

RESULTS

There were important differences between the 2 groups according to mean postoperative tramadol consumption (Group T and Group C; 180 mg [100-260] vs. 210 mg [100-300]; p=0.001) and the number of patients requiring additional analgesia (n=4; 12.5% vs. n=24; 75%, p=0.000). There were important differences between the 2 groups according to the postoperative VAS pain score (p=0.000).

CONCLUSION

Ultrasound-TLIP reduces analgesic consumption and pain severity after vertebral surgery. Therefore, it is an important regional analgesia technique. CLINICALTRIALSGOV GRANT NO: NCT04548076.

Effect of Ultrasound-Guided Thoracolumbar Interfascial Plane Block on the Analgesic Requirements in Patients Undergoing Lumbar Spine Surgery Under General Anesthesia: A Randomized Controlled Trial

BACKGROUND

Thoracolumbar interfascial plane (TLIP) block was recently described as a regional anesthetic technique to achieve analgesia for lumbar spine surgery by blocking the dorsal rami of spinal nerves. The study aims to test the hypothesis that TLIP block can offer pain control and reduce the perioperative analgesic requirement in patients undergoing spinal surgery.

METHODS

There were 60 patients scheduled for lumbar spine surgery who were randomly assigned into two equal groups, TLIP and control groups. Patients in the TLIP group received general anesthesia and TLIP block while patients in the control group received general anesthesia alone. The primary outcome was the analgesic consumption in the first postoperative 24 hours, while intraoperative additional analgesic needs, time to the first request of postoperative analgesia, and pain scores were the secondary outcomes.

RESULTS

At 24 hours postoperatively, morphine consumption was lower in the TLIP group (5.13±1.55) versus the control group (14.33±2.58) mg. The intraoperative fentanyl consumption was lower in the TLIP group (15±35.11 mcgs) versus the control group (105±62.08 mcgs). Postoperative first request for analgesia was delayed in the TLIP group (7.30±2.69 h) compared to the control group (0.92±1.23 h). Postoperative Pain scores at rest were 2.53 ± 0.97 and 3.43 ± 0.50 at 24 hours in the TLIP group and the control group, respectively. Postoperative Pain scores at passive flexion of spine were 2.73 ±0.87 and 3.93 ±0.78 at 24 hours in the TLIP group and the control group, respectively. Patients in the TLIP group had lower perioperative hemodynamic responses to surgical stimulation in comparison to the control group.

CONCLUSION

Combined TLIP block with general anesthesia in patients undergoing spinal surgery reduced both postoperative and intraoperative analgesic needs, reduced intra-operative hemodynamic response to surgery, and achieved good postoperative pain control.

Thoracolumbar interfascial plane block for postoperative analgesia in spine surgery: A systematic review and meta-analysis

INTRODUCTION

Thoracolumbar interfascial plane (TLIP) block has been discussed widely in spine surgery. The aim of our study is to evaluate analgesic efficacy and safety of TLIP block in spine surgery.

METHOD

We performed a quantitative systematic review. Randomized controlled trials that compared TLIP block to non-block care or wound infiltration for patients undergoing spine surgery and took the pain or morphine consumption as a primary or secondary outcome were included. The primary outcome was cumulative opioid consumption during 0-24-hour. Secondary outcomes included postoperative pain intensity, rescue analgesia requirement, and adverse events.

RESULT

9 randomized controlled trials with 539 patients were included for analysis. Compared with non-block care, TLIP block was effective to decrease the opioid consumption (WMD -16.00; 95%CI -19.19, -12.81; p<0.001; I2 = 71.6%) for the first 24 hours after the surgery. TLIP block significantly reduced postoperative pain intensity at rest or movement at various time points compared with non-block care, and reduced rescue analgesia requirement ((RR 0.47; 95%CI 0.30, 0.74; p = 0.001; I2 = 0.0%) and postoperative nausea and vomiting (RR 0.58; 95%CI 0.39, 0.86; p = 0.006; I2 = 25.1%). Besides, TLIP block is superior to wound infiltration in terms of opioid consumption (WMD -17.23, 95%CI -21.62, -12.86; p<0.001; I2 = 63.8%), and the postoperative pain intensity at rest was comparable between TLIP block and wound infiltration.

CONCLUSION

TLIP block improved analgesic efficacy in spine surgery compared with non-block care. Furthermore, current literature supported the TLIP block was superior to wound infiltration in terms of opioid consumption.