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

Abstract

Background We compare two perioperative pain management procedures(a radioscopicallyguided erector spinae plane [ESP] block versus the standard wound infiltration technique with local anesthetics) 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 anesthetics, or a radioscopicallyguided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilized due to wound pain, length of hospitalization, and complications were recorded.

Results Over the first 7 postoperative hours, pain relief was superior in the ESP block group among patients who underwent diskectomies 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 multilevel decompression: visual analog scale (VAS) pain severity over the first 7 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 hospitalization (p = 0.0007), number of patients immobilized for wound pain (p = 0.0004) and rescue morphine consumption (p< 0.0001).

Conclusion The ESP block is a safe procedure that 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 minimallyinvasive procedures, and for chronic spine pain relief.

Keywords

erector muscles - spinal surgery - postoperative analgesia - nerve block

Publication History

Received: 04 August 2021

Accepted: 07 February 2022

Accepted Manuscript online:
10 February 2022

Article published online:
28 July 2022

• References

• 1 Bianconi M, Ferraro L, Ricci R. et al. The pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg 2004; 98 (01) 166-172
• 2 Cohen BE, Hartman MB, Wade JT, Miller JS, Gilbert R, Chapman TM. Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia. Spine 1997; 22 (16) 1892-1896 , discussion 1896–1897
• 3 Gottschalk A, Freitag M, Tank S. et al. Quality of postoperative pain using an intraoperatively placed epidural catheter after major lumbar spinal surgery. Anesthesiology 2004; 101 (01) 175-180
• 4 Blumenthal S, Min K, Nadig M, Borgeat A. Double epidural catheter with ropivacaine versus intravenous morphine: a comparison for postoperative analgesia after scoliosis correction surgery. Anesthesiology 2005; 102 (01) 175-180
• 5 Eilers K, Schenk M, Putzier M, Volk T, Kox WJ, Zippel H. Use of peridural catheters in the treatment of postoperative pain after spinal instrumentated fusion: an experience report. Z Orthop Ihre Grenzgeb 2002; 140 (06) 621-625
• 6 Lowry KJ, Tobias J, Kittle D, Burd T, Gaines RW. Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis. Spine 2001; 26 (11) 1290-1293
• 7 Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362 (9399): 1921-1928
• 8 O'Neill P, Knickenberg C, Bogahalanda S, Booth AE. Use of intrathecal morphine for postoperative pain relief following lumbar spine surgery. J Neurosurg 1985; 63 (03) 413-416
• 9 Dietz N, Sharma M, Adams S. et al. Enhanced recovery after surgery (eras) for spine surgery: a systematic review. World Neurosurg 2019; 130: 415-426
• 10 Ross DA, Drasner K, Weinstein PR, Flaherty JF, Barbaro NM. Use of intrathecally administered morphine in the treatment of postoperative pain after lumbar spinal surgery: a prospective, double-blind, placebo-controlled study. Neurosurgery 1991; 28 (05) 700-704
• 11 Joshi GP, McCarroll SM, O'Rourke K. Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine. Anesth Analg 1995; 80 (03) 511-514
• 12 Fisher CG, Belanger L, Gofton EG. et al. Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion. Spine 2003; 28 (08) 739-743
• 13 Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290 (18) 2455-2463
• 14 Schenk MR, Putzier M, Kügler B. et al. Postoperative analgesia after major spine surgery: patient-controlled epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg 2006; 103 (05) 1311-1317
• 15 Mullen JB, Cook Jr WA. Reduction of postoperative lumbar hemilaminectomy pain with Marcaine. Technical note. J Neurosurg 1979; 51 (01) 126-127
• 16 Kjærgaard M, Møiniche S, Olsen KS. Wound infiltration with local anesthetics for post-operative pain relief in lumbar spine surgery: a systematic review. Acta Anaesthesiol Scand 2012; 56 (03) 282-290
• 17 Ersayli DT, Gurbet A, Bekar A, Uckunkaya N, Bilgin H. Effects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar discectomy. Spine 2006; 31 (19) 2221-2226
• 18 Gurbet A, Bekar A, Bilgin H, Korfali G, Yilmazlar S, Tercan M. Pre-emptive infiltration of levobupivacaine is superior to at-closure administration in lumbar laminectomy patients. Eur Spine J 2008; 17 (09) 1237-1241
• 19 Steel T, Jones R, Crossman J, Sheehy J, Bentivoglio P, Pell M. Intraoperative wound infiltration with bupivacaine in patients undergoing lumbar spine surgery. J Clin Neurosci 1998; 5 (03) 298-303
• 20 Mack PF, Hass D, Lavyne MH, Snow RB, Lien CA. Postoperative narcotic requirement after microscopic lumbar discectomy is not affected by intraoperative ketorolac or bupivacaine. Spine 2001; 26 (06) 658-661
• 21 Esmail F, Mohammad-Reza F, Homayoon T. Preemptive analgesia with local lidocaine infiltration for single-level open disc operation. Pak J Biol Sci 2008; 11 (14) 1868-1871
• 22 Milligan KR, Macafee AL, Fogarty DJ, Wallace RG, Ramsey P. Intraoperative bupivacaine diminishes pain after lumbar discectomy. A randomised double-blind study. J Bone Joint Surg Br 1993; 75 (05) 769-771
• 23 Teddy PJ, Fabinyi GC, Kerr JH, Briggs M. Bupivacaine infiltration after lumbar laminectomy. Local infiltration in the control of early postoperative lumbar laminectomy pain. Anaesthesia 1981; 36 (04) 380-383
• 24 Cherian MN, Mathews MP, Chandy MJ. Local wound infiltration with bupivacaine in lumbar laminectomy. Surg Neurol 1997; 47 (02) 120-122 , discussion 122–123
• 25 Yörükoğlu D, Ateş Y, Temiz H, Yamali H, Kecik Y. Comparison of low-dose intrathecal and epidural morphine and bupivacaine infiltration for postoperative pain control after surgery for lumbar disc disease. J Neurosurg Anesthesiol 2005; 17 (03) 129-133
• 26 Perera AP, Chari A, Kostusiak M, Khan AA, Luoma AM, Casey ATH. Intramuscular local anesthetic infiltration at closure for postoperative analgesia in lumbar spine surgery: a systematic review and meta-analysis. Spine 2017; 42 (14) 1088-1095
• 27 Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block. A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016; 41 (05) 621-627
• 28 Ahiskalioglu A, Yayik AM, Celik EC, Ahiskalioglu EO, Emsen M. Two plane two block for surgical anesthesia: ultrasound-guided serratus and erector spinae plane blocks. J Clin Anesth 2018; 47: 19-20
• 29 Ahiskalioglu A, Alici HA, Ciftci B, Celik M, Karaca O. Continuous ultrasound guided erector spinae plane block for the management of chronic pain. Anaesth Crit Care Pain Med 2019; 38 (04) 395-396
• 30 Chung K, Kim ED. Erector spinae plane block at the lower thoracic level for postoperative pain management after spinal cord stimulation implantation. Pain Med 2018; 19 (11) 2330-2332
• 31 Adhikary SD, Pruett A, Forero M, Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: a case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth 2018; 62 (01) 75-78
• 32 Ueshima H, Otake H. Withdrawn: clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery. J Clin Anesth 2017; 38: 137
• 33 Tulgar S, Senturk O. Ultrasound guided erector spinae plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty. J Clin Anesth 2018; 44: 68
• 34 Chung K, Kim ED. Continuous erector spinae plane block at the lower lumbar level in a lower extremity complex regional pain syndrome patient. J Clin Anesth 2018; 48: 30-31
• 35 Melvin JP, Schrot RJ, Chu GM, Chin KJ. Low thoracic erector spinae plane block for perioperative analgesia in lumbosacral spine surgery: a case series. Can J Anaesth 2018; 65 (09) 1057-1065
• 36 Singh S, Choudhary NK, Lalin D, Verma VK. Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in lumbar spine surgery: a randomized control trial. J Neurosurg Anesthesiol 2020; 32 (04) 330-334
• 37 Forero M, Rajarathinam M, Adhikary SD, Chin KJ. Erector spinae plane block for the management of chronic shoulder pain: a case report. Can J Anaesth 2018; 65 (03) 288-293
• 38 Miller DRonald. “Miller Anestesia.” Octava edición. Philadelphia, PA: Saunders, Elsevier Inc.; 2015
• 39 Jadon A, Swarupa CP, Amir M. Fluoroscopic-guided erector spinae plane block: a feasible option. Indian J Anaesth 2018; 62 (10) 806-808