Efficacy of Sacral Erector Spinae Plane Block for Postoperative Pain Management in Hemorrhoid and Pilonidal Sinus Surgeries: A Prospective Randomized Controlled Study

Abstract

Background

This study was conducted to evaluate the efficacy of the sacral erector spinae plane block (ESPB) in postoperative pain management. We aimed to demonstrate the effectiveness of sacral ESPB implemented alongside analgesic treatment in patients undergoing hemorrhoid and pilonidal sinus (PS) surgeries.

Materials and Methods

The study design involves a prospective randomized controlled. Sixty-eight patients were randomly divided into a sacral ESPB group and a control group. Following surgery, the ESPB group received an ultrasound-guided injection of a local anesthetic. Both groups received standardized pain management protocols. Pain scores were recorded using the numeric rating scale at 30 minutes, 2 hours, 8 hours, and 24 hours after surgery. Additionally, tramadol consumption and hospital length of stay were also recorded.

Results

Patients in the sacral ESPB group had significantly lower pain scores at 8 and 24 hours compared with the control group. They also consumed less tramadol on average. There were no significant differences in pain scores or tramadol use between patients who underwent hemorrhoid surgery and those who underwent PS surgery.

Conclusion

Sacral ESPB effectively managed postoperative pain and reduced analgesic consumption in hemorrhoid and PS surgeries. The results of this study suggest that incorporating sacral ESPB into multimodal analgesic protocols for anorectal surgery may be clinically beneficial.

 

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Keywords

analgesic techniques - postoperative recovery - pain management - erector spinae block - surgical outcomes - anorectal surgery

Introduction

The erector spinae plane block (ESPB) is an innovation in interfascial block techniques. Despite its novelty, it is rapidly gaining popularity for treating postoperative pain through various procedures. The lumbar ESPB technique has been described for its use in abdominal surgeries, gender reassignment surgery, and the treatment of vaginismus.[1] Besides the other documented applications, lumbar ESPB has recently been successfully used as a primary anesthetic technique for hip surgery.[2] Upon closer examination, the erector spinae muscle group can be observed to span from the cervical to the sacral region. This implies that ESPB has the potential to be conducted at various levels within the vertebral column. Compared to peripheral nerve blocks, the ESPB acts on both visceral and somatic nerve fibers, providing adequate analgesia to control both deep (visceral) and superficial (somatic) pain. Although conventional blocks typically work only in a limited area, ESPB can achieve a broad analgesic effect that covers multiple dermatomes, due to its ability to extend into the fascial planes.[3] [4] Tulgar et al[5] reported the use of ESPB in the sacral region to achieve sensory blockade in the parasacral area by blocking the posterior branches of the sacral nerves.[6]

Hemorrhoid and pilonidal sinus (PS) can be highly painful both before and after surgery. Postoperative pain control plays a crucial role in the effective management of these conditions. The use of sacral ESPB, particularly in PS surgery, is a novel approach. Despite the use of analgesic medications, inadequate implementation of multimodal analgesia management in minor surgeries such as hemorrhoid and PS surgeries can result in postoperative pain. This underscores the possibility of sacral ESPB as a significant element of multimodal analgesia in PS surgery. In this study, we aimed to demonstrate the efficacy of sacral ESPB implemented alongside analgesic treatment in patients undergoing hemorrhoid and PS surgeries. The primary end point of this study was the efficacy of the sacral ESPB in reducing postoperative pain in patients undergoing hemorrhoid and PS surgeries. Secondary end points were the need for rescue analgesia, the consumption of tramadol in the first 24 hours, and the length of hospital stay.

 

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Materials and Methods

This prospective, randomized, controlled study was conducted in the Department of Anesthesiology and Reanimation at Mengucek Gazi Training and Research Hospital, Erzincan Binali Yıldırım University, Erzincan, Türkiye. The study was approved by the Clinical Research Ethics Committee (Decision Number: 2023/01-08). It was registered on ClinicalTrials.gov (NCT06459739). All research procedures involving human volunteers complied with ethical standards, the Declaration of Helsinki, and any other relevant ethical guidelines.

Informed consent was obtained from a total of 70 patients who were scheduled to undergo PS and hemorrhoid surgeries. These patients were divided into two groups of 35 patients: those who received sacra ESPB (group S) and those who did not (group C) ([Fig. 1]). American Society of Anesthesiologists (ASA) I to II patients aged 18 to 70 years were included in the study. Patients classified as ASA III to IV, patients with coagulopathies, pregnant women with significant cardiovascular, hepatic, or renal disease who declined spinal anesthesia or were contraindicated for it, who had undergone the same surgery before, and those younger than 18 or older than 70 years were all excluded from the study.

Fig. 1 CONSORT diagram for participants.

Participants were randomly assigned to the sacral ESPB group or the control group. Randomization was performed using numbered, sealed, and opaque envelopes, and the selection was made by an independent person not involved in the study. Following surgery, patients assigned to the sacral ESPB group received the block under ultrasound guidance by a dedicated anesthesiologist. This physician remained uninvolved in the data collection to ensure objectivity. A standardized analgesic protocol was used for both groups. The pain assessments were performed by an independent anesthesiologist, unaware of the group assignment, to minimize bias.

All patients underwent comprehensive anesthesia surveillance and received a standardized fluid regimen. Spinal anesthesia was performed in the sitting position if the patients were able and in the lateral decubitus position if they were not. A Quincke spinal needle (25 gauge, Egemen, Türkiye) was inserted into the L3–L4 or L4–L5 interspace. After the cerebrospinal fluid was determined, 2 to 2.5 mL of 0.5% bupivacaine hydrochloride was administered into the intrathecal area. Standard supportive treatments for hypotension and bradycardia during surgery were implemented, including positioning, fluid resuscitation, vasopressors, and atropine, as needed. After the surgical procedure, each patient received a slow infusion of 10 mg/kg paracetamol and 100 mg tramadol in 100 mL of isotonic solution.

Following the establishment of aseptic and antiseptic conditions, sacral ESPB was administered to the study participants using a high-frequency ultrasound probe. The application was performed bilaterally while the subjects were in a prone position. After the fifth lumbar spinous process was palpated, the probe was moved downward to access the first and second median sacral crests. The ultrasound transducer was placed 3 to 4 cm lateral to the second median sacral crest, allowing visualization of the deeper intermediate sacral crest. Subsequently, a 20-mL dose of 0.25% bupivacaine was carefully injected between the erector spinae muscle and the sacral crest ([Fig. 2]). The same procedural steps were replicated on the opposite side, and the intervention was completed.

Fig. 2 (a) The sonoanatomy of the ESP. (b) Image captured after injection of LA, with the presumed spread indicated in green. The white arrow indicates the needle trajectory. ESP, erector spinae plane; ISC, intermediate sacral crest; LA: local anesthetics.

Age, sex, ASA physical condition score, height, weight, body mass index (BMI), duration of surgery, hemodynamic variables (heart rate, pulse oximetry, noninvasive blood pressure), and tramadol consumption of all participants were recorded. The numeric rating scale (NRS) assessed postoperative pain at 30 minutes, 2 hours, 8 hours, and 24 hours. This scale is a segmented numeric adaptation of the visual analog scale, requiring respondents to choose an integer from 0 to 10 that accurately represents their pain intensity. Recognized as a one-dimensional measure of adult pain intensity, the NRS spans 11 points, with 0 indicating “no pain” and 10 indicating “the worst pain imaginable.” The postoperative pain level at rest was documented at specified intervals using this scale. The length of hospital stay was also recorded.

Sample Size Calculation

The literature was reviewed, and the results of similar studies were evaluated using the G-Power program. A total of 64 patients were found to be sufficient (effect size d: 0.8595, α err prob: 0.05, Power [1-β err prob]: 0.961).

 

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Statistical Analysis

The normality of the distribution of the quantitative data obtained in the study across the groups was examined using the Shapiro–Wilk's test, and Levene's test verified homogeneity of variance across the groups. Quantitative data were expressed as mean ± standard deviation or median (first quartile–third quartile), and categorical variables were expressed as frequencies and percentages. The relationship structure between the quantitative data was examined using two-way Pearson's correlation analysis. To conduct pairwise comparisons between independent groups, the independent t-test or the Mann–Whitney's U test was used. Pearson's chi-square analysis was used to explore the relationships between categorical variables. Histogram graphs were generated at a 95% confidence interval (CI) and error bars represent ± 2 standard errors in width. In this study, a p-value < 0.05 was considered significant, and the type-I error rate was determined to be 5%. The statistical analyses were performed using the SPSS 25.0 program (IBM Inc., Chicago, Illinois, United States).

 

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Results

Two of the 70 planned participants refused the procedure in the operating room and were excluded from the study. The study was conducted with 68 participants, divided into two groups: 34 participants in group S and 34 participants in group C. [Table 1] provides a summary of critical demographic data. When evaluated by type of surgery, 27 participants with hemorrhoids and 41 with PS were included. There were no significant differences in height between the two groups (p = 0.360), weight (p = 0.177), BMI (p = 0.347), or tramadol consumption (p = 0.621). As summarized in [Table 2], when comparing participants by age, 34 ± 9 patients had undergone hemorrhoid surgery, 27 ± 8 patients had undergone PS surgery, and the difference was significant (p < 0.001).

Table 1 Analysis of demographic and clinical variables between the sample groups

Parameter	Control (n = 34)	Sacral ESPB (n = 34)	p-Value	d
Age (y), mean ± SD (95% CI)	30 ± 10 (26–33)	29 ± 9 (26–32)	0.773	0.11
Weight (kg), mean ± SD (95% CI)	78 ± 10 (74–81)	76 ± 15 (71–82)	0.649	0.16
Height (cm), mean ± SD (95% CI)	171 ± 10 (168–174)	172 ± 10 (169–176)	0.592	0.10
BMI (kg/m2), mean ± SD (95% CI)	26.74 ± 3.61 (25.48–28.00)	25.60 ± 3.83 (24.26–26.94)	0.212	0.31
Operation duration (min), mean ± SD (95% CI)	45 ± 16 (39–50)	45 ± 18 (38–51)	0.989	0.00
Gender n (%)
Female	9 (26.5%)	10 (29.4%)	0.78
Male	25 (73.5%)	24 (70.6%)
n (%) within group
ASA I	18 (52.9%)	19 (55.9%)	0.82
ASA II	16 (47.06%)	15 (44.1%)

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CI, confidence interval; d, Cohen's effect size; ESPB, erector spinae plane block; SD, standard deviation.

Note: p < 0.001 was considered significant.

Table 2 Comparison of age between various groups

Groups		Age (y), mean ± SD (95% CI)
Operation	Hemorrhoid	34 ± 9 (30–37)
	Pilonidal sinus	27 ± 8 (24–29)
	p	0.001
	d	0.823
Sacral ESP	Control	30 ± 10 (26–33)
	Sacral ESPB	29 ± 9 (26–32)
	p	0.773
	d	0.11
Rescue analgesia	No	30 ± 9 (26–34)
	Yes	29 ± 9 (26–32)
	p	0.742
	d	0.11

Abbreviations: CI, confidence interval; d, Cohen's effect size; ESPB, erector spinae plane block; SD, standard deviation.

Note: p-Value < 0.001 was considered significant, statistically significant items are written in bold.

There were no significant differences in NRS scores at the 30th minute or the 2nd hour between the sacral ESPB group and the control group (p = 0.306 and p = 0.454, respectively). However, significant differences were found after the 8th hour and 24th hour, with the sacral ESPB group reporting lower pain scores (p < 0.001 for both time points) ([Fig. 3]). The NRS scores at the 30th minute, 8th hour, and 24th hour were not significantly different between hemorrhoid and PS groups (p = 0.140, p = 0.829, and p = 0.182, respectively). However, a significant difference was observed in the second hour when the hemorrhoid group reported higher pain scores (p < 0.001). The NRS scores did not differ significantly between the male and female participants at the 30th minute, the 2nd hour, the 8th hour, or the 24th hour (p = 0.893, p = 0.311, p = 0.200, and p = 0.229, respectively).

Fig. 3 Comparison of repeated measurements of NRS scores over time in patient groups. Histogram graphs were generated at a 95% confidence interval and error bars represent ± 2 standard errors in width. * indicates a significant difference in 8th hour NRS scores between patient groups (p < 0.001).# Indicates a significant difference in 24th hour NRS scores between patient groups (p < 0.001). NRS, numeric rating scale.

As summarized in [Table 3], when evaluating tramadol consumption as a rescue analgesic, the mean dose of tramadol in the sacral ESPB group (44.71 ± 74.19 mg) was significantly lower than in the control group (218.82 ± 63.23 mg; p < 0.001). The mean difference was 174.11 mg (95% CI: 141.34–206.88), with a large effect size (Cohen's d = 2.52). Furthermore, the number of patients requiring rescue analgesics was 14 (29.8%) in the sacral ESPB group and 33 (70.2%) in the control group. The difference was significant (p < 0.001). Furthermore, tramadol consumption was 122.96 ± 129.34 in patients undergoing hemorrhoid surgery, while this value was 137.56 ± 98.81 in the patients undergoing PS surgery. The difference was not statistically significant (p = 0.621). Additionally, 15 (31.9%) and 32 (68.1%) patients who required rescue analgesics underwent hemorrhoid and PS surgeries, respectively, and the difference was significant (p = 0.04). When the length of hospital stay was evaluated, the mean stay for group S was 25.47 ± 1.73 hours, while for group C, it was 33.82 ± 9.09 hours, with a significant difference (p < 0.001). The mean difference was 8.35 hours (95% CI: 5.24–11.46), with a large effect size (Cohen's d = 1.28). The length of stay for hemorrhoid surgery was 26.14 ± 4.3 hours, while for PS surgery, it was 31.95 ± 8.68 hours, with a significant difference (p = 0.002). The mean length of stay was 24.56 ± 1.08 hours for group S, who underwent hemorrhoid surgery, and 26.45 ± 4.73 hours for group C, with no significant difference. For PS surgery patients, the mean stay was 26.28 ± 1.81 hours in group S and 36.39 ± 9.37 hours in group C, with a significant difference (p < 0.001).

Table 3 Comparison of tramadol consumption, the number of patients requiring rescue analgesics, and the length of hospital stay

Parameter	Control (n = 34)	Sacral ESPB (n = 34)	p-Value	d
Total tramadol (dose) (mg), mean ± SD (95% CI)	218.82 ± 63.23 (196.76–240.89)	44.71 ± 74.19 (18.82–70.59)	< 0.001	2.52
Rescue analgesic required, frequency (%)
Yes	33 (70.2%)	14 (29.8%)	< 0.001
No	1 (4.8%)	20 (95.2%)
Length of hospital stay (time) (h), mean ± SD (95% CI)	33.82 ± 9.09 (30.65–36.99)	25.47 ± 1.73 (24.86–26.08)	< 0.001	1.28

Abbreviations: CI, confidence interval; d, Cohen's effect size; ESPB, erector spinae plane block; SD, standard deviation.

Note: p < 0.001 was considered significant, statistically significant items are written in bold.

The relationships between age and pain scores over time were analyzed using Pearson's correlation coefficients. After 30 minutes, 2 hours, and 8 hours, there was no significant correlation between the pain score and age (r = 0.149, p = 0.226; r = 0.142, p = 0.249; r = 0.006, p = 0.962). However, significant correlations were observed between pain scores at 24 hours and pain scores at 8 hours (r = 0.471, p < 0.01) and 2 hours (r = 0.881, p < 0.01), indicating a strong relationship between earlier pain scores and scores at 24 hours, but no significant direct correlation with age (r = 0.001, p = 0.994). Tramadol consumption at 8 hours demonstrated a strong positive correlation with pain scores (r = 0.915, p < 0.001). At 24 hours, tramadol consumption was significantly associated with pain scores at 8 hours (r = 0.769, p < 0.001), 2 hours (r = 0.471, p < 0.001), and 30 minutes (r = 0.881, p < 0.001), suggesting that earlier high pain scores were associated with later high tramadol consumption.

 

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Discussion

This study investigated the effect of sacral ESPB on postoperative pain and tramadol consumption in hemorrhoid and PS surgeries. Postoperative pain control was more tolerable and moderately reduced, with tramadol consumption decreasing to approximately one-fifth of the total. Postoperative use of sacral ESPBs resulted in a significant reduction in pain scores at all measured intervals and was correlated with a decrease in 24-hour tramadol consumption.

The fact that the participants were young adults and the mean age of those in the hemorrhoid group was high was in line with the existing literature.[7] [8] Considering the relationship between the ages of patients who underwent hemorrhoid surgery and those who underwent PS surgery, it was not surprising that patients who underwent PS surgery were significantly younger. Some researchers have found similar results in previous studies.[9] [10] The principle that the pain threshold changes and increases with age was also demonstrated in our research, and older patients could tolerate pain more quickly. A recent study has also shown that the pain threshold for some surgical procedures increases with age, and opioid consumption decreases.[11]

In our study, we used the NRS to assess pain. The lack of significant differences in NRS scores during the first 2 hours was attributed to the prolonged analgesic effect of spinal anesthesia administered to the patients. Costa et al reported that spinal anesthesia also influenced postoperative pain management.[12] In contrast to general anesthesia, which usually wears off soon after awakening, spinal anesthesia provides a persistent sensory blockade that can last several hours after the operation. This prolonged analgesic effect can mask the actual intensity of pain in the postoperative period, limiting the ability to accurately assess the early effectiveness of the intervention. The fact that the patients who underwent sacral ESPB reported feeling less pain in the following hours was consistent with the purpose of the study and the nature of the ESPB.[13] The absence of significant differences in the evaluations performed after the loss of effectiveness of spinal anesthesia suggests that the procedure was sufficiently compelling. For anorectal surgeries performed under general anesthesia, this difference may become apparent earlier in the postoperative period.

Tramadol, an atypical opioid, acts centrally through two different mechanisms of action. It acts by activating the mu-opioid receptor and inhibiting the reuptake of serotonin and norepinephrine. Combining these two mechanisms contributes to the efficacy and tolerability of tramadol.[14] [15] In our study, we used tramadol as a rescue analgesic. The need for rescue analgesics in patients who underwent sacral ESPB was less than half that of the control group, and the total dose of tramadol consumed was one-fifth of that in the control group. Yıldız et al compared the efficacy of ESPBs in laparoscopic cholecystectomy surgery and reported that tramadol consumption was reduced by half, a finding similar to our study.[16]

Although pain after anorectal surgery is severe in the first 24 hours, it decreases in the following hours. Several strategies have been employed with success in pain management. In particular, local perianal anesthesia, the administration of analgesic medications, and the use of pudendal nerve blocks have demonstrated efficacy in effectively controlling pain.[17] In a recently published study similar to our research, it was found that applying ESPB in patients with hemorrhoids reduced postoperative pain and decreased analgesic consumption. This finding is consistent with our study and supports the potential benefit of sacral ESPB as a viable approach for pain management in hemorrhoid patients.[18] Furthermore, Kaya et al reported a case report of two patients in which they successfully used ESPB under ambulatory anesthesia for anorectal surgery.[1] However, sacral ESPB for pain control after PS surgery has not been reported in the literature. The use of sacral ESPB in PS surgery represents a novel approach that is consistent with recent evidence of its effectiveness in reducing postoperative pain and opioid requirements. This emphasizes the potential of sacral ESPB as a valuable component of multimodal analgesia in PS surgery. Mahajan et al investigated sacral ESPB as a promising analgesic technique for painful sacrococcygeal procedures after sacrococcygeal teratoma surgery in two neonates.[19] This study could be a milestone in this regard.

The management of postoperative pain affects the length of hospital stay and recovery speed. Severe pain can also lead to pulmonary complications, such as atelectasis and pulmonary infection. In our study, there were no noticeable differences in the duration of hospital stay after hemorrhoid surgery. The most obvious reason for this was that the operations were minor. Sacral ESPB significantly shortened the length of hospital stay in patients who underwent PS surgery. A meta-analysis similar to our study reported that pudendal nerve blockade has an impact on the length of hospital stay.[20]

After anorectal surgery, the pain experience consists of both visceral and somatic elements. The differences between postoperative PS pain and hemorrhoidal pain can be traced back to differences in the specific surgical site. Sacral ESPB provides unilateral, diffuse, and potent analgesia. Local anesthetic is injected into the area between the erector spinae muscle and the midsacral crest to achieve this result. The anesthetic disperses through the gaps between neighboring vertebrae into the paravertebral space, effectively blocking both the dorsal and ventral branches of the spinal nerves.[21] [22] Recently, significant progress has been made in the development of multimodal analgesia techniques to reduce dependence on opioids. As part of these protocols, peripheral nerve blocks and truncal blocks have emerged as practical components. The ESPB is a recently described technique that provides analgesia through truncal nerve block. The erector spinae muscle consists of a series of muscle structures that extend from the sacral region to the cervical spine. It has proven effective in various surgical procedures and provides postoperative pain relief for varying periods of time. Sacral ESPB has recently gained popularity and has been applied to a variety of surgical procedures with efficacy for the management of postoperative pain. Kukreja et al[23] successfully used gender reassignment surgery, Kaya et al[1] used ambulatory anorectal surgery, and Mermer et al[18] used hemorrhoidectomy surgery. This study showed that sacral ESPB is sufficiently compelling after hemorrhoid and PS surgeries.

This study has several limitations. The sensory distribution of the sacral ESPB could not be tested after the procedure because the patients were still under spinal anesthesia. Due to the short duration of the procedures, the patients still experienced numbness from spinal anesthesia. Pin-prick testing would not have been effective for this procedure. However, since all procedures were performed under ultrasound guidance, drug distribution could be observed in the transverse and sagittal planes, and it is believed to be an effective sacral ESBP. This sonographic visualization supports the possibility of a practical block application. However, the lack of objective sensory verification is a significant limitation, as it prevents definitive confirmation of the successful dermatomal coverage in all cases. Future studies may consider performing the block prior to spinal anesthesia or postoperative cold sensation testing once the spinal block has regressed, allowing sensory verification. Surgeries performed under general anesthesia can also be chosen. The fact that this is a single-center study may introduce variations due to potential demographic differences. In a study conducted in a relatively young population, differences in pain thresholds may be observed. Although a reduction in tramadol consumption was observed, the combination of multimodal analgesics may have limited the effect of sacral ESPB. The fact that such surgeries are performed daily in some centers may bring sacral ESPB to the forefront of postoperative pain management. The fact that patients, surgeons, and anesthesiologists in the operating room were not blinded to the intervention could represent an additional element of bias. However, it was assumed that blinding the anesthesiologist who performed the pain assessment would minimize bias. However, the lack of blinding of the patients can lead to a particular bias, which should be taken into account when interpreting the results.

 

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Conclusion

In this study, sacral ESPB effectively managed postoperative pain and reduced analgesic consumption in hemorrhoid and PS surgeries. The outcomes showed that sacral ESPB considerably decreased the amount of tramadol used and helped manage postoperative pain. We also highlight the potential of this technique to improve postoperative recovery and shorten hospital stays. Despite the various treatment options, several methods are still under investigation. Sacral ESPB, another variant of ESPB that has gained popularity in recent years, is a candidate alternative to postoperative pain management in anorectal surgeries. The results of this study suggest that incorporating sacral ESPB into multimodal analgesic protocols for anorectal surgery may be clinically beneficial.

 

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Conflict of Interest

None declared.

Authors' Contributions

A.K., F.A., and U.M. conceptualized and designed the study. A.K., F.A., M.T.H., U.M., M.G., A.C.S., and M.S. drafted the manuscript and also performed acquisition, analysis, and interpretation of data for the study. A.K., F.A., M.T.H., and U.M. performed critical review or quality check. All authors approved the final manuscript.

Data Availability Statement

The datasets generated during and/or analyzed during the present study are available from the corresponding author upon reasonable request.

Compliance with Ethical Principles

All research procedures involving human volunteers complied with ethical standards, the Declaration of Helsinki, and any other relevant ethical guidelines. This prospective randomized controlled study was performed in the Department of Anesthesiology and Reanimation, Mengucek Gazi Training and Research Hospital, Erzincan Binali Yıldırım University, Erzincan, Türkiye. The study was approved by the Clinical Research Ethics Committee (Decision Number: 2023/01-08). It was registered in ClinicalTrials.gov (NCT06459739).

Patient's Consent

Written informed consents was obtained from all participants prior to their participation.

Declaration of GenAI Use

AI-unassisted work.

• References

• 1 Kaya C, Dost B, Tulgar S. Sacral erector spinae plane block provides surgical anesthesia in ambulatory anorectal surgery: two case reports. Cureus 2021; 13 (01) e12598
• 2 Ahiskalioglu A, Tulgar S, Celik M, Ozer Z, Alici HA, Aydin ME. Lumbar erector spinae plane block as a main anesthetic method for hip surgery in high risk elderly patients: initial experience with a magnetic resonance imaging. Eurasian J Med 2020; 52 (01) 16-20
• 3 Bilge A, Arıcan Ş. Sacral erector spinae plane block for analgesia after hip surgery. Journal of Surgery and Medicine 2021; 5 (06) 648-650
• 4 Kaye AD, Nguyen A, Thomassen AS. et al. Efficacy of erector spinae plane block for pain management after hip surgery: a narrative review. Curr Pain Headache Rep 2025; 29 (01) 79
• 5 Tulgar S, Senturk O, Thomas DT, Deveci U, Ozer Z. A new technique for sensory blockage of posterior branches of sacral nerves: ultrasound guided sacral erector spinae plane block. J Clin Anesth 2019; 57: 129-130
• 6 Tulgar S, Ahiskalioglu A, De Cassai A, Gurkan Y. Efficacy of bilateral erector spinae plane block in the management of pain: current insights. J Pain Res 2019; 12: 2597-2613
• 7 Siggins LA, Fagan PVB, Kim HM, Lin AY. Risk factors for readmission in excisional hemorrhoidectomy at a tertiary teaching center. J Surg Res 2024; 297: 128-135
• 8 Hong YS, Jung KU, Rampal S. et al. Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults. Sci Rep 2022; 12 (01) 129
• 9 Albabtain IT, Alkhaldi A, Aldosari L, Alsaadon L. Pilonidal sinus disease recurrence at a tertiary care center in Riyadh. Ann Saudi Med 2021; 41 (03) 179-185
• 10 Kibret AA, Oumer M, Moges AM. Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. PLoS One 2021; 16 (04) e0249736
• 11 Kim J-H, Sohn J-H, Lee J-J, Kwon Y-S. Age-related variations in postoperative pain intensity across 10 surgical procedures: a retrospective study of five hospitals in South Korea. J Clin Med 2023; 12 (18) 5912
• 12 Costa F, Pascarella G, Luffarelli P. et al. Selective spinal anesthesia with hyperbaric prilocaine provides better perioperative pain control than local anesthesia for ambulatory inguinal hernia repair without affecting discharging time: a randomized controlled trial. J Anesth Analg Crit Care 2022; 2 (01) 6
• 13 Basyouny KAR, Abd Elkader MAE, Mahmoud MF, Abdelhamid BM, Waheeb MME. Erector spinae plane block for pain management in blunt chest trauma in military prehospital medicine, an interventional study. Egypt J Anaesth 2024; 40 (01) 351-357
• 14 Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet 2004; 43 (13) 879-923
• 15 Singla NK, Pollak R, Gottlieb I. et al. Efficacy and safety of intravenously administered tramadol in patients with moderate to severe pain following bunionectomy: a randomized, double-blind, placebo-controlled, dose-finding study. Pain Ther 2020; 9 (02) 545-562
• 16 Yildiz M, Kozanhan B, Iyisoy MS, Canıtez A, Aksoy N, Eryigit A. The effect of erector spinae plane block on postoperative analgesia and respiratory function in patients undergoing laparoscopic cholecystectomy: a double-blind randomized controlled trial. J Clin Anesth 2021; 74: 110403 .3
• 17 He J, Zhang L, Li DL. et al. Ultrasound-guided pudendal nerve block combined with propofol deep sedation versus spinal anesthesia for hemorrhoidectomy: a prospective randomized study. Pain Res Manag 2021; 2021: 6644262
• 18 Mermer A, Simsek G, Mermer HA, Tire Y, Kozanhan B. Effect of sacral erector spinae plane block on post-hemorrhoidectomy pain: a randomized controlled trial. Medicine (Baltimore) 2023; 102 (37) e35168
• 19 Mahajan R, Gulati S, Gupta K, Jain K, Bloria S, Jitendra M. Ultrasound-guided sacral multifidus plane block for analgesia following excision of sacrococcygeal teratoma in two neonates. Anaesth Rep 2021; 9 (01) 81-84
• 20 Mongelli F, Treglia G, La Regina D. et al. Pudendal nerve block in hemorrhoid surgery: a systematic review and meta-analysis. Dis Colon Rectum 2021; 64 (05) 617-631
• 21 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
• 22 Boules ML, Goda AS, Abdelhady MA, Abu El-Nour Abd El-Azeem SA, Hamed MA. Comparison of analgesic effect between erector spinae plane block and transversus abdominis plane block after elective cesarean section: a prospective randomized single-blind controlled study. J Pain Res 2020; 13: 1073-1080
• 23 Kukreja P, Deichmann P, Selph JP, Hebbard J, Kalagara H. Sacral erector spinae plane block for gender reassignment surgery. Cureus 2020; 12 (04) e7665

Publication History

Article published online:
25 June 2025