The Efficacy of Intraoperative Freehand Erector Spinae Plane Block in Lumbar Spondylolisthesis

Abstract

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 for spinal surgery: a systematic review and meta-analysis

“…A total of 696 patients were enrolled in this systematic review and meta-analysis: 348 in the ESPB group (patients administered ESPB) and the remaining 348 in the control group (patients administered no block or a sham block). Eleven trials [ 13 - 16 , 18 - 24 ] reported the performance of ESPB before the surgery via ultrasound guidance and one trial [ 17 ] via intraoperative freehand administration. Four studies [ 15 , 16 , 20 , 23 ] confirmed the blocking effect of ESPB.…”

“…One study [ 24 ] performed sequential randomization via the order of surgery, which did not meet the allocation of randomization, and therefore was at high risk for risk of bias arising from the randomization process. Nine studies [ 13 , 15 - 18 , 21 - 24 ] did not describe whether the allocation sequence was concealed until the participants were enrolled and assigned to interventions, and thus these items created some concerns. Three studies [ 14 , 20 , 22 ] did not describe the details of their random sequence generation, so these studies created some concerns.…”

“…Therefore, these nine trials were at high risk for risk of bias. One trial [ 19 ] that performed sham blocks used subcutaneous infiltration (1 mL of 1% lidocaine) as a control, while two trials [ 17 , 18 ] that performed the sham block using saline were at low risk for risk of bias. Four trial [ 18 , 21 , 22 , 24 ] did not describe whether outcome assessors were aware of the intervention received by study participants, so the risk of bias in the measurement of the outcome (detection bias) was of some concerns.…”

“…Eight [ 13 - 15 , 17 - 20 , 23 ] and five [ 14 , 18 - 20 , 23 ] RCTs reported the 24- and 48-hour cumulative postoperative intravenous morphine equivalent consumption, respectively. Different types of opioids were converted into intravenous morphine doses.…”

“…In terms of safety, we attempted to evaluate the complications related to ESPB in the included studies; however, no block-related complications, including local anesthetic toxicity, bleeding, or infection, were reported in any of them, probably because most of the ESPB procedures reported in the included studies were performed under ultrasound guidance (in one study [ 17 ] alone, the procedure was performed intraoperatively via freehand delivery). Visualization and the fact that the target site was away from important vessels and nerves may also explain the rarity of associated complications.…”