- Email: [email protected]
Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study
Original Article
Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study Ahmet Murat Yayik1, Sevim Cesur1, Figen Ozturk1, Ali Ahiskalioglu3, Ayse Nur Ay1, Erkan Cem Celik1, Nuh Cagrı Karaavci2
BACKGROUND: Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsalventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery.
-
METHODS: Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n [ 30) received ultrasoundguided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n [ 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patientcontrolled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated.
28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group. CONCLUSIONS: ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.
-
-
RESULTS: Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 73.27 mg and 268.33 71.44 mg; P < 0.001, respectively) and the difference was
-
Key words Erector spinae plane block - Postoperative analgesia - Spinal decompression surgery -
Abbreviations and Acronyms ASA: American Society of Anesthesiologists CONSORT: Consolidated Standards of Reporting Trials ESP: Erector spinae plane IV: Intravenous TLIP: Thoracolumbar interfascial plane VAS: Visual analogue scale
WORLD NEUROSURGERY -: e1-e7, - 2019
INTRODUCTION
P
ostoperative pain management is a significant problem following spinal surgery. Postoperative pain that cannot be well controlled may lead to delayed mobilization, pulmonary and thromboembolic complications, prolonged hospital stays, and chronic pain syndromes. Effective postoperative pain management can also contribute to better surgical outcomes.1 Several pathways, including nociceptive, neuropathic, and inflammatory sources, contribute to perioperative pain in spinal surgery.2 Pain after spinal surgery can arise from several different tissues, such as the vertebrae, disks, ligaments, dura, facet joint, muscle, fascia, and subcutaneous and cutaneous tissues.3 All these tissues are innervated by the dorsal rami of the spinal nerves. Although opioids are 1 mainstay for perioperative analgesia, other non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Systemic agents, such as gabapentinoids, non-steroid anti-inflammatories, ketamine, intravenous lidocaine, neuraxial blocks, such as epidural and spinal
From the Departments of 1Anesthesiology and Reanimation and 2Neurosurgery, Regional Training and Research Hospital, Erzurum; and 3Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey To whom correspondence should be addressed: Ahmet Murat Yayik, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.02.149 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e1
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
anesthesia, and more recently, regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae plane (ESP) block, have been used for this purpose in spinal surgery.2,4 Plane blocks have gained popularity with the recent introduction of ultrasonography into the regional anesthesia practice. These blocks are frequently employed because of their ease of application, low complication rates, effective postoperative analgesia, and reduction of opioid consumption.5 First described by Forero et al.6 in 2016, the ESP block is a paraspinal interfascial plane block targeting the ventral and dorsal branches (rami) of the spinal nerves. In the ultrasound-guided block, local anesthetic is injected between the deep fascia of the erector spinae muscle and the vertebral transverse process. The ESP block has been used as an effective postoperative analgesic treatment method in abdominal, thoracic, and breast surgeries.6-10 Although there have been case reports showing that the ESP block establishes effective postoperative analgesia in spinal surgery,11-13 there are no previously published randomized, controlled studies of ESP block use in spinal surgery. To our knowledge, this is the first randomized clinical study concerning the ESP block applied from the lumbar region.
Figure 1. (A) Probe and ultrasound set up for erector spinae muscle block. (B) Sonographic anatomy of the block. L2-TP: transverse process of second lumbar vertebrae, L3-TP: transverse process of third lumbar
e2
www.SCIENCEDIRECT.com
The purpose of this study is to investigate the effects of the ultrasound-guided ESP block on postoperative opioid consumption and pain scores in patients undergoing lumbar spinal decompression surgery.
MATERIALS AND METHODS Ethical approval for this randomized controlled study was provided by the local ethical committee. Once written informed consent had been obtained from patients, 60 American Society of Anesthesiologists (ASA) IeIII group patients, aged 18e65 years, scheduled for 1- or 2-level open lumbar decompression surgery, were enrolled. Patients with known severe heart, kidney, liver, or life threatening hematologic diseases and peptic ulcer, gastrointestinal bleeding, central or peripheral neurologic disease, psychiatric disorders, drug allergy or a history of allergy to amide-type local anesthetics, infection in the intervention region, bleeding diathesis, a history of narcotic drug use within 24 hours before the operation, a history of chronic pain, narcotic substance or alcohol dependence, or declining to take part in the study were excluded.
vertebrae. Red arrows show the needle. (C) Local anesthetic spreading after block procedure. ESM, erector spinae muscle, TP, transverse process.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
With the help of computer software, patients were randomly assigned into two equal groups: ESP Group and Control Group. All patients were taken to the regional anesthesia room 30 minutes before surgery. Standard monitoring was established with pulse oximetry, non-invasive arterial blood pressure measurement, and electrocardiogram observation. The patients were placed in the prone position with the intravenous (IV) administration of 2 mg midazolam for preoperative sedation. The ultrasound probe and the region scheduled for the procedure were sterilized in the ESP Group. The probe was installed in the sagittal axis in the midline at the L3 vertebral level. The spinous processes were first visualized, after which the probe was lateralized, and the transverse processes and the erector spinae muscle were visualized approximately 3 cm laterally to the midline (Figure 1A). A 100-mm sonovisible needle was inserted from the cranial to the caudal portion using the inplane technique. The needle was advanced between the transverse process and the deep fascia of the erector spinae muscle (Figure 1B). The location of the needle was confirmed with 2 mL saline solution, after which 20 mL of 0.025% bupivacaine was administered (Figure 1C). The same procedure was also performed on the opposite side. Sensory examination with the hotecold test was performed 20 minutes after the block procedure. The presence of anesthesia in the L1-5 dermatomal area at sensory examination was
regarded as a successful block. No intervention was performed in the Control Group. The patient was then taken to the operating room, and crystalloid infusion was started at 6 mL/kg with a 20-G intravenous catheter. Induction of anesthesia was done with 2 mg/kg IV propofol (Propofol, Fresenius Kabi, Melsungen, Germany), 0.6 mg/kg IV rocuronium (Esmeron, Organon, Kloosterstraat, the Netherlands), and 2 mcg/kg IV fentanyl (Fentanyl Citrate, Hospira, Lake Forest, Illinois, USA). When necessary, 0.1 mg/kg rocuronium was administered for muscle relaxation during operation. Maintenance of anesthesia was established with 1%e2% sevoflurane (Sevorane, Abbott, Chicago, Illinois, USA), 50% air, 50% O2, and 0.25e1 mcg/kg/minute remifentanil. Open decompression (lumbar laminectomy) was performed by the same surgical team, using the same technique, on all patients. Postoperatively, the muscle relaxant was antagonized using 2.5 mg neostigmine and 1 mg atropine. All patients were taken from the operating room to the postanesthesia care unit with tracheal extubation once all extubation criteria were met. Postoperative Analgesia The same protocol was applied for postoperative analgesia in both groups. Thirty minutes before the end of the surgery, all the patients
Figure 2. CONSORT diagram.
WORLD NEUROSURGERY -: e1-e7, - 2019
www.journals.elsevier.com/world-neurosurgery
e3
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
Table 1. Demographic and Operative Characteristics of Study Patients Control Group (n [ 30)
ESP Group (n [ 30)
P Value
54.30 8.56
50.53 8.50
0.093*
Weight (kg)
83.83 9.93
84.40 14.70
0.862*
Height (cm)
168.83 7.26
167.83 8.60
0.628*
19/11
17/13
0.598z
Age (years)
Sex (M/F) ASA status (I/II/III)
13/12/5
12/10/8
0.633z
Duration of anesthesia (minutes)
114.17 22.82
125.17 38.85
0.430y
Duration of surgery (minutes)
88.83 19.99
91.50 32.30
0.702*
22/8
24/6
0.542z
Surgical level (I/II)
Values are presented as number or mean standard deviation. ESP, erector spinae plane; M, male; F, female; ASA, American Society of Anesthesiologists. *Independent sample t test. yManneWhitney U test. zc2 test.
received 400 mg IV ibuprofen, repeated at 12 hours postoperatively. Intravenous tramadol was also administered with a patientcontrolled analgesia device as described in the next paragraphs. Postoperative care and assessment were performed by a researcher blinded to the study groups. Patient-controlled analgesia devices prepared with tramadol were attached after surgery in the postoperative recovery room. These were set to a concentration of 5 mg/mL, loading dose of 100 mg, lockout interval of 15 minutes, and 15 mg bolus, without basal infusion, maintained for 24 hours. All patients with visual analogue scale (VAS) scores of 4 or more in the recovery room received 25 mg pethidine (Aldolan, G.L. Pharma, Austria) as rescue analgesia. The same protocol was applied for postoperative analgesia in both groups. Patients with Aldrete14 scores of 9 or more were transferred to the ward. Postoperative tramadol consumption was recorded as 0e4, 4e 8, 8e24, and 24-hour total values. Postoperative pain was assessed at 1, 2, 4, 8, 12, and 24 hours using VAS scores at rest and with active movement (VAS 0 ¼ no pain; VAS 10 ¼ the worst possible pain). Active movement was defined as moving from the lying to a semi-seated position. Time to first analgesic requirement (minutes) was defined as the time elapsing between block application and a VAS pain score 4. Any opioid-associated side effects such
as nausea, vomiting, constipation, and urinary retention were recorded. Sample Size Determination The primary purpose of the study was to measure tramadol consumption in the first 24 hours after surgery. In our preliminary unpublished data, tramadol consumption was 346.50 70.32 mg in the Control Group and 286.00 49.04 mg in the ESP Group. Assuming the 60 mg difference between the groups in terms of 24-hour tramadol consumption to be significant, the number of patients required for each group was determined as 28 using Russ Lenth’s Piface Java module (Iowa City, USA) with 90% power and 0.05 alpha error. Statistical Analysis Statistical analysis was performed on SPSS software Version 20.0 (IBM Corp., Armonk, New York, USA). The distribution of variables was evaluated for normality using the Kolmogorov-Smirnov and histogram tests. Descriptive data were expressed as mean standard deviation. Categorical variables were analyzed using the c2 test. Normally, distributed data comprising continuous variables were analyzed using the Student t test. Otherwise, the
Table 2. Tramadol Consumption in the First 24 Hours Following Surgery Control Group (n [ 30)
ESP Group (n [ 30)
P Value*
0e4 hours (mg)
196.50 43.67
141.66 29.25
<0.001
4e8 hours (mg)
80.16 35.73
57.66 29.61
0.010
8e24 hours (mg)
97.00 41.63
71.00 28.14
0.006
Total 24 hours (mg)
370.33 73.27
268.33 71.44
<0.001
Values are presented as mean standard deviation. ESP, erector spinae plane. *Independent sample t test.
e4
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
Table 3. Comparison of Visual Analog Pain Scores at Postoperative Time Points Control Group (n [ 30)
ESP Group (n [ 30)
Table 4. First Analgesic Requirement Time, Rescue Analgesia, and Nausea and Vomiting Control ESP Group (n [ 30) Group (n [ 30) P Value
P Value
At rest
First analgesic requirement time (minutes)
174.17 22.82
325.17 22.82
<0.001*
PACU
3.70 1.60
1.10 1.03
<0.001*
2 hours
4.03 0.85
1.63 1.07
<0.001y
Rescue analgesia (yes/no)
10/20
3/27
0.028y
4 hours
3.63 1.13
1.50 0.97
<0.001y
PONV (yes/no)
7/23
2/28
0.071y
8 hours
3.83 1.18
1.93 0.87
<0.001*
12 hours
3.37 1.35
2.40 0.89
0.004y
24 hours
2.83 1.51
2.00 1.36
0.029*
Values are given as number or mean SD. ESP, erector spinae plane; PONV, postoperative nausea and vomiting. *ManneWhitney U test. yc2 test.
During active movement PACU
4.20 1.40
1.53 1.04
<0.001*
2 hours
4.57 0.82
2.00 0.87
<0.001*
4 hours
4.23 0.94
1.97 0.89
<0.001*
8 hours
4.63 1.10
2.30 0.60
<0.001y
12 hours
3.77 0.82
2.63 0.56
<0.001y
24 hours
3.23 0.77
2.30 1.06
<0.001y
Values are presented as mean standard deviation. ESP, erector spinae plane; PACU, postanesthesia care unit. *Independent sample t test. yManneWhitney U test.
ManneWhitney U test was used. P < 0.05 was considered statistically significant.
RESULTS Sixty-six patients were enrolled in this study. Four patients from the Control Group and 2 patients from the ESP Group were excluded owing to application of interlaminar stabilization surgery. Data for 2 groups, each consisting of 30 subjects, were therefore subjected for analysis. Eligible patients for this study were analyzed for primary outcomes, and are shown in a Consolidated Standards of Reporting Trials (CONSORT) flow chart (Figure 2). Demographic characteristics and intraoperative data are shown in Table 1. No significant difference was determined between the 2 groups in terms of age, weight, height, sex, ASA class, length of surgery, duration of anesthesia, or level of surgery (P > 0.05). Tramadol consumption was significantly lower in the ESP Group compared with the Control Group at all measurement times (0e4 hours, 141.66 29.25 mg and 196.50 43.67 mg, P <0.001; 4e8 hours, 57.66 29.61 mg and 80.16 35.73 mg, P ¼ 0.010; 8e24 hours, 71.00 28.14 mg and 97.00 41.63 mg, P ¼ 0.006, respectively). The differences between time intervals were 28%, 29%, and 27%, respectively. Twenty-four-hour opioid consumption in the Control Group was significantly higher compared with the ESP Group
WORLD NEUROSURGERY -: e1-e7, - 2019
(370.33 73.27 mg and 268.33 71.44 mg, P < 0.001, respectively), and the difference was 28% (Table 2). Postoperative VAS scores were assessed at rest and with active movement. Scores were significantly lower in the ESP Group than in the Control Group at all time intervals (P < 0.05) (Table 3). Time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group (325.17 22.82 minutes and 174.17 22.82 minutes, respectively; P < 0.001). Additional analgesic requirements occurred in 10 patients in the Control Group and 3 patients in the ESP Group, the difference being statistically significant (P ¼ 0.028). No significant difference was determined between the 2 groups in terms of postoperative nausea and vomiting (P ¼ 0.071) (Table 4).
DISCUSSION Application of the ESP block in patients undergoing spinal decompression surgery significantly reduced opioid consumption at all time points in the first 24 hours and resulted in lower pain scores compared with the Control Group. It also prolonged time to first analgesic use and reduced additional analgesia requirements. Spinal surgery is characterized by severe and diffuse pain in the postoperative period.15 Effective postoperative pain management leads to increased patient satisfaction and early mobilization, prevents the development of pulmonary and thromboembolic complications, and reduces postoperative mortality and morbidity.16 Opioid-based patient-controlled intravenous analgesia is most commonly employed for overcoming the pain after spinal decompression surgery in the literature.17 However, side effects ranging from relatively mild disorders, such as nausea, vomiting, and hypotension, to severe side effects, such as loss of consciousness and respiratory depression, may develop following opioid use. Regional applications rather than a medication capable of causing systemic effects are therefore more rational in terms of analgesia planning. Epidural and spinal analgesia, and the recently popular plane blocks have been applied for this purpose.4,18,19 Plane blocks are definitely the safer regional analgesic techniques in terms of systemic effects. Plane blocks identified for the paraspinal region include the TLIP block,19 the modified TLIP block,4 and the ESP block. Although there have been a few case reports on the use of
www.journals.elsevier.com/world-neurosurgery
e5
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
the ESP block in spinal surgery,11,12 there has to date been no randomized, controlled studies showing its effectiveness. The aim of the ESP block is to affect the dorsal and ventral rami of the spinal nerves by injecting local anesthetic between the deep fascia of the erector spinae muscle and the transverse process. Although cadaveric and radiologic studies have resulted in no definite mechanism being identified, the analgesic efficacy of the ESP block is thought to be because of local anesthetics entering the paravertebral or epidural space.6,20 With this effect, the ESP block provides both parietal and visceral analgesics, similar to the paravertebral block. The injected local anesthetic exhibits a wide area of effect through cephalic and caudal diffusion. The basic factors in the popularity of this block are easy sonographic identification of landmarks and a lower complication rate compared with paravertebral block and its variants. Since 2016, the ESP block has been increasingly used for anesthesia and analgesia in thoracic and abdominal surgery and has been shown to be effective.21-23 To the best of our knowledge, the present study is the first randomized, controlled study of the ESP block in spinal surgery, and also the first clinical study concerning the ESP block applied from the lumbar level. The ESP block was applied bilaterally in the present study and is quite a safe procedure. Despite bilateral application, no block-related complications occurred. Based on previous studies, the block was performed with a 20-mL volume for both sides.22-24 However, it should also be considered that in the ESP block applied from the lumbar region, very high volumes may also result in diffusion to the lumbar plexus. Case series and reports have reported the use of ESP block leading to effective postoperative analgesia management in spinal surgeries.13,24,25 Also, in a retrospective study, patients in the ESP block group had lower pain scores and less opioid consumption when compared to a control group.26 We decided to administer the ESP block before surgery. Our reason for using this technique is that sonographic anatomy is not impaired before surgery, and that a clearer image might be obtained. In addition, because tissue integrity is compromised after surgery, the distribution of local anesthetic drugs for plane blocks
REFERENCES 1. Gottschalk A, Durieux ME, Nemergut EC. Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112:218-223. 2. Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30:79-89. 3. Bajwa SJ, Haldar R. Pain management following spinal surgeries: an appraisal of the available options. J Craniovertebr Junction Spine. 2015;6:105-110. 4. Ahiskalioglu A, Yayik AM, Doymus O, et al. Efficacy of ultrasound-guided modified thoracolumbar interfascial plane block for postoperative analgesia after spinal surgery: a randomized-controlled trial. Can J Anaesth. 2018; 65:603-604.
e6
www.SCIENCEDIRECT.com
might have been affected. Sensory examination following injection at the L3 vertebral level in our study showed that anesthesia was established in the L1eL5 dermatomal area. This showed that the ESP block may be suitable for use in multilevel spinal surgery. The recent multimodal analgesic approach in pain treatment after spinal surgery is thought to be more effective than the traditional approach. The optimal strategy in perioperative pain control consists of multimodal approaches that minimize opioid requirements. Regional anesthetic techniques constitute an important part of this approach.27 We also established multimodal analgesia in our study with the application of a preoperative ESP block together with non-steroidal anti-inflammatory drugs, and opioids were used in the postoperative period. There are several limitations to this study. First, no information is available concerning patients’ preoperative pain scores. Preoperative pain status can affect postoperative analgesic consumption. Second, the ESP block applied preemptively can reduce intraoperative analgesic requirements and surgical stress, but these parameters were not evaluated in our study. Third, the study was only single blinded. No sham injection was performed on the Control Group, and the placebo effect of injection could not, therefore, be assessed. Finally, the study sample size was determined based on opioid requirements, the primary aim of the study. ESP block-related side effects may not be fully identified with a small sample size. Further studies with a larger sample size may be needed. CONCLUSIONS The ESP block made a significant contribution to the treatment of postoperative pain after spinal surgery. Clinical studies investigating the volume, concentration, and type of local anesthetic are now required. Combined ultrasound, magnetic resonance imaging, and cadaveric studies will be useful in assessing the effectiveness of this block. We think that the ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in lumbar decompression surgery procedures.
5. Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med. 2017;42:133-183. 6. 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;41:621-627.
anaesthesia for thoracic mass excision: a report of two cases. Anaesth Crit Care Pain Med. 2019;38: 189-190. 10. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. A A Case Rep. 2017;8:254-256.
7. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017;42:372-376.
11. Singh S, Chaudhary NK. Bilateral ultasound guided erector spinae plane block for postoperative pain management in lumbar spine surgery: a case series [e-pub ahead of print]. J Neurosurg Anesthesiol. 2018. https://doi.org/10.1097/ ANA.0000000000000518.
8. Kumar A, Hulsey A, Martinez-Wilson H, Kim J, Gadsden J. The use of liposomal bupivacaine in erector spinae plane block to minimize opioid consumption for breast surgery: a case report. A A Pract. 2018;10:239-241.
12. Ueshima H, Otake H. Clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery. J Clin Anesth. 2017;38:137.
9. Cesur S, Ay AN, Yayik AM, Naldan ME, Gurkan Y. Ultrasound-guided erector spinae plane block provides effective perioperative analgesia and
13. 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;65:1057-1065.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
14. Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J Perianesth Nurs. 2006;21:259-267. 15. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eu Spine J. 2013;22:2089-2096. 16. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1493. 17. Bohl DD, Louie PK, Shah N, et al. Multimodal versus patient-controlled analgesia after an anterior cervical decompression and fusion. Spine. 2016;41:994-998. 18. De Rojas JO, Syre P, Welch WC. Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature. Clin Neurol Neurosurg. 2014;119:39-43.
its mechanism of action. Rev Esp Anestesiol Reanim. 2018;65:514-519.
plane (ESP) blocks in a multimodal anesthetic regimen. Spine (Phila Pa 1976). 2019;44:E379-E383.
21. Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 2018;53: 29-34.
26. Ueshima H, Inagaki M, Toyone T, Otake H. Efficacy of the erector spinae plane block for lumbar spinal surgery: a retrospective study [e-pub ahead of print]. Asian Spine J. 2018. https://doi.org/ 10.31616/asj.2018.0114.
22. Gurkan Y, Aksu C, Kus A, Yorukoglu UH, Kilic CT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: a randomized controlled study. J Clin Anesth. 2018;50:65-68.
27. Kurd MF, Kreitz T, Schroeder G, Vaccaro AR. The role of multimodal analgesia in spine surgery. J Am Acad Orthop Surg. 2017;25:260-268.
23. Tulgar S, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasoundguided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a prospective, randomized, controlled clinical trial. J Clin Anesth. 2018;49:101-106.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
19. Hand WR, Taylor JM, Harvey NR, et al. Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers. Can J Anaesth. 2015;62: 1196-1200.
24. Cesur S, Yayik AM, Ozturk F, Ahiskalioglu A. Ultrasound-guided low thoracic erector spinae plane block for effective postoperative analgesia after lumbar surgery: report of five cases. Cureus. 2018;10:e3603.
20. Vidal E, Gimenez H, Forero M, Fajardo M. Erector spinae plane block: a cadaver study to determine
25. Chin KJ, Lewis S. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae
WORLD NEUROSURGERY -: e1-e7, - 2019
Received 3 December 2018; accepted 16 February 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.02.149 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e7
Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study Ahmet Murat Yayik1, Sevim Cesur1, Figen Ozturk1, Ali Ahiskalioglu3, Ayse Nur Ay1, Erkan Cem Celik1, Nuh Cagrı Karaavci2
BACKGROUND: Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsalventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery.
-
METHODS: Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n [ 30) received ultrasoundguided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n [ 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patientcontrolled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated.
28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group. CONCLUSIONS: ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.
-
-
RESULTS: Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 73.27 mg and 268.33 71.44 mg; P < 0.001, respectively) and the difference was
-
Key words Erector spinae plane block - Postoperative analgesia - Spinal decompression surgery -
Abbreviations and Acronyms ASA: American Society of Anesthesiologists CONSORT: Consolidated Standards of Reporting Trials ESP: Erector spinae plane IV: Intravenous TLIP: Thoracolumbar interfascial plane VAS: Visual analogue scale
WORLD NEUROSURGERY -: e1-e7, - 2019
INTRODUCTION
P
ostoperative pain management is a significant problem following spinal surgery. Postoperative pain that cannot be well controlled may lead to delayed mobilization, pulmonary and thromboembolic complications, prolonged hospital stays, and chronic pain syndromes. Effective postoperative pain management can also contribute to better surgical outcomes.1 Several pathways, including nociceptive, neuropathic, and inflammatory sources, contribute to perioperative pain in spinal surgery.2 Pain after spinal surgery can arise from several different tissues, such as the vertebrae, disks, ligaments, dura, facet joint, muscle, fascia, and subcutaneous and cutaneous tissues.3 All these tissues are innervated by the dorsal rami of the spinal nerves. Although opioids are 1 mainstay for perioperative analgesia, other non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Systemic agents, such as gabapentinoids, non-steroid anti-inflammatories, ketamine, intravenous lidocaine, neuraxial blocks, such as epidural and spinal
From the Departments of 1Anesthesiology and Reanimation and 2Neurosurgery, Regional Training and Research Hospital, Erzurum; and 3Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey To whom correspondence should be addressed: Ahmet Murat Yayik, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.02.149 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e1
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
anesthesia, and more recently, regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae plane (ESP) block, have been used for this purpose in spinal surgery.2,4 Plane blocks have gained popularity with the recent introduction of ultrasonography into the regional anesthesia practice. These blocks are frequently employed because of their ease of application, low complication rates, effective postoperative analgesia, and reduction of opioid consumption.5 First described by Forero et al.6 in 2016, the ESP block is a paraspinal interfascial plane block targeting the ventral and dorsal branches (rami) of the spinal nerves. In the ultrasound-guided block, local anesthetic is injected between the deep fascia of the erector spinae muscle and the vertebral transverse process. The ESP block has been used as an effective postoperative analgesic treatment method in abdominal, thoracic, and breast surgeries.6-10 Although there have been case reports showing that the ESP block establishes effective postoperative analgesia in spinal surgery,11-13 there are no previously published randomized, controlled studies of ESP block use in spinal surgery. To our knowledge, this is the first randomized clinical study concerning the ESP block applied from the lumbar region.
Figure 1. (A) Probe and ultrasound set up for erector spinae muscle block. (B) Sonographic anatomy of the block. L2-TP: transverse process of second lumbar vertebrae, L3-TP: transverse process of third lumbar
e2
www.SCIENCEDIRECT.com
The purpose of this study is to investigate the effects of the ultrasound-guided ESP block on postoperative opioid consumption and pain scores in patients undergoing lumbar spinal decompression surgery.
MATERIALS AND METHODS Ethical approval for this randomized controlled study was provided by the local ethical committee. Once written informed consent had been obtained from patients, 60 American Society of Anesthesiologists (ASA) IeIII group patients, aged 18e65 years, scheduled for 1- or 2-level open lumbar decompression surgery, were enrolled. Patients with known severe heart, kidney, liver, or life threatening hematologic diseases and peptic ulcer, gastrointestinal bleeding, central or peripheral neurologic disease, psychiatric disorders, drug allergy or a history of allergy to amide-type local anesthetics, infection in the intervention region, bleeding diathesis, a history of narcotic drug use within 24 hours before the operation, a history of chronic pain, narcotic substance or alcohol dependence, or declining to take part in the study were excluded.
vertebrae. Red arrows show the needle. (C) Local anesthetic spreading after block procedure. ESM, erector spinae muscle, TP, transverse process.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
With the help of computer software, patients were randomly assigned into two equal groups: ESP Group and Control Group. All patients were taken to the regional anesthesia room 30 minutes before surgery. Standard monitoring was established with pulse oximetry, non-invasive arterial blood pressure measurement, and electrocardiogram observation. The patients were placed in the prone position with the intravenous (IV) administration of 2 mg midazolam for preoperative sedation. The ultrasound probe and the region scheduled for the procedure were sterilized in the ESP Group. The probe was installed in the sagittal axis in the midline at the L3 vertebral level. The spinous processes were first visualized, after which the probe was lateralized, and the transverse processes and the erector spinae muscle were visualized approximately 3 cm laterally to the midline (Figure 1A). A 100-mm sonovisible needle was inserted from the cranial to the caudal portion using the inplane technique. The needle was advanced between the transverse process and the deep fascia of the erector spinae muscle (Figure 1B). The location of the needle was confirmed with 2 mL saline solution, after which 20 mL of 0.025% bupivacaine was administered (Figure 1C). The same procedure was also performed on the opposite side. Sensory examination with the hotecold test was performed 20 minutes after the block procedure. The presence of anesthesia in the L1-5 dermatomal area at sensory examination was
regarded as a successful block. No intervention was performed in the Control Group. The patient was then taken to the operating room, and crystalloid infusion was started at 6 mL/kg with a 20-G intravenous catheter. Induction of anesthesia was done with 2 mg/kg IV propofol (Propofol, Fresenius Kabi, Melsungen, Germany), 0.6 mg/kg IV rocuronium (Esmeron, Organon, Kloosterstraat, the Netherlands), and 2 mcg/kg IV fentanyl (Fentanyl Citrate, Hospira, Lake Forest, Illinois, USA). When necessary, 0.1 mg/kg rocuronium was administered for muscle relaxation during operation. Maintenance of anesthesia was established with 1%e2% sevoflurane (Sevorane, Abbott, Chicago, Illinois, USA), 50% air, 50% O2, and 0.25e1 mcg/kg/minute remifentanil. Open decompression (lumbar laminectomy) was performed by the same surgical team, using the same technique, on all patients. Postoperatively, the muscle relaxant was antagonized using 2.5 mg neostigmine and 1 mg atropine. All patients were taken from the operating room to the postanesthesia care unit with tracheal extubation once all extubation criteria were met. Postoperative Analgesia The same protocol was applied for postoperative analgesia in both groups. Thirty minutes before the end of the surgery, all the patients
Figure 2. CONSORT diagram.
WORLD NEUROSURGERY -: e1-e7, - 2019
www.journals.elsevier.com/world-neurosurgery
e3
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
Table 1. Demographic and Operative Characteristics of Study Patients Control Group (n [ 30)
ESP Group (n [ 30)
P Value
54.30 8.56
50.53 8.50
0.093*
Weight (kg)
83.83 9.93
84.40 14.70
0.862*
Height (cm)
168.83 7.26
167.83 8.60
0.628*
19/11
17/13
0.598z
Age (years)
Sex (M/F) ASA status (I/II/III)
13/12/5
12/10/8
0.633z
Duration of anesthesia (minutes)
114.17 22.82
125.17 38.85
0.430y
Duration of surgery (minutes)
88.83 19.99
91.50 32.30
0.702*
22/8
24/6
0.542z
Surgical level (I/II)
Values are presented as number or mean standard deviation. ESP, erector spinae plane; M, male; F, female; ASA, American Society of Anesthesiologists. *Independent sample t test. yManneWhitney U test. zc2 test.
received 400 mg IV ibuprofen, repeated at 12 hours postoperatively. Intravenous tramadol was also administered with a patientcontrolled analgesia device as described in the next paragraphs. Postoperative care and assessment were performed by a researcher blinded to the study groups. Patient-controlled analgesia devices prepared with tramadol were attached after surgery in the postoperative recovery room. These were set to a concentration of 5 mg/mL, loading dose of 100 mg, lockout interval of 15 minutes, and 15 mg bolus, without basal infusion, maintained for 24 hours. All patients with visual analogue scale (VAS) scores of 4 or more in the recovery room received 25 mg pethidine (Aldolan, G.L. Pharma, Austria) as rescue analgesia. The same protocol was applied for postoperative analgesia in both groups. Patients with Aldrete14 scores of 9 or more were transferred to the ward. Postoperative tramadol consumption was recorded as 0e4, 4e 8, 8e24, and 24-hour total values. Postoperative pain was assessed at 1, 2, 4, 8, 12, and 24 hours using VAS scores at rest and with active movement (VAS 0 ¼ no pain; VAS 10 ¼ the worst possible pain). Active movement was defined as moving from the lying to a semi-seated position. Time to first analgesic requirement (minutes) was defined as the time elapsing between block application and a VAS pain score 4. Any opioid-associated side effects such
as nausea, vomiting, constipation, and urinary retention were recorded. Sample Size Determination The primary purpose of the study was to measure tramadol consumption in the first 24 hours after surgery. In our preliminary unpublished data, tramadol consumption was 346.50 70.32 mg in the Control Group and 286.00 49.04 mg in the ESP Group. Assuming the 60 mg difference between the groups in terms of 24-hour tramadol consumption to be significant, the number of patients required for each group was determined as 28 using Russ Lenth’s Piface Java module (Iowa City, USA) with 90% power and 0.05 alpha error. Statistical Analysis Statistical analysis was performed on SPSS software Version 20.0 (IBM Corp., Armonk, New York, USA). The distribution of variables was evaluated for normality using the Kolmogorov-Smirnov and histogram tests. Descriptive data were expressed as mean standard deviation. Categorical variables were analyzed using the c2 test. Normally, distributed data comprising continuous variables were analyzed using the Student t test. Otherwise, the
Table 2. Tramadol Consumption in the First 24 Hours Following Surgery Control Group (n [ 30)
ESP Group (n [ 30)
P Value*
0e4 hours (mg)
196.50 43.67
141.66 29.25
<0.001
4e8 hours (mg)
80.16 35.73
57.66 29.61
0.010
8e24 hours (mg)
97.00 41.63
71.00 28.14
0.006
Total 24 hours (mg)
370.33 73.27
268.33 71.44
<0.001
Values are presented as mean standard deviation. ESP, erector spinae plane. *Independent sample t test.
e4
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
Table 3. Comparison of Visual Analog Pain Scores at Postoperative Time Points Control Group (n [ 30)
ESP Group (n [ 30)
Table 4. First Analgesic Requirement Time, Rescue Analgesia, and Nausea and Vomiting Control ESP Group (n [ 30) Group (n [ 30) P Value
P Value
At rest
First analgesic requirement time (minutes)
174.17 22.82
325.17 22.82
<0.001*
PACU
3.70 1.60
1.10 1.03
<0.001*
2 hours
4.03 0.85
1.63 1.07
<0.001y
Rescue analgesia (yes/no)
10/20
3/27
0.028y
4 hours
3.63 1.13
1.50 0.97
<0.001y
PONV (yes/no)
7/23
2/28
0.071y
8 hours
3.83 1.18
1.93 0.87
<0.001*
12 hours
3.37 1.35
2.40 0.89
0.004y
24 hours
2.83 1.51
2.00 1.36
0.029*
Values are given as number or mean SD. ESP, erector spinae plane; PONV, postoperative nausea and vomiting. *ManneWhitney U test. yc2 test.
During active movement PACU
4.20 1.40
1.53 1.04
<0.001*
2 hours
4.57 0.82
2.00 0.87
<0.001*
4 hours
4.23 0.94
1.97 0.89
<0.001*
8 hours
4.63 1.10
2.30 0.60
<0.001y
12 hours
3.77 0.82
2.63 0.56
<0.001y
24 hours
3.23 0.77
2.30 1.06
<0.001y
Values are presented as mean standard deviation. ESP, erector spinae plane; PACU, postanesthesia care unit. *Independent sample t test. yManneWhitney U test.
ManneWhitney U test was used. P < 0.05 was considered statistically significant.
RESULTS Sixty-six patients were enrolled in this study. Four patients from the Control Group and 2 patients from the ESP Group were excluded owing to application of interlaminar stabilization surgery. Data for 2 groups, each consisting of 30 subjects, were therefore subjected for analysis. Eligible patients for this study were analyzed for primary outcomes, and are shown in a Consolidated Standards of Reporting Trials (CONSORT) flow chart (Figure 2). Demographic characteristics and intraoperative data are shown in Table 1. No significant difference was determined between the 2 groups in terms of age, weight, height, sex, ASA class, length of surgery, duration of anesthesia, or level of surgery (P > 0.05). Tramadol consumption was significantly lower in the ESP Group compared with the Control Group at all measurement times (0e4 hours, 141.66 29.25 mg and 196.50 43.67 mg, P <0.001; 4e8 hours, 57.66 29.61 mg and 80.16 35.73 mg, P ¼ 0.010; 8e24 hours, 71.00 28.14 mg and 97.00 41.63 mg, P ¼ 0.006, respectively). The differences between time intervals were 28%, 29%, and 27%, respectively. Twenty-four-hour opioid consumption in the Control Group was significantly higher compared with the ESP Group
WORLD NEUROSURGERY -: e1-e7, - 2019
(370.33 73.27 mg and 268.33 71.44 mg, P < 0.001, respectively), and the difference was 28% (Table 2). Postoperative VAS scores were assessed at rest and with active movement. Scores were significantly lower in the ESP Group than in the Control Group at all time intervals (P < 0.05) (Table 3). Time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group (325.17 22.82 minutes and 174.17 22.82 minutes, respectively; P < 0.001). Additional analgesic requirements occurred in 10 patients in the Control Group and 3 patients in the ESP Group, the difference being statistically significant (P ¼ 0.028). No significant difference was determined between the 2 groups in terms of postoperative nausea and vomiting (P ¼ 0.071) (Table 4).
DISCUSSION Application of the ESP block in patients undergoing spinal decompression surgery significantly reduced opioid consumption at all time points in the first 24 hours and resulted in lower pain scores compared with the Control Group. It also prolonged time to first analgesic use and reduced additional analgesia requirements. Spinal surgery is characterized by severe and diffuse pain in the postoperative period.15 Effective postoperative pain management leads to increased patient satisfaction and early mobilization, prevents the development of pulmonary and thromboembolic complications, and reduces postoperative mortality and morbidity.16 Opioid-based patient-controlled intravenous analgesia is most commonly employed for overcoming the pain after spinal decompression surgery in the literature.17 However, side effects ranging from relatively mild disorders, such as nausea, vomiting, and hypotension, to severe side effects, such as loss of consciousness and respiratory depression, may develop following opioid use. Regional applications rather than a medication capable of causing systemic effects are therefore more rational in terms of analgesia planning. Epidural and spinal analgesia, and the recently popular plane blocks have been applied for this purpose.4,18,19 Plane blocks are definitely the safer regional analgesic techniques in terms of systemic effects. Plane blocks identified for the paraspinal region include the TLIP block,19 the modified TLIP block,4 and the ESP block. Although there have been a few case reports on the use of
www.journals.elsevier.com/world-neurosurgery
e5
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
the ESP block in spinal surgery,11,12 there has to date been no randomized, controlled studies showing its effectiveness. The aim of the ESP block is to affect the dorsal and ventral rami of the spinal nerves by injecting local anesthetic between the deep fascia of the erector spinae muscle and the transverse process. Although cadaveric and radiologic studies have resulted in no definite mechanism being identified, the analgesic efficacy of the ESP block is thought to be because of local anesthetics entering the paravertebral or epidural space.6,20 With this effect, the ESP block provides both parietal and visceral analgesics, similar to the paravertebral block. The injected local anesthetic exhibits a wide area of effect through cephalic and caudal diffusion. The basic factors in the popularity of this block are easy sonographic identification of landmarks and a lower complication rate compared with paravertebral block and its variants. Since 2016, the ESP block has been increasingly used for anesthesia and analgesia in thoracic and abdominal surgery and has been shown to be effective.21-23 To the best of our knowledge, the present study is the first randomized, controlled study of the ESP block in spinal surgery, and also the first clinical study concerning the ESP block applied from the lumbar level. The ESP block was applied bilaterally in the present study and is quite a safe procedure. Despite bilateral application, no block-related complications occurred. Based on previous studies, the block was performed with a 20-mL volume for both sides.22-24 However, it should also be considered that in the ESP block applied from the lumbar region, very high volumes may also result in diffusion to the lumbar plexus. Case series and reports have reported the use of ESP block leading to effective postoperative analgesia management in spinal surgeries.13,24,25 Also, in a retrospective study, patients in the ESP block group had lower pain scores and less opioid consumption when compared to a control group.26 We decided to administer the ESP block before surgery. Our reason for using this technique is that sonographic anatomy is not impaired before surgery, and that a clearer image might be obtained. In addition, because tissue integrity is compromised after surgery, the distribution of local anesthetic drugs for plane blocks
REFERENCES 1. Gottschalk A, Durieux ME, Nemergut EC. Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. Anesth Analg. 2011;112:218-223. 2. Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30:79-89. 3. Bajwa SJ, Haldar R. Pain management following spinal surgeries: an appraisal of the available options. J Craniovertebr Junction Spine. 2015;6:105-110. 4. Ahiskalioglu A, Yayik AM, Doymus O, et al. Efficacy of ultrasound-guided modified thoracolumbar interfascial plane block for postoperative analgesia after spinal surgery: a randomized-controlled trial. Can J Anaesth. 2018; 65:603-604.
e6
www.SCIENCEDIRECT.com
might have been affected. Sensory examination following injection at the L3 vertebral level in our study showed that anesthesia was established in the L1eL5 dermatomal area. This showed that the ESP block may be suitable for use in multilevel spinal surgery. The recent multimodal analgesic approach in pain treatment after spinal surgery is thought to be more effective than the traditional approach. The optimal strategy in perioperative pain control consists of multimodal approaches that minimize opioid requirements. Regional anesthetic techniques constitute an important part of this approach.27 We also established multimodal analgesia in our study with the application of a preoperative ESP block together with non-steroidal anti-inflammatory drugs, and opioids were used in the postoperative period. There are several limitations to this study. First, no information is available concerning patients’ preoperative pain scores. Preoperative pain status can affect postoperative analgesic consumption. Second, the ESP block applied preemptively can reduce intraoperative analgesic requirements and surgical stress, but these parameters were not evaluated in our study. Third, the study was only single blinded. No sham injection was performed on the Control Group, and the placebo effect of injection could not, therefore, be assessed. Finally, the study sample size was determined based on opioid requirements, the primary aim of the study. ESP block-related side effects may not be fully identified with a small sample size. Further studies with a larger sample size may be needed. CONCLUSIONS The ESP block made a significant contribution to the treatment of postoperative pain after spinal surgery. Clinical studies investigating the volume, concentration, and type of local anesthetic are now required. Combined ultrasound, magnetic resonance imaging, and cadaveric studies will be useful in assessing the effectiveness of this block. We think that the ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in lumbar decompression surgery procedures.
5. Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med. 2017;42:133-183. 6. 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;41:621-627.
anaesthesia for thoracic mass excision: a report of two cases. Anaesth Crit Care Pain Med. 2019;38: 189-190. 10. Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous erector spinae plane block for rescue analgesia in thoracotomy after epidural failure: a case report. A A Case Rep. 2017;8:254-256.
7. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med. 2017;42:372-376.
11. Singh S, Chaudhary NK. Bilateral ultasound guided erector spinae plane block for postoperative pain management in lumbar spine surgery: a case series [e-pub ahead of print]. J Neurosurg Anesthesiol. 2018. https://doi.org/10.1097/ ANA.0000000000000518.
8. Kumar A, Hulsey A, Martinez-Wilson H, Kim J, Gadsden J. The use of liposomal bupivacaine in erector spinae plane block to minimize opioid consumption for breast surgery: a case report. A A Pract. 2018;10:239-241.
12. Ueshima H, Otake H. Clinical experiences of ultrasound-guided erector spinae plane block for thoracic vertebra surgery. J Clin Anesth. 2017;38:137.
9. Cesur S, Ay AN, Yayik AM, Naldan ME, Gurkan Y. Ultrasound-guided erector spinae plane block provides effective perioperative analgesia and
13. 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;65:1057-1065.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.02.149
ORIGINAL ARTICLE AHMET MURAT YAYIK ET AL.
ESP BLOCK FOR LUMBAR SPINAL DECOMPRESSION
14. Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J Perianesth Nurs. 2006;21:259-267. 15. Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eu Spine J. 2013;22:2089-2096. 16. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1493. 17. Bohl DD, Louie PK, Shah N, et al. Multimodal versus patient-controlled analgesia after an anterior cervical decompression and fusion. Spine. 2016;41:994-998. 18. De Rojas JO, Syre P, Welch WC. Regional anesthesia versus general anesthesia for surgery on the lumbar spine: a review of the modern literature. Clin Neurol Neurosurg. 2014;119:39-43.
its mechanism of action. Rev Esp Anestesiol Reanim. 2018;65:514-519.
plane (ESP) blocks in a multimodal anesthetic regimen. Spine (Phila Pa 1976). 2019;44:E379-E383.
21. Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 2018;53: 29-34.
26. Ueshima H, Inagaki M, Toyone T, Otake H. Efficacy of the erector spinae plane block for lumbar spinal surgery: a retrospective study [e-pub ahead of print]. Asian Spine J. 2018. https://doi.org/ 10.31616/asj.2018.0114.
22. Gurkan Y, Aksu C, Kus A, Yorukoglu UH, Kilic CT. Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: a randomized controlled study. J Clin Anesth. 2018;50:65-68.
27. Kurd MF, Kreitz T, Schroeder G, Vaccaro AR. The role of multimodal analgesia in spine surgery. J Am Acad Orthop Surg. 2017;25:260-268.
23. Tulgar S, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasoundguided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a prospective, randomized, controlled clinical trial. J Clin Anesth. 2018;49:101-106.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
19. Hand WR, Taylor JM, Harvey NR, et al. Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers. Can J Anaesth. 2015;62: 1196-1200.
24. Cesur S, Yayik AM, Ozturk F, Ahiskalioglu A. Ultrasound-guided low thoracic erector spinae plane block for effective postoperative analgesia after lumbar surgery: report of five cases. Cureus. 2018;10:e3603.
20. Vidal E, Gimenez H, Forero M, Fajardo M. Erector spinae plane block: a cadaver study to determine
25. Chin KJ, Lewis S. Opioid-free analgesia for posterior spinal fusion surgery using erector spinae
WORLD NEUROSURGERY -: e1-e7, - 2019
Received 3 December 2018; accepted 16 February 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.02.149 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e7