USE OF THE ERECTOR SPINAE PLANE BLOCK IN SPINAL SURGERIES

USO DO BLOQUEIO DO PLANO ERETOR DA ESPINHA EM CIRURGIAS DE COLUNA VERTEBRAL

USO DEL BLOQUEO DEL PLANO ERECTOR DE LA COLUMNA EN CIRUGíAS DE LA COLUMNA VERTEBRAL

ABSTRACT

Postoperative pain management in spinal surgeries remains a challenge, and the erector spinae plane (ESP) block has emerged as a promising analgesic technique, offering significant benefits in pain reduction and opioid consumption. This prospective case series aimed to evaluate the efficacy and safety of ESP block in patients undergoing elective lumbar surgeries. Patients aged 18 to 60 years undergoing surgeries of up to two levels were included, with bilateral ESP blocks performed in conjunction with general anesthesia before the start of surgery. Data were collected in the Post-Anesthesia Care Unit, at 6, 12, 24, and 48 hours postoperatively. The analysis included pain intensity, opioid use, and the occurrence of side effects. Results demonstrated that the ESP block provided satisfactory analgesia, with low morphine usage and no significant adverse effects. Postoperative pain was effectively controlled, with no prolonged hospitalization or block-related complications. Although this study is limited by its case series design, the findings suggest that ESP block may be an effective strategy for pain management in lumbar surgeries. Level of Evidence IV; Case series.

Keywords: Surgical Procedures; Operative; Pain; Spine; Anesthesia Recovery Period; Analgesics; Opioid.

RESUMO

A dor pós-operatória em cirurgias da coluna vertebral continua sendo um desafio, e o bloqueio do plano eretor da espinha (PEE) parece ser uma técnica analgésica promissora, apresentando benefícios significativos em relação à redução da dor e ao consumo de opioides. Esta série prospectiva de casos teve como objetivo avaliar a eficácia e segurança do uso do bloqueio PEE em pacientes submetidos a cirurgias lombares eletivas. Pacientes entre 18 e 60 anos submetidos a cirurgias de até dois níveis foram incluídos, sendo o bloqueio bilateral realizado em associação com anestesia geral. Os dados foram coletados na Sala de Recuperação Pós-anestésica e às 6, 12, 24 e 48 horas pós-operatório. A análise incluiu a intensidade da dor, uso de opioides e ocorrência de efeitos colaterais. Os resultados mostraram que o bloqueio ESP proporcionou uma analgesia satisfatória, com baixa utilização de morfina e ausência de efeitos adversos significativos. A dor no pós-operatório foi controlada efetivamente, e não houve prolongamento da internação ou complicações relacionadas ao bloqueio. Embora o estudo tenha limitações próprias de uma série de casos, os achados indicam que o bloqueio PEE pode ser uma estratégia eficaz para o controle da dor em cirurgias lombares. Nível de evidência IV, série de casos.

Descritores: Procedimentos Cirúrgicos Operatórios; Dor; Coluna Vertebral; Período de Recuperação da Anestesia; Analgésicos Opioides.

RESUMEN

El control del dolor postoperatoria en cirugías de columna vertebral sigue siendo un desafío, y el bloqueo del plano erector de la espina (PEE) parece ser una técnica analgésica prometedora, presentando beneficios significativos en cuanto a la reducción del dolor y el consumo de opioides. Esta serie prospectiva de casos tuvo como objetivo evaluar la eficacia y seguridad del uso del bloqueo PEE en pacientes sometidos a cirugías lumbares electivas. Se incluyeron pacientes de entre 18 y 60 años sometidos a cirugías de hasta dos niveles, realizándose el bloqueo bilateral en asociación con anestesia general. Los datos fueron recogidos en la Sala de Recuperación Postanestésica y a las 6, 12, 24 y 48 horas postoperatorias. El análisis incluyó la intensidad del dolor, el uso de opioides y la ocurrencia de efectos secundarios. Los resultados mostraron que el bloqueo PEE proporcionó una analgesia satisfactoria, con baja utilización de morfina y ausencia de efectos adversos significativos. El dolor postoperatorio fue controlado eficazmente, sin prolongación de la hospitalización ni complicaciones relacionadas con el bloqueo. Aunque el estudio tiene las limitaciones propias de una serie de casos, los hallazgos indican que el bloqueo PEE puede ser una estrategia eficaz para el control del dolor en cirugías lumbares. Nivel de Evidencia IV; Estudio Prospectivo Comparativo.

Descriptores: Procedimientos Quirúrgicos Operativos; Dolor; Columna Vertebral; Periodo de Recuperación de la Anestesia; Analgésicos Opioides.

INTRODUCTION

In recent decades, the field of spinal surgery has experienced remarkable advances, but effective control of postoperative pain remains a significant challenge, especially amid the crisis of opioid overuse.¹,² In this context, regional anesthesia techniques have proven valuable for improving perioperative pain control in various orthopedic subspecialties.

The erector spinae plane block (erector spinae plane - ESP) has emerged as a promising technique for pain control in spinal surgeries, offering significant benefits such as better perioperative analgesia, reduced opioid consumption, shorter time to first ambulation, and earlier hospital discharge.³,⁴,⁵ Initial studies have investigated the use of the ESP block as an analgesia technique for lumbar spine surgeries, including decompressions and arthrodesis, showing promising, yet still controversial, results in terms of pain control.⁵,⁶

The small number of published articles and the disagreement between some data justify the realization of this work, which aimed to preliminarily evaluate the use of ESP block as an analgesic technique in lumbar spine surgeries.

METHODOLOGY

This prospective work was submitted to the Ethics Committee of Hospital Mater Dei on 04/15/2024 and was approved under CAAE 74224623.3.0000.5128. All participants signed the informed consent form (ICF).

The research prospectively evaluated cases involving patients aged between 18 and 60 undergoing elective spinal surgeries at up to two levels. Patients with central neurological disorders (including cognitive impairments), coagulation disorders, chronic opioid use, infection at the paravertebral puncture site, previous spinal surgeries, allergy to any study medication, and inability or refusal to sign the informed consent form were excluded.

In the preoperative period, demographic data were collected, in addition to surgical diagnosis, associated diseases, ASA physical status classification, medications in use (including opioids), smoking, alcohol consumption, and pain intensity.

The patients underwent total intravenous general anesthesia, with standard non-invasive monitoring and consciousness level assessment through bispectral index. General anesthesia was performed with lidocaine (1mg/kg at induction), remifentanil (0.05-0.3mcg/kg/min), target-controlled infusion of propofol guided by the bispectral index, dexmedetomidine (0.3-0.5mcg/kg/h), and rocuronium (0.6mg/kg). Before the surgical incision and after positioning, a bilateral ESP block was performed under ultrasound guidance, at the same level or an intermediate level as the surgical approach, with an A100 needle (Pajunk^R), using a 0.5% ropivacaine solution (20mL on each side). The same anesthesiologist with regional anesthesia experience performed the block.

Blood pressure and heart rate were recorded immediately before and 2 minutes after the surgical incision. The doses of remifentanil, dexmedetomidine, and propofol were adjusted as needed and according to the clinical judgment of the attending anesthesiologist. The total consumption and duration of the anesthesia were recorded.

Multimodal analgesia was supplemented with dipyrone 2g and parecoxib 40mg at the end of the procedure, and prophylaxis for postoperative nausea was done with dexamethasone 10mg and ondansetron 4mg. If the pain immediately after waking up in the surgical room or in the Post-Anesthesia Care Unit (PACU) was greater than 5 on the numerical scale (where 0 indicates no pain and 10 the maximum imaginable pain), intravenous morphine was administered, with an initial dose of 0.1 mg/kg, followed by 0.05 mg/kg, up to a maximum of 0.3 mg/kg.

The postoperative prescription included dipyrone 1g every 6 hours, parecoxib 40mg every 12 hours, pregabalin 75mg/day, and morphine 0.05mcg/kg/dose for rescue. The data was collected in the PACU, at 6, 12, 24, and 48 hours after discharge to the room. The assessment included measuring pain levels, opioid use, occurrence of nausea, vomiting, urinary retention, itching, time required for first ambulation, and length of hospital stay.

As a statistical analysis, the profile of the patients was characterized by absolute frequency, relative frequency, mean, and standard deviation. The normality of the data was verified by the Shapiro-Wilk test. Data was compared throughout the intervention using paired t-tests and Friedman’s ANOVA. The data were analyzed using the Statistical Package for Social Science (IBM Corporation, Armonk, USA) version 26.0. The significance level adopted was 5% (p < 0.05).

RESULTS

Table 1 presents the demographic and preoperative data of the patients.

Table 1
Characterization of the demographic and clinical profile of patients in the preoperative period.

Variables	Descriptive
Age-years (Mean ± SD)	50.00 ± 16.52
Gender - n (%)
Male	3 (100.0)
Female	0 (0.0)
Anthropometric
Height - m (Mean ± SD)	1.74 ± 0.07
Weight - kg (Mean ± SD)	74.33 ± 18.88
BMI - kg/m2 (Mean ± SD)	24.23 ± 4.31
IMC Classification - n (%)
< 25 kg/m2	2 (66.7)
≥ 25 kg/m2	1 (33.3)
ASA - n (%)
1	0 (0.0)
2	3 (100.0)
Surgical diagnosis - n (%)
Fracture of T12	1 (33.3)
Lumbar disc herniation	2 (66.7)
Surgery - n (%)
Thoracolumbar arthrodesis	3 (100.0)
Comorbidities - n (%)
Dyslipidemia	1 (33.3)
History of pulmonary thromboembolism	1 (33.3)
Opioid use - n (%)
No	1 (33.3)
Yes	2 (66.7)
Smoking - n (%)
No	3 (100.0)
Yes	0 (0.0)

n, absolute frequency; %, relative frequency; SD, standard deviation

In Table 2, the details of the intraoperative period are described.

Table 2
Characterization of patients in the intraoperative period.

Variables	Descriptive
Duration of surgery - minutes (Mean ± SD)	243.33 ± 5.77
Number of levels operated - n (%)
1	1 (33.3)
2	2 (66.7)
Surgical complications - n (%)
No	3 (100.0)
Yes	0 (0.0)
Anesthetic complications - n (%)
No	3 (100.0)
Yes	0 (0.0)

n, absolute frequency; %, relative frequency

Table 3 compares systolic (SBP), diastolic (DBP), and mean arterial pressures (MAP), as well as heart rate (HR), before and after the surgical incision, demonstrating that there were no statistically significant differences between the values.

Table 3
SBP, DBP, MAP, and HR before and after surgical incision.

(Mean ± SD)	Before the incision	After the incision	p*
SBP (mmHg)	105.67 ± 34.93	105.33 ± 25.70	0.95
DPB (mmHg)	65.33 ± 20.98	63.33 ± 15.37	0.62
MAP (mmHg)	78.67 ± 25.42	76.33 ± 19.73	0.59
HR (bpm)	62.33 ± 4.62	62.33 ± 4.62	1.00

• ^*
  Student’s t-test; SD, standard deviation

In Table 4, data related to the total dose of morphine used in the PACU and the use of adjuvant analgesics for the treatment of pain related to the surgical site are presented. One of the patients required analgesia for pain radiating to the left lower limb, not related to the surgical site.

Table 4
Characterization of pain and analgesic dose in the PACU.

Variables	Descriptive
Pain at surgical site - n (%)
Yes	2 (66.6)
No	1 (33.3)
Total dose of morphine used (mg/kg)
Mean ± SD	0.13
Adjuvant analgesics - n (%)
No	3 (100.0)
Yes	0 (0.0)

n, absolute frequency; %, relative frequency; SD, standard deviation

Table 5 presents the postoperative data, with pain assessed using a numerical scale with the same parameters described previously.

Table 5
Characterization of patients in the postoperative period.

Variables	Descriptive
Mean ± SD
Pain at the surgical site (6h)	4.33 ± 4.04
Pain at the surgical site (12h)	2.67 ± 2.52
Pain at the surgical site (24h)	2.50 ± 3.54
Pain at the surgical site (48h)	2.67 ± 2.52
Morphine dose used (after PACU up to 24h)	2.33 ± 4.04
Total dose of morphine used (between 24 and 48h)	0.00 ± 0.00
Time to first ambulation (hours)	16.67 ± 7.09
Length of stay (after surgery completion in hours) n (%)	34.17 ± 12.39
Nausea
No	3 (100.0)
Yes	0 (0.0)
Vomiting
No	3 (100.0)
Yes	0 (0.0)
Urinary retention
No	3 (100.0)
Yes	0 (0.0)
Pruritus
No	3 (100.0)
Yes	0 (0.0)

n, absolute frequency; %, relative frequency; SD, standard deviation

DISCUSSION

The use of ESP block has been increasingly explored in different contexts, and its effectiveness in reducing pain and opioid consumption has already been demonstrated in thoracic surgeries, cardiac surgeries, mastectomies, and even in the emergency department.⁷-¹⁰ Additional studies also corroborate the safety and feasibility of ESP block in patients undergoing spinal procedures, highlighting the absence of surgical and anesthetic complications during the intraoperative process.³

In this study, we investigated the potential benefits of this technique in patients undergoing elective spinal surgeries at up to two levels, taking into account its previously demonstrated effectiveness in reducing postoperative opioid consumption and promoting early recovery. The analysis of hemodynamic variables did not reveal statistically significant differences before and after the surgical incision, indicating adequate inhibition of the pain stimulus.

In the same way, the pain values assessed by the numerical scale were low in the PACU and postoperatively, as well as the dose of morphine used for rescue, suggesting a satisfactory analgesic effect of the ESP block as part of a multimodal strategy. No adverse effects related to the use of opioids were reported, possibly due to the low dose of morphine administered. The time until the first ambulation, allowing for an adequate gait test, remained within the planned timeframe, with pain not being an obstacle to its execution. There was no prolonged hospital stay due to pain management issues or side effects from cumulative opioid doses.

This work has the limitations inherent to a series of cases, which does not allow us to reach conclusions regarding the results obtained. However, its importance lies in being a pilot to guide the creation of a randomized clinical study, with no observed failures in methodology, forms, and data collection logistics.

CONCLUSION

The ESP block appears to be a promising strategy for pain control in patients undergoing lumbar spine surgeries. However, further studies are needed to confirm these findings and better explore the potential benefits of blocking concerning functional recovery and patient satisfaction. Future investigations may include a larger sample of patients and comparisons with other analgesic techniques.

All authors declare no potential conflict of interest related to this article.

• Study conducted by the Hospital Mater Dei, Belo Horizonte, MG, Brazil.

REFERENCES

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Edited by

• Reviewed by:
  Rodrigo Amaral

Publication Dates

• Publication in this collection
  25 Nov 2024
• Date of issue
  2024

History

• Received
  29 Mar 2024
• Accepted
  26 Sept 2024