Original Contribution
Bilateral ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal fusion: A randomized controlled trial

https://doi.org/10.1016/j.jclinane.2020.110090Get rights and content

Highlights

  • We tested the analgesic efficacy of erector spinae plane block for spinal fusion.

  • Erector spinae plane block alleviated pain in the first 12 h after surgery.

  • Erector spinae plane block decreased analgesia requirement after surgery.

  • Erector spinae plane block may be used as a part of multimodal analgesia.

Abstract

Study objective

Spinal fusion surgery is associated with severe postoperative pain. We examined whether bilateral ultrasound-guided erector spinae plane block could alleviate postoperative pain in patients undergoing lumbar spinal fusion.

Design

Blinded, randomized, controlled study.

Setting

Tertiary university hospital, operating room, postoperative recovery room and ward.

Patients

Sixty patients with American Society of Anesthesiologists grade I or II scheduled for lumbar spinal fusion surgery were randomized into the erector spinae plane block group (ESPB group) and the control group in a 1:1 ratio.

Interventions

Pre-operative ultrasound-guided bilateral erector spinae plane block was performed in the ESPB group, while sham subcutaneous infiltration was performed in the control group.

Measurements

The primary outcome was pain intensity at rest within 12 h postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included NRS pain scores at rest and on movement, postoperative opioid consumption and proportions of patients requiring opioid during the first 48 h after surgery.

Main results

The ESPB group (n = 30) showed significantly lower pain scores at rest at 4 h after surgery (estimated mean difference − 1.6, 95% confidence interval [CI] -2.4 to −0.8, p < 0.001), at 8 h (−1.3, 95% CI -1.9 to −0.6, p < 0.001), and at 12 h (−0.7, 95% CI -1.3 to −0.1, p = 0.023). The two groups showed similar pain scores at rest at 24 h after surgery (estimated mean difference − 0.2, 95% CI -0.8 to 0.5) and 48 h (−0.3, 95% CI -0.8 to 0.2). The ESPB group also showed significantly lower pain score on movement at 4 h after surgery (−1.5, 95% CI -2.5 to −0.6). The ESPB group showed a significantly smaller proportion of patients requiring sufentanil within 12 h after surgery (p = 0.020), and the group consumed significantly less sufentanil during that period (p = 0.042).

Conclusions

Bilateral ultrasound-guided erector spinae plane block improves postoperative analgesia in patients undergoing lumbar spinal fusion.

Introduction

Spinal fusion surgery is associated with severe postoperative pain because of extensive dissection of the skin, subcutaneous tissues, bones, and ligaments. In a large cohort study of 115,775 patients undergoing 179 types of surgical procedures, postoperative pain was most severe among those undergoing spinal fusion surgery [1]. Severe postoperative pain reduces patients' satisfaction with surgery and can delay postoperative recovery, ambulation, and discharge from the hospital [2]. Therefore, it is critical to provide adequate control of postoperative pain in spinal fusion surgery patients.

Regional anesthesia is a component of multimodal pain management in many surgeries [3]. Erector spinae plane (ESP) block is a novel regional anesthesia in which local anesthetic agents are injected into the plane between the deep fascia of the erector spinae muscle and the vertebral transverse process. This block may act on the dorsal rami of spinal nerves [4], and it is safe and easy to perform under ultrasound guidance to reveal bony landmarks, making it an attractive regional anesthesia modality for spinal fusion surgery. It was first applied in spinal fusion surgery as part of a multimodal anesthetic regimen, and it was found to eliminate the need for opioids [5]. In another case report, ESP block significantly improved the pain trajectory and reduced opioid consumption in two patients undergoing extensive multilevel spinal fusion [6].

In order to verify the analgesic efficacy and safety of ESP block in spinal fusion surgery, we conducted what appears to be the first randomized controlled trial. Our goal was to test the hypothesis that ESP block would significantly reduce pain scores at rest within 12 h after lumbar spinal fusion surgery.

Section snippets

Study design

The study protocol was approved by the Ethics Committee of Peking University People's Hospital (2019PHB123-01), and it adhered to the SPIRIT statement [7]. All study subjects provided written informed consent prior to enrollment. The trial was registered at the Chinese Clinical Trial Registry (ChiCTR1900026260) on September 28, 2019 and was conducted in accordance with the Declaration of Helsinki. The present report was composed according to the Consolidated Standards of Reporting Trials

Baseline patient characteristics

The study flowchart is shown in Fig. 2. Sixty-six patients were assessed for eligibility. Two patients aged >75 years were excluded, three patients were excluded due to ASA III physical status and one patient was excluded because of a refusal to participate. Finally, 60 patients were randomized equally into the ESPB or control group. All participants successfully completed the study. The two groups were comparable in demographic and baseline clinical variables (Table 1).

NRS scores

The linear mixed-effect

Discussion

This randomized controlled study indicated that bilateral ultrasound-guided ESP block provided superior pain relief with significantly lower pain scores at rest in the first 12 h after lumbar spinal fusion surgery, with lower PCA sufentanil consumption and a smaller proportion of patients requiring PCA sufentanil during the first 12 h after surgery. It also significantly reduced pain scores on movement at 4 h after surgery.

How ESP block provides analgesia is unclear. One study has suggested

Conclusion

Bilateral lumbar ESP block can decrease pain scores and postoperative opioid consumption and may be an effective component of multimodal analgesia in patients undergoing lumbar spinal fusion surgery. Future work should confirm and extend our findings in patients using different types of multimodal analgesia, and based on a more comprehensive set of outcomes, including patient-centered ones such as quality of recovery, pain interference, and rehabilitation metrics.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclosures

The authors have no sources of funding to declare for this manuscript.

Declaration of Competing Interest

None declared.

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