Intraoperative freehand erector spinae plane block is effective and can reduce backache and opioid consumption, new study finds

Serdar Yeşiltaş

Intraoperative freehand erector spinae plane block (ESPB) as part of multimodal analgaesia is effective and, for posterior instrumented patients with spondylolisthesis, it can relieve postoperative backache and reduce opioid consumption. This is according to new data published in the journal Spine.

The findings of this prospective randomised controlled study, which were published by Serdar Yeşiltaş (Bezmialem Vakif University, Istanbul, Turkey) and Anas Abdallah (Aile Hospital, Istanbul, Turkey) et al, were intended to shed light on the efficacy of intraoperative freehand ESPB after spinal surgeries.

The study authors note that management of the severe postoperative back pain followed the major spinal surgeries “remains a challenge” and that research is currently ongoing to find “simple, efficient, and reliable perioperative analgaesia with low side effects”.

A total of 56 consecutive adult patients who underwent posterior spinal instrumentation and fusion for spondylolisthesis were randomly divided into two groups.

The ESPB group received intraoperative freehand bilateral ESPB with a 20ml mixture solution of 0.25% bupivacaine and 1% lidocaine equally divided into all operating levels. In the control group 20ml physiological saline was injected.

Postoperatively, the researchers ordered 1g paracetamol thrice/day, besides patient-controlled analgaesia pumps with morphine. A postoperative evaluation was performed with a visual analogue scale (VAS), morphine consumption, ESPB-related adverse effects, and postoperative length of hospital stay (PLOS).

Study findings showed that morphine consumption was significantly higher in the control group within the first 24 hours’ post-procedure (44.75 ± 12.3mg versus 33.75 ± 6.81mg in the ESPB group; 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 control group (p<0.05). In control group patients, the first analgaesic demand time was shorter, and PLOS was longer (p<0.001). Patient satisfaction was significantly higher in the ESPB group. There was no significant difference regarding postoperative complications.

Speaking to Spinal News International, Yeşiltaş and Abdallah said: “Today, with the advent of posterior spinal fusion, the need for strong analgaesia has increased. The most advanced spinal centres worldwide ought to use opioids as the mainstay of perioperative analgaesia to manage such hard painful surgical interventions; however, the adverse effects of opioids, such as opioid-induced hyperalgesia, cognitive impairment, risk of opioid habituation, respiratory depression, gastrointestinal dysmotility, and nausea, are still the challenge for spine surgeons.

“ESPB is a promising technique for analgaesia to relieve both acute severe postoperative and chronic neuropathic pains. This technique is a newly described regional anaesthetic technique that is generally performed using ultrasound. Ultrasound-guided ESPB requires a separate room as it is performed preoperatively in a separate preparing room, additional time, sedation doses, radiologist team to perform the technique, and special additional advice (ultrasound).

“Although there is no comparative study to compare between both techniques, we believe that the freehand technique has several advantages such as the accuracy of the injection into the target area, reducing the risk of serious injection-related complications caused by misplaced needles, and it is easily applied without any advice (ultrasound) at the end of the surgery and can be applied on several levels, not on a single level as in the ultrasound-guided technique.

“The freehand technique does not require a separate room, additional time, sedation doses, and preparing preoperatively. Since the anaesthetic solution has been applied intraoperatively and directly to the target areas by freehand technique spreading the anaesthetic solution into the musculofacial plane and between muscles is guaranteed rather than by ultrasound-guided technique that may complicate with leakage out of the anaesthetic solution due to the separation of local muscular and ligaments.

“Thus, spine surgeons can easily apply ESPB at the last stage of posterior spinal fusion operations. We kept using this technique for posterior spinal fusion, lumbar discectomy, and lumbar laminectomy surgeries with good results.”


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