Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

Abstract

Background: Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis. Materials and methods: The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective. Results: The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =−15.0 mg; 95% CI: −18.8 to −11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=−1.9 in early, −1.4 in middle, −0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: −3.6 to 5.6). Conclusions: TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

Perioperative pain management for spine surgeries

“…In some spine surgery studies, it has been shown to be effective, 70,71 but a definite conclusion cannot be drawn due to heterogeneity and a lack of robust data 72 . In recent studies, PNBs have outshone LA infiltration in this matter 73,74 . In addition, similar to epidural catheters, surgeons are able to insert PVB or ESP catheters directly between desired muscles toward the end of surgery, reducing the risk of surgical damage as these are placed under direct visualization 44,53 .…”

“…72 In recent studies, PNBs have outshone LA infiltration in this matter. 73,74 In addition, similar to epidural catheters, surgeons are able to insert PVB or ESP catheters directly between desired muscles toward the end of surgery, reducing the risk of surgical damage as these are placed under direct visualization. 44,53 See Table 1 for comparisons of neuraxial and PNB techniques in the adult and pediatric population.…”

“…Erector spinae plane block [47][48][49][50][51][52][53] Most studied block in adult spine surgeries Associated with reduced opioid consumption intraoperatively and postoperatively, lower pain scores, less NV and better patient satisfaction More comparative effectiveness studies are required Most studied block in pediatric spine surgeries Associated with reduced opioid consumption intraoperatively and postoperatively, lower pain scores, less NV and better patient satisfaction More comparative effectiveness studies are required Thoracolumbar interfascial plane block [56][57][58][59] Limited studies with mixed results Not studied Midpoint transverse process to pleura block 45,46 Inadequate data Not studied Quadratus lumborum block 60 Single retrospective study Can be used for anterior and posterior approach lumbar spine surgeries Not studied Surgical infiltration [67][68][69][70][71][72][73][74]…”

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

“…We read with great interest the recent article by Hong et al . 1 . The authors performed an interesting network meta-analysis that evaluated the postoperative analgesic efficacy of erector spinae plane block (ESPB), thoracolumbar interfascial plane (TLIP) block, wound infiltration (WI), and controls.…”

“…Third, the questionable clinical significance was further biased by using nonopioid multimodal analgesia, which may attenuate perceived pain and mask a possible effect of the intervention 1 . Perioperative administration of other analgesics, such as paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs), was also not considered in the analyses, which led to further doubt about the robustness of results.…”