Surgeon-Placed Erector Spinae Plane Catheters for Multilevel Lumbar Spine Fusion: Technique and Outcomes Compared With Single-Shot Blocks

Abstract

Background: Postoperative pain management of multilevel lumbar fusion remains challenging. There are few reports of opioid-sparing regional analgesia for spine surgery. We present a novel method for surgeon-placed erector spinae plane (ESP) catheters for multilevel lumbar spine fusion and compare pain-and opioid-related outcomes in a matched cohort who received anesthesiologist-placed ESP blocks.Methods: A retrospective matched pilot study of 18 patients: 6 received intraoperative, bilateral ESP catheters. Tunneled catheters were placed under the intact ESP at the proximal end of the incision. Continuous infusions of ropivacaine (0.2%) were started in the postanesthesia care unit (PACU) after emergence from anesthesia and maintained for 48 hours. Catheter patients were matched 1:2 with 12 patients who received preincision single-shot ESP blocks administered by an anesthesiologist, according to age, gender, American Society of Anesthesiologists class, body mass index, and number of spinal levels fused. All patients were provided opioid intravenous patient-controlled analgesia (IV-PCA). Numeric rating scale pain scores (NRS, 0-10), length of stay (LOS), opioid consumption (oral morphine equivalents, mg), opioid side effects, and complications (motor weakness, local anesthetic toxicity, infection, technical issues, and failure), were compared in the PACU and on the nursing floor.Results: Only 1/6 patients with ESP catheter used opioid IV-PCA, compared with 11/12 who received ESP blocks. There were no differences in total opioid consumption (catheters: 135 ± 141 mg; blocks: 183 ± 112 mg; P = 0.448) or median (interquartile range) LOS (catheters: 73 [50,107] hours; blocks: 90 [72,116] hours, P = 0.708). NRS pain was significantly higher in the PACU after ESP catheters (5.9 ± 1.7) vs ESP blocks (3.3 ± 2.4; P = 0.036), but no differences were found at later timepoints (5.0 ± 1.6 vs 4.3 ± 1.1, respectively; P = 0.383). No catheter-related complications were found.Conclusion: Surgeon-placed ESP catheters represent a simple technique to provide regional analgesia, particularly in centers lacking regional anesthesiology services. Risks, benefits, and efficacy compared to other techniques require prospective study.

Erector spinae plane block in spine surgeries: Single-level versus bi-level, single-shot versus continuous catheter technique

“…Similar to the previous point, no prospective, randomized study is available to evaluate the effects of cESP catheters. Only case reports[ 12 13 14 ] and retrospective analysis[ 15 ] are available, and no complication was reported in these small numbers of patients. [ 12 13 14 15 ]…”

“…Only case reports[ 12 13 14 ] and retrospective analysis[ 15 ] are available, and no complication was reported in these small numbers of patients. [ 12 13 14 15 ]…”

Perioperative pain management for spine surgeries

“…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.…”

“…[47][48][49][50][51] Other benefits include intraoperative opioid sparing, 47 less postoperative NV, 47,51 and better patient satisfaction. [49][50][51] ESPB also provides an opportunity to provide prolonged analgesia through catheters, 52,53 or the addition of adjuvants like dexmedetomidine, but more studies are warranted. 54 Contrary to adult data, a meta-analysis of seven trials involving 379 patients by Luo et al 55 did not confirm the superiority and efficacy of ESPB in the 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]…”