QLB vs mTLIP for Lumbar Spinal Surgery
Condition: Lumbar Disc Herniation
MeSH terms: Intervertebral Disc Displacement; Hernia
Study type: Interventional

Summary: 
      Ultrasound-guided quadratus lumborum block (QLB) is a fascial plane block where local
      anesthetic is injected adjacent to the quadratus lumborum muscle with the goal of
      anesthetizing the thoracolumbar nerves.

      In TLIP block, local anesthetic solution is injected between the multifidus and logissimus
      muscles nearly at the level of the 3rd lumbar vertebra and targets the dorsal rami of the
      thoracolumbar nerves. Ahiskalioglu et al. defined modified-lateral technique of TLIP (mTLIP)
      block as a new approach. Ahiskalioglu et al. have reported that this approach has some
      advantages. Firstly, sonographic visualisation is more easily than the classical technique.
      Secondly, insertion of the needle from medial to lateral direction reduces the risk of
      possible neuraxial injection. It has been reported that this technique provides effective
      analgesia after lumbar spinal surgery.

      The aim of this study is to compare US-guided mTLIP block and QLB for postoperative analgesia
      management after lumbar disc herniation-laminectomy surgery.
    

Detailed description: 
      Spine surgery in thoracolumbar region is one of the most common surgeries performed for the
      treatment of leg and back pain. Pain management is especially important for these patients
      since chronic pain often occurs after surgery. Severe pain may occur at postoperative period
      in patients following lumbar disc herniation (LDH) operation. Postoperative effective pain
      treatment provides early mobilization and shorter hospital stay, thus complications due to
      hospitalization such as infection and thromboembolism may be reduced.

      Opioids are one of the most preferred drugs among the analgesic agents. Parenteral opioids
      are generally performed for patients after surgery. However opioids have undesirable adverse
      events such as nausea, vomiting, itching, sedation and respiratory depression (opioid-related
      adverse events).

      Various methods may be performed to reduce the use of systemic opioids and for effective pain
      treatment. US-guided interfascial plane blocks have been used increasily due to the
      advantages of ultrasound in anesthesia practice. Ultrasound-guided quadratus lumborum block
      (QLB) is a fascial plane block where local anesthetic is injected adjacent to the quadratus
      lumborum muscle with the goal of anesthetizing the thoracolumbar nerves.

      In TLIP block, local anesthetic solution is injected between the multifidus and logissimus
      muscles nearly at the level of the 3rd lumbar vertebra and targets the dorsal rami of the
      thoracolumbar nerves. Ahiskalioglu et al. defined modified-lateral technique of TLIP (mTLIP)
      block as a new approach. Ahiskalioglu et al. have reported that this approach has some
      advantages. Firstly, sonographic visualisation is more easily than the classical technique.
      Secondly, insertion of the needle from medial to lateral direction reduces the risk of
      possible neuraxial injection. It has been reported that this technique provides effective
      analgesia after lumbar spinal surgery.

      The aim of this study is to compare US-guided mTLIP block and QLB for postoperative analgesia
      management after lumbar disc herniation-laminectomy surgery.
    

Intervention name(s): Quadratus Lumborum Block; Modified-thoracolumbar interfascial plane block
Intervention type(s): Other; Other
Intervention description(s): The block procedure will be applied after the surgery and before extubation with patients in the prone position by using US (Vivid Q, GE Healthcare, US). Under aseptic conditions, the probe will be covered with a sterile sheath and a 22G, 80 mm block needle (Braun Stimuplex Ultra 360, Germany) will be used. After visualizing the abdominal muscles, the needle will be punctured and 5 ml of saline will be injected into the postero-lateral border of the quadratus lumborum muscle. After the block location is confirmed, 15 ml of 0.25% bupivacaine will be injected. The same process will be applied to the opposite side (30 ml totally).; US probe will be placed vertically at the L3 vertebrae level. After visualizing the hyperechoic shadow of the spinous process and interspinous muscles as an anatomical guide point, the probe will be moved forward to the lateral to visualize the longissimus and iliocostal muscles. Between these muscles, block needle will be inserted within in plane technique in a medial-to-lateral direction in the interfascial plane. Once the needle tip will be placed within the interfacial plane and after careful aspiration to rule out intravascular needle placement, 2 mL of saline will be injected to confirm the proper injection site, and then a dose of 0.25% bupivacaine 15 mL will be injected in each side (30 ml totally).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Sixty patients aged 18-65 years old with American Society of Anesthesiologists (ASA) classification I-II and scheduled for lumbar disc herniation surgery will be included in the study. Patients will be randomly divided into two groups (Group Q = QLB group, Group M = mTLIP group) including 30 patients each, before entering the operating room.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Lumbar Disc Herniation; Postoperative pain management; Quadratus Lumborum Block; mTLIP block