Erector Spinae Plane Block and Modified-Thoracolumbar Interfascial Plane Block Following Lumbar Spinal Surgery
Condition: Lumbar Disc Herniation
MeSH terms: Intervertebral Disc Displacement
Study type: Interventional

Summary: 
      Ultrasound (US)-guided peripheral nerve blocks have been used increasily due to the
      advantages of ultrasound in anesthesia practice. TLIP block is one of these nerve blocks
      performed under US guidance. In this technique, 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. However, the visualisation of this
      technique may be difficult under US guidance. Therefore, modified-TLIP (mTLIP) block was
      defined as a new approach. It has been reported that mTLIP block may provide effective
      analgesia management after lumbar spine surgery.

      The ultrasound (US) guided erector spina plane block (ESPB) is a novel interfacial plan block
      defined by Forero et al. at 2016. Visualization of sonoanatomy with US is easy, and the
      spread of local anesthesic agents can be easily seen under the erector spinae muscle. Thus,
      analgesia occurs in several dermatomes with cephalad-caudad way. It has been reported that
      ESPB provides lumbar analgesia at T10-12, L3. The aim of this study is to compare US-guided
      mTLIP block and ESPB pain management after lumbar discectomy+ 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. TLIP block is one of these nerve blocks
      performed under US guidance and defined by Hand et al. in 2015. In this technique, 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.
      However, the visualisation of this technique may be difficult under ultrasound (US) guidance.
      Therefore, 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 ultrasound (US) guided erector spina plane block (ESPB) is a novel interfacial plan block
      defined by Forero et al. at 2016 The ESPB contains a local anesthetic injection into the deep
      fascia of erector spinae. This area is away from the pleural and neurological structures and
      thus minimizes the risk of complications due to injury. Visualization of sonoanatomy with US
      is easy, and the spread of local anesthesic agents can be easily seen under the erector
      spinae muscle. Thus, analgesia occurs in several dermatomes with cephalad-caudad way.
      Cadaveric studies have shown that the injection spreads to the ventral and dorsal roots of
      the spinal nerves. ESPB provides thoracic analgesia at T5 level, abdominal analgesia at T7-9
      level, and lumbar analgesia at T10-12, L3 level. In the literature, it has been reported that
      ESPB provides effective analgesia after lumbar spine surgery.

      The aim of this study is to compare US-guided mTLIP block and ESPB for postoperative
      analgesia management after after lumbar disc herniation-laminectomy surgery. The primary aim
      is to compare perioperative and postoperative opioid consumption and the secondary aim is to
      evaluate postoperative pain scores (VAS), adverse effects related with opioids (allergic
      reaction, nausea, vomiting).
    

Intervention name(s): Erector spinae plane block (Group E); modified-thoracolumbar interfascial plane block (Group T)
Intervention type(s): Other; Other
Intervention description(s): Patients will be administered ibuprofen 400 mgr IV every 8 hours in the postoperative period.A patient controlled device prepared with 10 mcg/ ml fentanyl will be attached to all patients with a protocol included 10 mcg bolus without infusion dose, 10 min lockout time and 4 hour limit. Postoperative patient evaluation will be performed by an anesthesiologist blinded to the procedure.
Postoperative pain assessment will be performed using the VAS score (0 = no pain, 10 = the most severe pain felt). The VAS scores at rest and during cough will be recorded at postoperative 1, 2, 4, 8, 16 and 24 hours. If the VAS score will be ≥ 4, 0.5 mg/ kg meperidine IV will be administered. The first time of the use of rescue analgesic, intraoperative and postoperative opioid consumption, side effects such as nausea, vomiting, itching and block related complications will be recorded.; Patients will be administered ibuprofen 400 mgr IV every 8 hours in the postoperative period.A patient controlled device prepared with 10 mcg/ ml fentanyl will be attached to all patients with a protocol included 10 mcg bolus without infusion dose, 10 min lockout time and 4 hour limit. Postoperative patient evaluation will be performed by an anesthesiologist blinded to the procedure.
Postoperative pain assessment will be performed using the VAS score (0 = no pain, 10 = the most severe pain felt). The VAS scores at rest and during cough will be recorded at postoperative 1, 2, 4, 8, 16 and 24 hours. If the VAS score will be ≥ 4, 0.5 mg/ kg meperidine IV will be administered. The first time of the use of rescue analgesic, intraoperative and postoperative opioid consumption, side effects such as nausea, vomiting, itching and block related complications will be recorded.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: There are three models for this study. The first group is erector spinae plane block group, the second one is modified-thoracolumbar interfascial plane block, the third group is the no intervention control group
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Lumbar spinal surgery; Postoperative pain management; Erector spina plane block; Modified thoracolumbar interfacial plane block