Sacral Erector Spinae Plane Block Effect on Post-Hemorrhoidectomy Pain
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Hemorrhoids are commonly observed surgical conditions affecting the anorectal area,
      characterized by symptoms such as pain, bleeding, and the presence of a protruding mass from
      the anal opening. Fear of postoperative pain is one of the most important factors for
      patients to avoid surgical interventions. Postoperative pain is a significant concern, with
      over 80% of patients encountering moderate to severe pain.

      The main aim is to evaluate ESPB from the sacral level would result in effective analgesia
      following hemorrhoidectomy. It is also aimed if sacral ESPB would reduce the use of
      additional analgesics after hemorrhoidectomy and increase patient satisfaction. In this
      prospective, randomized, controlled trial, our main objective was to examine the
      postoperative analgesic effects of sacral ESPB following hemorrhoidectomy.
    

Detailed description: 
      Hemorrhoids are commonly observed surgical conditions affecting the anorectal area,
      characterized by symptoms such as pain, bleeding, and the presence of a protruding mass from
      the anal opening. Fear of postoperative pain is one of the most important factors for
      patients to avoid surgical interventions. Postoperative pain is a significant concern, with
      over 80% of patients encountering moderate to severe pain. This heightened pain level
      contributes to an elevated risk of complications including atelectasis, thromboembolism,
      myocardial ischemia, cardiac arrhythmia, electrolyte imbalance, urinary retention, and ileus.
      The two main unresolved issues following surgery are postoperative pain and urinary
      retention. In addition to improving patient satisfaction, pain management will decrease
      urinary retention and constipation, especially in the first 24 hours following surgery.
      According to earlier research, even with analgesic therapy, 20% to 40% of patients who
      underwent hemorrhoidectomy would experience severe postoperative pain. Commonly used pain
      relievers like nonsteroidal anti-inflammatory drugs, paracetamol, and opioids often come with
      adverse effects such as dizziness, nausea, vomiting, and constipation and can even lead to
      tolerance. These side effects could prevent a full recovery and result in a poor prognosis.
      Bilateral pudendal nerve blocks are said to significantly reduce postoperative pain, but they
      are technically difficult and require specific positioning. Furthermore, the administration
      of pudendal nerve block carries the risk of potential complications, including hematoma
      formation, sciatic nerve injury, and accidental rectal puncture. Therefore, an alternative
      analgesic method with minimal adverse effects would be beneficial.

      The erector spinae plane block (ESPB) was initially introduced as an interfascial plane block
      performed at the upper thoracic levels with the purpose of alleviating neuropathic pain.
      Subsequently, its application expanded to encompass a range of thoracic interventions,
      including mastectomy, video-assisted thoracoscopy (VATS), and cardiac surgery, while also
      being utilized at lumbar levels for procedures such as abdominal surgery, prostatectomy,
      lumbar spine surgery, total hip arthroplasty, and proximal femur surgery. A newly introduced
      method called the sacral Erector Spinae Plane Block (ESPB) has been recently documented in
      scientific literature. Case studies have demonstrated its effectiveness in various surgical
      procedures. Specifically, it has shown promise in managing radicular pain at the L5-S1 level
      after sex reassignment surgery and hypospadias surgery, as well as providing analgesia for
      the posterior branches of the sacral nerves during pilonidal sinus surgery.

      The main hypothesis is that performing ESPB from the sacral level would result in effective
      analgesia following hemorrhoidectomy. It is also hypothesized that sacral ESPB would reduce
      the use of additional analgesics after hemorrhoidectomy and increase patient satisfaction. In
      this prospective, randomized, controlled trial, the main objective is to examine the
      postoperative analgesic effects of sacral ESPB following hemorrhoidectomy.
    

Intervention name(s): Sacral Erector Spinae Plane Block
Intervention type(s): Procedure
Intervention description(s): The transducer will be placed 3-4 cm laterally to the second medial sacral crest in order to visualize the intermediate sacral crest. In the interfascial plane, a total of 20 mL of local anesthetic solution (comprised of 10 mL bupivacaine 0.5%, 5 mL lidocaine 2%, and 5 mL normal saline) will be injected between the erector spinae muscles and the intermediate sacral crest. The same procedure will be performed on the contralateral side.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment
Keywords: Sacral Erector Spinae Plane Block; Post-Hemorrhoidectomy Pain; Analgesic consumption