Erector Spinae Plane Block for Lumbar Spine Surgery
Erector spinae plane block should be used as an effective adjunct to multimodal analgesia in lumbar spine surgery, as it significantly reduces postoperative opioid consumption, improves pain control, and enhances patient satisfaction compared to no block or local infiltration alone. 1, 2, 3
Evidence Supporting ESPB in Lumbar Spine Surgery
The evidence for ESPB in lumbar spine surgery is robust and consistently positive, though notably this differs from the guideline recommendations which focus primarily on thoracic surgery applications:
Analgesic Efficacy
ESPB reduces 24-hour postoperative opioid consumption by approximately 14.55 morphine milligram equivalents compared to no block, representing a clinically meaningful reduction in opioid exposure 3
Pain scores are significantly lower at rest and during movement at 2,6,12,24, and 48 hours postoperatively when ESPB is used 1, 3
Bilateral ultrasound-guided ESPB with 0.375% ropivacaine 40 mL provides superior analgesia compared to local wound infiltration, with NRS pain scores of 1.9±1.5 versus 5.9±1.6 at rest postoperatively 2
Clinical Outcomes Beyond Pain
Patient satisfaction scores increase significantly (mean difference of 2.38 on a 0-10 scale) with ESPB 3
Hospital length of stay decreases by approximately 1.24 days when ESPB is incorporated into the pain management strategy 3
Postoperative nausea and vomiting incidence is reduced by 64% (risk ratio 0.36) with ESPB use 1, 3
Intraoperative opioid consumption, muscle relaxant usage, surgical duration, and blood loss are all reduced when ESPB is performed preoperatively 4
Technical Approach
Block Technique
Perform bilateral ultrasound-guided ESPB at the vertebral level of the surgical incision rather than at a fixed thoracic or lumbar level, as this provides superior opioid-sparing effects 3
Use 20 mL of 0.375-0.5% ropivacaine or bupivacaine per side (total 40 mL for bilateral blocks) 5, 2
Timing: Perform the block after induction of anesthesia and positioning but before surgical incision for optimal intraoperative and postoperative benefits 4
Adding Adjuvants
Consider adding dexamethasone (8 mg) to the local anesthetic to prolong analgesic duration and improve outcomes 4
Dexmedetomidine as an adjuvant reduces pain scores, rescue analgesia requirements, and hospital stays compared to plain local anesthetic 5, 6
Integration with Multimodal Analgesia
ESPB must be part of a comprehensive multimodal strategy—it is an adjunct, not a replacement for systemic analgesia:
Foundation Medications (Always Include)
Administer NSAIDs and acetaminophen preoperatively and continue postoperatively as the cornerstone of pain management 7, 8
Pregabalin 150-300 mg or gabapentin ≥900 mg/day started preoperatively and continued postoperatively significantly reduces opioid consumption and side effects 8
Opioid Management
Reserve opioids for rescue analgesia only, using patient-controlled analgesia (PCA) for breakthrough pain in the immediate postoperative period 5, 8
Limit opioid prescriptions to maximum 7 days to minimize risks of respiratory depression, tolerance, and addiction 8
Additional Considerations
IV lidocaine or ketamine infusions may provide additional benefit as part of the multimodal approach 7
Liposomal bupivacaine wound infiltration can be considered, though evidence is mixed and it should not replace ESPB 7, 8
Critical Caveats and Pitfalls
Duration Limitations
The analgesic effect of single-shot ESPB diminishes after 6-8 hours, requiring robust multimodal analgesia to maintain pain control beyond this window 5, 8, 6
Plan for transition to oral analgesics and ensure adequate non-opioid medications are prescribed before the block wears off 5
Comparison to Other Regional Techniques
ESPB appears comparable to other fascial plane blocks (thoracolumbar interfascial plane block, midtransverse process to pleura block) in lumbar surgery, with no clear superiority of one technique over another 1, 3
The choice between regional techniques should be based on operator experience and institutional resources rather than expecting dramatic differences in efficacy 1
Patient Selection
Identify patients with preoperative chronic pain, mental health comorbidities, or substance abuse history, as these patients require more intensive perioperative pain management strategies 7
ESPB may be particularly valuable in patients with coagulation disorders where neuraxial techniques are contraindicated 7
Quality of Evidence Considerations
While the meta-analyses demonstrate consistent benefits of ESPB in lumbar spine surgery 1, 3, 9, it's important to note that the overall quality of evidence is rated as low-grade due to heterogeneity in study designs, block techniques, and outcome measures 3. However, the consistency of findings across multiple studies and the magnitude of benefit support its clinical use as part of multimodal analgesia.
The pediatric anesthesia guidelines mention ESPB only as an emerging technique for specialized centers 7, and the spine surgery guidelines do not specifically address ESPB 7, suggesting this is an evolving area where clinical practice may be ahead of formal guideline recommendations.