Evaluation of ultrasound-guided lateral thoracolumbar interfascial plane block for postoperative analgesia in lumbar spine fusion surgery: a prospective, randomized, and controlled clinical trial

Exploring the Thoracolumbar Interfascial Plane (TLIP) Block as a Novel Approach for Improved Pain Management After Spine Surgery: A Comparative Review

Postoperative pain management following spine surgery remains a significant challenge, often requiring multimodal approaches to achieve adequate analgesia while minimizing side effects. The thoracolumbar interfascial plane (TLIP) block has emerged as a novel regional anesthesia technique for addressing this issue. By targeting the interfascial plane between the erector spinae and quadratus lumborum muscles at the thoracolumbar junction, the TLIP block aims to provide targeted analgesia to the surgical site while reducing systemic opioid requirements. This review explores the anatomy, technique, mechanism of action, and clinical evidence supporting the TLIP block for post-spine surgery pain management. Additionally, it compares the TLIP block with traditional pain management approaches and discusses its implications for clinical practice and future research. Overall, the TLIP block shows promise as an effective and potentially safer alternative for post-spine surgery pain management, potentially improving patient outcomes and enhancing recovery. Further research is warranted to optimize its utilization and comprehensively evaluate its long-term effects.

Modified Thoracolumbar Interfascial Plane Block Versus Erector Spinae Plane Block in Patients Undergoing Spine Surgeries: A Randomized Controlled Trial

BACKGROUND

Lumbar spine surgery is associated with significant postoperative pain. Interfascial plane blocks, such as erector spinae plane (ESP) and thoracolumbar interfascial plane (TLIP) blocks, can play a significant role in multimodal analgesic regimens.

METHODS

Sixty patients aged 18 to 60 years undergoing elective single or double-level lumbar discectomy or primary lumbar laminoplasty were recruited into this randomized double‑blind study. All patients received general anesthesia and were randomly allocated to either modified TLIP (mTLIP) block (group M) or ESP block (group E). Postoperative and intraoperative fentanyl consumption, and postoperative pain scores, were recorded.

RESULTS

Total 48 h postoperative fentanyl consumption was higher in Group M (189.66±141.11 µg) than in Group E (124.16±80.83 µg; P =0.031). In the first 24 postoperative hours, fentanyl consumption was higher in Group M (150.3±120.9 µg) than in group E (89.9±65.3 µg; P =0.01) but was similar between groups in postoperative hours 24to 48 (39.0±20.2 µg versus 34.7±17.1 µg in group M and group E, respectively; P =0.37). Additional intraoperative fentanyl requirement was 57.66±21.76 µg in group M compared with 40.33±21.89 µg in group E ( P <0.01). Postoperative pain scores were higher in group M than in group E at 1, 2, 4, 6, 12, and 24 hours postoperatively ( P <0.001), but similar at 48 hours ( P =0.164).

CONCLUSION

Compared with the mTLIP block, the ESP block was associated with lower pain scores and a small decrease in perioperative fentanyl consumption in patients undergoing lumbar spine surgeries. Both blocks could form a part of a multimodal analgesic regimen in spine surgery patients.

Analgesic efficacy of classical thoracolumbar interfascial plane block versus modified thoracolumbar interfascial plane block in patients undergoing lumbar disc surgeries: A comparative, randomised controlled trial

Background and Aims

We compared classical (medial) and modified (lateral) thoracolumbar interfascial plane block (TLIP) with only general anaesthesia (GA) using multimodal analgesia in patients undergoing lumbar disc surgeries.

Methods

In this study, 100 patients aged 18-70 years were randomised to Group cTLIP (conventional TLIP block with 20 mL of 0.25% ropivacaine with GA), Group mTLIP (modified TLIP block with 20 mL of 0.25% ropivacaine with GA), and Group C (only GA using multimodal analgesia). The primary outcome was to assess the total peri-operative opioid consumption in the first 24 h. The secondary outcomes were to assess pain score upon arriving in the post-anaesthesia care unit, time to first analgesic need after surgery, post-operative opioid consumption in 24 h, and incidence of nausea and vomiting.

Results

The total peri-operative opioid consumption in Group cTLIP (507.58 (258.55) μg) and Group mTLIP (491.67 (165.39) μg) was significantly lower than that in Group C (1225.4 (237.03) μg); (P < 0.001). However, it was comparable between groups cTLIP and mTLIP (P = 0.767). Pain score was comparable in groups cTLIP and mTLIP. It was significantly lower than Group C (P = 0.001). Rescue analgesia was needed in all (100%) patients of Group C but in only 15.2% of patients of the cTLIP and mTLIP groups. No patient in groups cTLIP and mTLIP complained of nausea and vomiting in the first 24 h, whereas it was significantly higher (61.8%) in Group C (P = 0.001).

Conclusion

The analgesic effect of the modified TLIP block was not superior to the conventional TLIP block. Both techniques provided the same intra-operative and post-operative analgesia for lumbar disc surgeries.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements.

METHODS

A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements.

RESULTS

The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts.

CONCLUSION

The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis

BACKGROUND

Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis.

MATERIALS AND METHODS

The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective.

RESULTS

The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6).

CONCLUSIONS

TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.

The efficacy of thoracolumbar interfascial plane block for lumbar spinal surgeries: a systematic review and meta-analysis

BACKGROUND

The intent of this meta-analysis was to examine the efficacy of thoracolumbar interfascial plane block (TLIP) for pain control after lumbar spinal surgery.

METHODS

Randomized controlled trials (RCTs) published on PubMed, CENTRAL, Scopus, Embase, and Web of Science databases up to February 10, 2023, comparing TLIP with no or sham block or wound infiltration for lumbar spinal surgeries were included. Pain scores, total analgesic consumption, and postoperative nausea and vomiting (PONV) were analyzed.

RESULTS

Seventeen RCTs were eligible. Comparing TLIP with no block or sham block, the meta-analysis showed a significant decrease of pain scores at rest and movement at 2 h, 8 h, 12 h, and 24 h. Pooled analysis of four studies showed a significant difference in pain scores at rest between TLIP and wound infiltration group at 8 h but not at 2 h, 12 h, and 24 h. Total analgesic consumption was significantly reduced with TLIP block as compared to no block/sham block and wound infiltration. TLIP block also significantly reduced PONV. GRADE assessment of the evidence was moderate.

CONCLUSION

Moderate quality evidence indicates that TLIP blocks are effective in pain control after lumbar spinal surgeries. TLIP reduces pain scores at rest and movement for up to 24 h, reduces total analgesic consumption, and the incidence of PONV. However, evidence of its efficacy as compared to wound infiltration of local anesthetics is scarce. Results should be interpreted with caution owing low to moderate quality of the primary studies and marked heterogeneity.

The thoracolumbar interfascial block with local anesthesia in osteoporotic vertebral compression fractures treated with percutaneous kyphoplasty provides better analgesia compared with local anesthesia alone: A randomized controlled study

Objective

To evaluate the safety and efficacy of the thoracolumbar interfascial block (TLIPB) in percutaneous kyphoplasty (PKP), and to confirm that the TLIPB further minimizes perioperative pain and residual back pain on the basis of local anesthesia.

Method

From April 2021 to May 2022, 60 patients with osteoporotic vertebral compression fractures were included in this prospective randomized controlled trial. Patients were randomly assigned to a local anesthesia group (A group) or a TLIPB on the basis of local anesthesia group (A + TLIPB group) before PKP. Pain level (visual analog scale, VAS), amount of analgesic rescue drugs (parecoxib), operative time, mean arterial pressure, heart rate, and complications were assessed and compared between the two groups.

Results

Compared with the A group, VAS scores were lower in the A + TLIPB group, respectively, when the trocar punctured the vertebral body (7.4 ± 0.7 vs. 4.5 ± 0.9; P &lt; 0.01), during balloon dilatation (6.6 ± 0.9 vs. 4.6 ± 0.9; P &lt; 0.01), during bone cement injection (6.3 ± 0.6 vs. 4.3 ± 0.8; P &lt; 0.01), 1 h after surgery (3.5 ± 0.7 vs. 2.9 ± 0.7; P &lt; 0.01), and 24 h after surgery (2.5 ± 0.8 vs. 1.9 ± 0.4; P &lt; 0.01). Residual back pain (VAS: 1.9 ± 0.9 vs. 0.9 ± 0.8; P &lt; 0.01) and the incidence of rescue analgesic use (P = 0.02) in the A + TLIPB group were lower compared with the A group. Compared with the A group, mean arterial pressure and heart rate were lower in the A + TLIPB group when the trocar punctured the vertebral body, and with balloon dilatation and bone cement injection; however, there were no statistical differences between the groups 1 and 24 h after surgery. The incidences of bone cement leakage, constipation, and nausea were similar between the two groups. No patient developed infection, neurological injuries, constipation in either group.

Conclusion

The addition of the TLIPB to local anesthesia can further minimize perioperative pain and residual back pain, and reduce perioperative rescue analgesic use. When added to local anesthesia, the TLIPB is an effective and safe anesthetic method for PKP.

Clinical trial registration

This study has been registered in the Clinical Trial registration: ChiCTR-2100044236.

Ultrasound-guided erector spinae plane block for postoperative short-term outcomes in lumbar spine surgery: A meta-analysis and systematic review

BACKGROUND

Patients undergoing lumbar spine surgery usually suffer from moderate to severe acute pain. Erector spinae plane block (ESPB) has been applied to relieve acute pain in various surgeries and improve postoperative outcomes. This study aimed to further identify the efficacy and safety of erector spinae plane block in patients undergoing lumbar spine surgery. This study also evaluates the outcomes of the erector spinae plane block compared with other regional blocks.

METHODS

We searched PubMed, Web of Science, Cochrane library, Embase, and CINAHL databases to identify all randomized controlled trials evaluating the effects of ESPB on postoperative pain after lumbar spine surgery. The primary outcome is postoperative total opioid consumption in 24 hours. The secondary outcomes are postoperative pain scores, intraoperative opioid consumption, time to first rescue analgesia, number of patients requiring rescue analgesia, first time to ambulation after surgery, length of hospital stay, patients' satisfaction score, and postoperative side effects such as postoperative nausea and vomiting, itching.

RESULTS

A total of 19 randomized controlled trials are included in the final analysis. Compared with no/sham block, ultrasound-guided erector spinae plane block can decrease perioperative opioid consumption including intraoperative opioid consumption: standardized mean difference (SMD) = -3.04, 95% confidence interval (CI) (-3.99, -2.09), P < .01, and opioid consumption postoperatively: (SMD = -2.80, 95% CI [-3.61, -2.00], P < .01); reduce postoperative pain at 2, 6, 12, 24, and 48 hours both at rest and movement; meanwhile shorten time to hospital length of stay: (SMD = -1.01, 95% CI [-1.72, 0.30], P = .006), decrease postoperative nausea and vomiting (RR = 0.35, 95% CI [0.27, 0.46], P < .00001), and improve patient satisfaction (SMD = -2.03, 95% CI [-0.96, 3.11], P = .0002). But ultrasound-guided ESPB doesn't shorten the time to ambulation after surgery (SMD = -0.56, 95% CI [-1.21, 0.08], P = .09). Additionally, ESPB is not superior to other regional blocks (e.g., thoracolumbar interfascial plane/midtransverse process to pleura block).

CONCLUSION

This meta-analysis demonstrates that ultrasound-guided ESPB can provide effective postoperative analgesia in patients undergoing lumbar spine surgery and improve postoperative outcomes, and it deserves to be recommended as an analgesic adjunct in patients undergoing lumbar spine surgeries.

Comparison of postoperative IL-6 and IL-10 levels following Erector Spinae Plane Block (ESPB) and classical Thoracolumbar Interfascial Plane (TLIP) block in a posterior lumbar decompression and stabilization procedure: a randomized controlled trial

BACKGROUND AND OBJECTIVES

The erector spinae plane block (ESPB) and classical thoracolumbar interfascial plane (TLIP) block can reduce postoperative pain in lumbar surgery. In this study, we compared the efficacy of ESPB and classical TLIP block in providing perioperative analgesia in patients undergoing lumbar posterior decompression and stabilization by comparing postoperative pain, opioid consumption, and IL-6 and IL-10 serum concentrations between ESPB and classical TLIP block.

METHOD

This was a prospective, double-blinded, randomized controlled trial in tertiary referral hospitals. Forty patients were randomized into two equal groups, each receiving either ESPB or classical TLIP block. The primary outcome was the difference in IL-6 and IL-10 serum concentrations at baseline and 6 h after lumbar posterior decompression and stabilization. The secondary outcome was total opioid consumption and pain score 24 h post-operatively.

RESULT

There were no significant differences between the ESPB and classical TLIP block groups in pain score, IL-6 and IL-10 concentration change, and total opioid consumption post-operatively. There was a significant difference in the time until the first dose of morphine was needed between the ESPB and classical TLIP block groups (300 min vs. 547.5 min; p = 0.002).

CONCLUSION

ESPB and classical TLIP block performance during lumbar surgery have comparable pain scores, IL-6 and IL-10 concentration differences pre- and post-operation, and total opioid consumption post-operatively. However, classical TLIP block provides a prolonged duration of analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04951024.

Analgesic efficacy of two different volumes of local anaesthetics in ultrasound-guided modified approach to the thoracolumbar interfascial plane block in patients undergoing lumbar spine surgeries: a randomized controlled trial

INTRODUCTION

There is a lack of clarity regarding the ideal local anaesthetic volume for modified thoracolumbar interfascial plane (mTLIP) block. This study was designed to investigate the analgesic efficacy of two different volumes of bupivacaine 0.25% (20 mL, and 10 mL) for ultrasound-guided mTLIP block in patients undergoing lumbar spine surgeries.

MATERIAL AND METHODS

A total of 80 patients received single shot of bilateral mTLIP block at the mid- level of the operative intervention and were randomly allocated into one of the two groups to receive either 10 or 20 mL 0.25% bupivacaine on each side. Total morphine consumption in the first 24 hours postoperative was set as the primary outcome. Time to first rescue analgesia and Numeric Rating Scale (NRS) were set as secondary outcomes.

RESULTS

There was no significant difference in the primary outcome: 6.20 ± 2.18 mg (10 mL Group) vs. 5 ± 0.00 mg (20 mL Group), P = 0.056. The time of first request of rescue morphine was significantly shorter in 10 mL Group (7.80 ± 3.98 hours) as compared to the 20 mL Group (13.23 ± 3.00 hours), P < 0.001. NRS at rest and movement in all time measurements was significantly higher in 10 mL Group.

CONCLUSIONS

Bilateral mTLIP block using 40 mL of 0.25% bupivacaine (20 mL on each side) increased the postoperative total analgesic duration for lumbar spine surgeries, and was associated with a lower postoperative pain scores compared to 20 mL of 0.25% bupivacaine (10 mL on each side).

CLINICAL TRIAL REGISTRATION ID

The study was registered at clinicaltrials.gov (ID: NCT05276908) before patient's enrolment.

Investigation of the analgesic efficacy of ultrasound-guided thoracolumbar interfacial plane block in vertebral surgery: A prospective randomized clinical study

OBJECTIVES

To investigate the effect of thoracolumbar interfacial plane block (TLIP) on analgesic consumption and pain score in vertebral surgery.

METHODS

All patients (64 patients undergoing vertebral surgery) were randomly allocated as Group T (patients with block, n=32) and Group C (patients without block, n=32). After surgery, patient-controlled analgesia using tramadol was administered to all patients. Pain intensity was evaluated with visual analogue scale (VAS; recovery room at 1, 2, 6, 12, and 24 hours postoperative), and as rescue analgesia, morphine was administered to patients with VAS scores of >4. In this study, total tramadol consumption, the number of patients requiring morphine, VAS score, and Quality of Recovery-40 of all patients questionnaire was evaluated.

RESULTS

There were important differences between the 2 groups according to mean postoperative tramadol consumption (Group T and Group C; 180 mg [100-260] vs. 210 mg [100-300]; p=0.001) and the number of patients requiring additional analgesia (n=4; 12.5% vs. n=24; 75%, p=0.000). There were important differences between the 2 groups according to the postoperative VAS pain score (p=0.000).

CONCLUSION

Ultrasound-TLIP reduces analgesic consumption and pain severity after vertebral surgery. Therefore, it is an important regional analgesia technique. CLINICALTRIALSGOV GRANT NO: NCT04548076.

Regional and neuraxial anaesthesia techniques for spinal surgery: a scoping review

BACKGROUND

Whilst general anaesthesia is commonly used to undertake spine surgery, the use of neuraxial and peripheral regional anaesthesia techniques for intraoperative and postoperative analgesia is an evolving practice. Variations in practice have meant that it is difficult to know which modalities achieve optimal outcomes for patients undergoing spinal surgery. Our objective was to identify available evidence on the use of regional and neuraxial anaesthesia techniques for adult patients undergoing spinal surgery.

METHODS

This study was conducted using a framework for scoping reviews. This included a search of six databases searching for articles published since January 1980. We included studies that involved adult patients undergoing spinal surgery with regional or neuraxial techniques used as the primary anaesthesia method or as part of an analgesic strategy.

RESULTS

Seventy-eight articles were selected for final review. All original papers were included, including case reports, case series, clinical trials, or conference publications. We found that general anaesthesia remains the most common anaesthesia technique for this patient cohort. However, regional anaesthesia, especially non-neuraxial techniques such as fascial plane blocks, is an emerging practice and may have a role in terms of improving postoperative pain relief, quality of recovery, and patient satisfaction. In comparison with neuraxial techniques, the popularity of fascial plane blocks for spinal surgery has significantly increased since 2017.

CONCLUSIONS

Regional and neuraxial anaesthesia techniques have been used both to provide analgesia and anaesthesia for patients undergoing spinal surgery. Outcome metrics for the success of these techniques vary widely and more frequently use physiological outcome metrics more than patient-centred ones.

Comparing the Effect of Classical and Modified Thoracolumbar Interfascial Plane Block on Postoperative Pain and IL-6 Level in Posterior Lumbar Decompression and Stabilization Surgery

Background: Ultrasound (US)-guided classical and modified thoracolumbar interfascial plane (TLIP) blocks are often used to provide adequate analgesia after lumbar spinal surgery. Postoperative pro-inflammatory interleukin 6 (IL-6) blood concentrations after lumbar spine surgery are related to postoperative pain and inflammation. Objectives: The purpose of this prospective randomized parallel controlled study was to assess postoperative pain and serum levels of pro-inflammatory IL-6 after posterior lumbar decompression and stabilization surgery with a classical and modified technique of TLIP block. Methods: This prospective randomized, single-blinded controlled pilot study was conducted on eight patients who will undergo posterior lumbar decompression and stabilization surgery. After obtaining the ethical approval and an informed consent, all subjects were randomly allocated into the classic TLIP group and the modified TLIP group. Following general anesthesia induction, 20 mL bupivacaine 0.25% was injected on each side in interfascialis plane between m. longissimus and m. iliocostalis in modified TLIP group and between m. multifidus and m. longissimus in classical TLIP group. Intraoperative hemodynamic (blood pressure and heart rate) and noxious stimulation response level (qNOX), postoperative IL-6 level, 24-hour morphine consumption, and numerical rating score were recorded and analyzed. Results: The median of IL-6 level was found to be lower in the modified TLIP group 12 hours postoperatively compared to classic TLIP (29.91 (8.56 – 87.61) vs. 46.87 (2.87 – 92.35)). The mean Numerical Rating Scale (NRS) in the modified TLIP block was comparable with the classic TLIP group, although it was lower than the classic TLIP group (2.75 ± 1.5 vs. 3.75 ± 1.7 at 6 hours and 3.5 ± 1.3 vs. 4 ± 1.6 12 hours postoperatively). However, there was no difference in intraoperative hemodynamic, Qnox value, and total postoperative morphine consumption between the two groups. Conclusions: Our study showed that modified TLIP block resulted in lower IL-6 level and NRS 12 hours postoperatively compared to classical TLIP block. However, there were no differences in total postoperative morphine consumption between the two groups.

Effect of Ultrasound-Guided Thoracolumbar Interfascial Plane Block on the Analgesic Requirements in Patients Undergoing Lumbar Spine Surgery Under General Anesthesia: A Randomized Controlled Trial

BACKGROUND

Thoracolumbar interfascial plane (TLIP) block was recently described as a regional anesthetic technique to achieve analgesia for lumbar spine surgery by blocking the dorsal rami of spinal nerves. The study aims to test the hypothesis that TLIP block can offer pain control and reduce the perioperative analgesic requirement in patients undergoing spinal surgery.

METHODS

There were 60 patients scheduled for lumbar spine surgery who were randomly assigned into two equal groups, TLIP and control groups. Patients in the TLIP group received general anesthesia and TLIP block while patients in the control group received general anesthesia alone. The primary outcome was the analgesic consumption in the first postoperative 24 hours, while intraoperative additional analgesic needs, time to the first request of postoperative analgesia, and pain scores were the secondary outcomes.

RESULTS

At 24 hours postoperatively, morphine consumption was lower in the TLIP group (5.13±1.55) versus the control group (14.33±2.58) mg. The intraoperative fentanyl consumption was lower in the TLIP group (15±35.11 mcgs) versus the control group (105±62.08 mcgs). Postoperative first request for analgesia was delayed in the TLIP group (7.30±2.69 h) compared to the control group (0.92±1.23 h). Postoperative Pain scores at rest were 2.53 ± 0.97 and 3.43 ± 0.50 at 24 hours in the TLIP group and the control group, respectively. Postoperative Pain scores at passive flexion of spine were 2.73 ±0.87 and 3.93 ±0.78 at 24 hours in the TLIP group and the control group, respectively. Patients in the TLIP group had lower perioperative hemodynamic responses to surgical stimulation in comparison to the control group.

CONCLUSION

Combined TLIP block with general anesthesia in patients undergoing spinal surgery reduced both postoperative and intraoperative analgesic needs, reduced intra-operative hemodynamic response to surgery, and achieved good postoperative pain control.

Pain management after complex spine surgery: A systematic review and procedure-specific postoperative pain management recommendations

BACKGROUND

Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge.

OBJECTIVES

We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery.

DESIGN AND DATA SOURCES

A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.

RESULTS

Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin.

CONCLUSIONS

The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.

Mapping theme trends and recognizing research hot spots in the use of ultrasound in orthopaedics: a bibliometric analysis of global research

BACKGROUND

In the past decade, ultrasound has been increasingly used in the field of orthopaedics. The purpose of this study is to inspire future research in this field by analyzing the publications relating to ultrasound research in orthopaedics.

METHODS

All relevant articles published between 2009 and 2020 were retrieved from Web of Science. Statistical Package for Social Science and GraphPad Prism 8 software were used to generate and analyse diagrams. VOSviewer software and CiteSpace were employed to visualize the research trends based on co-occurring keywords. Finally, we obtained information about relevant clinical randomized controlled trials (http://clinicaltrials.gov.com/).

RESULTS

The United States had the most publications in this field and the most citations and the highest H-index. Furthermore, Skeletal Radiology published the most papers related to the use of ultrasound in orthopaedics, Ozcakar L published the most papers, and a study by Kwon, YM had the highest citation frequency. The keywords "MRI", "complication", "female" and "male" were identified as being indicative of emerging topics.

CONCLUSIONS

While the contribution of United States to publications in this field has been substantial, the future contributions of China cannot be ignored. Moreover, it is hypothesized that diagnostic and epidemiological aspects may become hotspots.

Thoracolumbar interfascial plane block for postoperative analgesia in spine surgery: A systematic review and meta-analysis

INTRODUCTION

Thoracolumbar interfascial plane (TLIP) block has been discussed widely in spine surgery. The aim of our study is to evaluate analgesic efficacy and safety of TLIP block in spine surgery.

METHOD

We performed a quantitative systematic review. Randomized controlled trials that compared TLIP block to non-block care or wound infiltration for patients undergoing spine surgery and took the pain or morphine consumption as a primary or secondary outcome were included. The primary outcome was cumulative opioid consumption during 0-24-hour. Secondary outcomes included postoperative pain intensity, rescue analgesia requirement, and adverse events.

RESULT

9 randomized controlled trials with 539 patients were included for analysis. Compared with non-block care, TLIP block was effective to decrease the opioid consumption (WMD -16.00; 95%CI -19.19, -12.81; p<0.001; I2 = 71.6%) for the first 24 hours after the surgery. TLIP block significantly reduced postoperative pain intensity at rest or movement at various time points compared with non-block care, and reduced rescue analgesia requirement ((RR 0.47; 95%CI 0.30, 0.74; p = 0.001; I2 = 0.0%) and postoperative nausea and vomiting (RR 0.58; 95%CI 0.39, 0.86; p = 0.006; I2 = 25.1%). Besides, TLIP block is superior to wound infiltration in terms of opioid consumption (WMD -17.23, 95%CI -21.62, -12.86; p<0.001; I2 = 63.8%), and the postoperative pain intensity at rest was comparable between TLIP block and wound infiltration.

CONCLUSION

TLIP block improved analgesic efficacy in spine surgery compared with non-block care. Furthermore, current literature supported the TLIP block was superior to wound infiltration in terms of opioid consumption.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Intrathecal morphine injections in lumbar fusion surgery: Case-control study

INTRODUCTION

Intrathecal morphine (ITM) is a well-known and extensively used method for analgesia in various surgical fields; however, its relevance in spine surgery is debated given the conflicting results in the literature. The aim of this study was to investigate the opioid-sparing effect of ITM after lumbar fusion.

METHODS

This retrospective study involves two consecutive series of patients undergoing posterior lumbar fusion. The first cohort (control group, n=30) received the standard analgesia protocol while the second cohort (ITM Group, n=30) had the standard protocol supplemented with ITM (100μg of morphine hydrochloride). Morphine consumption, pain assessment (VAS), specific complications and postoperative recovery data were collected.

RESULTS

Consumption of morphine at 24hours and 48hours postoperatively was lower in the ITM group than the control group (p<0.001 and p=0.004). The pattern was similar for pain on VAS at H6, H24 and H36 (p=0.001; p=0.003 and p=0.01). The patients in the ITM group were able to get out of bed faster than the controls (1.13 days vs 1.83 days, p=0.002) and the discharge was earlier in the ITM group (5.1 days vs. 6.2 days, p=0.002). There was no difference in morphine-specific complications between the two groups.

CONCLUSION

Adding ITM to the analgesia protocol for lumbar fusion provides better management of postoperative pain, without increasing early complications, and it accelerates the recovery process after surgery.

LEVEL OF EVIDENCE

IV.