P069: SUCCESSFUL COMBINATION OF THORACOLUMBAR INTERFACIAL PLANE BLOCK AND ERECTOR SPINAL PAIN BLOCK FOR PERI-OPERATIVE PAIN CONTROL AFTER LUMBAR LAMINECTOMY
Nazir Noor, MD1; Ruben Schwartz, DO1; Alexander Volsky, MD1; Ivan Urits, MD2; Omar Viswanath, MD3; Richard Urman, MD4; Alan Kaye, MD5; Jonathan Eskander, MD6; 1Mount Sinai Medical Center; 2Beth Israel Deaconess Medical Center; 3Valley Anesthesiology and Pain Consultants; 4Brigham and Women's Hospital; 5Louisiana State University Health Sciences Center; 6Portsmouth Anesthesia Associates
Introduction/Background: The thoracolumbar interfascial plane (TLIP) and erector spinae plane block (ESPB) were first described in 2015 and 2016, respectively. Though still fairly new, both the TLIP and ESPB have proven to provide effective analgesia in the peri-operative period. The TLIP consists of injecting local anesthetic (LA) within the fascial plan of the multifidus and longissimus muscles (2). The block is to reach and disrupt the ventral rami of the thoracolumbar nerves, resulting in effective peri-operative analgesia without opioid consumption (3). The ESPB also provides successful peri-operative analgesia for many painful surgeries (4,5,6). Given the individual successes of these two blocks, we decided to test the effectiveness of combining them for a patient undergoing L5/S1 laminectomy.
We present a case concerning a 39-year-old 70 kg female with a history of chronic right-sided leg pain radiating down to the right foot. The pain was a 6/10. Preoperative Magnetic Resonance Imaging (MRI) demonstrated right paracentral herniation compressing the S1 nerve root with evidence of pseudoarthrosis of L4 and L5 spinous processes.
Surgery was scheduled after a series of noninvasive treatments. She underwent general anesthesia, receiving 100 mcg fentanyl at induction as the only opioid during the peri-operative period. After induction, she was placed in the prone position. The ultrasound-guided TLIP was then performed using a high frequency linear probe placed transversely at L5 at the midline. The spinous process and interspinous musculature were identified. The probe was then positioned laterally to bring the multifidus and longissimus musculature into view (7). Once these muscles were identified, 30 mL 0.2% ropivacaine with 10 mg of preservative-free dexamethasone solution was delivered bilaterally within this interfascial plane.
After the TLIP, the ultrasound-guided ESPB was provided at the L5 level. The L5 transverse process was identified before insertion of the needle cranial to caudal. The needle was advanced through the erector spine muscle until it was superficial to the transverse process. Hydrodissection of the interfascial plane was used for confirmation. The 30 mL of the same ropivacaine solution used for the TLIP was injected in this plane at L5, superficial to the bilateral transverse processes.
After the surgery, the patient was extubated in the operating room and transported to the post-anesthesia care unit (PACU) in stable condition. During her three-day hospital course, she required neither opioid nor non-opioid analgesics. She rated her pain 0/10 on the third day and was discharged home. It was not until her fourth day home when she took 2000 mg acetaminophen for some discomfort.
Methods: N/A (case report)
Results: N/A (case report)
Discussion/Conclusion: Opioids seem to be the reflex treatment in the acute post-operative period. Recent protocols, such as the Enhanced Recovery After Surgery (ERAS) strongly advocate for the tremendous benefits of utilizing an opioid-sparing approach. ERAS has demonstrated shorter hospital courses, reduced post-operative complications, and lower costs with a reduction in opioid use for peri-operative pain. Though further studies are necessary for stronger evidence, we can confidently advocate for the combination of the TLIP and ESPB as a reasonable ERAS option.