Lumbar spine decompression surgery is commonly performed to relieve symptoms of nerve compression, including pain, numbness, and motor deficits, caused by conditions such as herniated discs and spinal stenosis. Postoperative pain management remains a critical aspect of care, as inadequate pain control can hinder recovery, prolong hospitalization, and increase the risk of chronic pain (1,2). Conventional approaches often rely on systemic opioids, which, although effective, are associated with significant adverse effects such as nausea, sedation, and the potential for dependency, particularly in individuals with a history of substance abuse (3,4). 

The erector spinae plane (ESP) block, first described by Forero et al., has gained attention as a regional anesthesia technique for managing postoperative pain in various surgical procedures, including thoracic, abdominal, and spinal surgeries (5). By targeting the erector spinae plane at the transverse process level, the ESP block facilitates the spread of local anesthetics, providing effective analgesia with minimal complications (6,7).

Despite the growing evidence supporting the use of the ESP block, limited data exist on its effectiveness in patients with a history of addiction undergoing lumbar spine decompression surgery. Substance abuse can alter pain perception, opioid requirements, and recovery outcomes, posing unique challenges in this patient population (8,9). Therefore, it is essential to evaluate the impact of the ESP block on the quality of recovery in addicts compared to non-addicts undergoing lumbar spine surgery.

This study aims to assess the efficacy of the ESP block in improving postoperative outcomes, including pain scores, opioid consumption, and quality of recovery, in addicts and non-addicts undergoing lumbar spine decompression surgery. The findings could inform perioperative pain management strategies and help optimize recovery in these distinct patient populations.

Study Design

This prospective, comparative study was conducted at a tertiary care hospital over a period of 12 months. Ethical approval was obtained from the institutional ethics committee, and informed consent was taken from all participants.

Study Population

A total of 120 patients scheduled for elective lumbar spine decompression surgery were enrolled and divided into two groups: addicts (n=60) and non-addicts (n=60). Addicts were defined as patients with a history of substance abuse, confirmed through medical records and patient interviews. Inclusion criteria included patients aged 18–65 years with ASA physical status I–III. Exclusion criteria were coagulation disorders, infection at the injection site, allergy to local anesthetics, or refusal to participate.

Intervention

Patients in each group were further randomized into two subgroups (ESP block and no block) using a computer-generated randomization table. The ESP block was administered preoperatively under ultrasound guidance at the L3 transverse process level using a high-frequency linear probe. A total of 20 mL of 0.375% bupivacaine was injected into the erector spinae plane.

Anesthesia and Surgery

All patients underwent standard general anesthesia with induction using propofol (2 mg/kg) and maintenance with sevoflurane (1–2%) in oxygen and air. Fentanyl (1–2 µg/kg) was used for intraoperative analgesia. The surgical procedure was performed by the same team of surgeons to ensure consistency.

Outcomes Measured

The primary outcome was the quality of recovery, assessed using the Quality of Recovery-15 (QoR-15) questionnaire at 24 and 48 hours postoperatively. Secondary outcomes included:

1. Pain scores: Measured using the Visual Analog Scale (VAS) at rest and on movement at 6, 12, 24, and 48 hours postoperatively.
2. Opioid consumption: Total opioid use (measured in morphine milligram equivalents) was recorded for the first 48 hours postoperatively.
3. Adverse events: Incidence of nausea, vomiting, and other complications were documented.

Statistical Analysis

Data were analyzed using SPSS version 26. Continuous variables were expressed as mean ± standard deviation and compared using the independent t-test or Mann-Whitney U test as appropriate. Categorical variables were expressed as frequencies and percentages and analyzed using the chi-square test. A p-value <0.05 was considered statistically significant.

Quality of Recovery (QoR-15) Scores

The QoR-15 scores were significantly higher in the ESP block groups compared to the no-block groups across both addicts and non-addicts. At 24 hours postoperatively, the QoR-15 score was 110 for addicts with ESP block and 95 for those without the block. Similarly, non-addicts scored 120 with the ESP block compared to 105 without it. This trend persisted at 48 hours, where addicts scored 115 with ESP block and 100 without, while non-addicts scored 125 with the block and 110 without (Table 1).

Pain Scores (VAS)

Pain scores measured via the VAS were consistently lower in the ESP block groups. At 6 hours postoperatively, addicts who received the ESP block had a VAS score of 4.5, compared to 6.0 in the no-block group. Among non-addicts, the scores were 3.5 for the ESP block group and 5.0 for the no-block group. This pattern was observed at all time points, with the most significant difference at 24 hours, where VAS scores for addicts were 3.0 (ESP block) versus 5.0 (no block), and for non-addicts, 2.5 (ESP block) versus 4.0 (no block) (Table 2).

Opioid Consumption

Patients in the ESP block groups required substantially less opioid analgesia than those in the no-block groups. Addicts in the ESP block group consumed an average of 25 mg of opioids compared to 40 mg in the no-block group. Non-addicts with ESP block used 20 mg, while those without the block required 35 mg (Table 3).

Tables

Table 1: Quality of Recovery (QoR-15) Scores

Table 2: VAS Scores Over Time

Table 3: Opioid Consumption Comparison

This study demonstrates that the erector spinae plane (ESP) block significantly improves postoperative recovery outcomes in patients undergoing lumbar spine decompression surgery. The results indicate that both addicts and non-addicts benefit from the ESP block, as evidenced by higher Quality of Recovery (QoR-15) scores, lower pain scores, and reduced opioid consumption. However, non-addicts showed slightly better overall outcomes, consistent with existing literature on altered pain perception and opioid requirements in individuals with a history of substance abuse (1,2).

The QoR-15 scores at 24 and 48 hours postoperatively were notably higher in the ESP block groups compared to those who did not receive the block. This finding aligns with previous studies that have demonstrated the efficacy of ESP block in enhancing recovery by providing prolonged and effective analgesia with minimal side effects (3,4). The improvement in QoR-15 scores underscores the role of regional anesthesia techniques in promoting a better postoperative experience and overall patient satisfaction.

Pain control, measured through Visual Analog Scale (VAS) scores, was significantly better in the ESP block groups. For example, at 24 hours postoperatively, the VAS score for addicts who received the ESP block was 3.0, compared to 5.0 for those who did not receive the block. Similarly, in non-addicts, the corresponding scores were 2.5 and 4.0, respectively. These results are consistent with the findings of Tulgar et al., who reported that the ESP block effectively reduces both static and dynamic pain after spinal surgery (5).

Opioid consumption, another critical secondary outcome, was substantially lower in patients receiving the ESP block. Addicts in the ESP block group required an average of 25 mg of opioids, whereas those without the block required 40 mg. Non-addicts exhibited an even greater reduction, with 20 mg consumed in the ESP block group compared to 35 mg in the no-block group. This reduction is particularly significant given the risks associated with opioid use, including dependency and respiratory depression (6). The findings suggest that the ESP block could play a pivotal role in multimodal pain management strategies aimed at minimizing opioid use, especially in high-risk populations like addicts.

Although the study highlights the benefits of the ESP block, some limitations should be noted. First, the relatively small sample size limits the generalizability of the results. Second, the subjective nature of pain assessment and potential variability in individual responses to analgesics might influence the findings. Future studies should explore long-term outcomes and incorporate larger, more diverse patient populations to validate these results

In conclusion, the ESP block significantly enhances the quality of recovery, reduces pain scores, and minimizes opioid requirements in patients undergoing lumbar spine decompression surgery. This technique is particularly valuable in optimizing perioperative pain management and improving recovery outcomes, even in populations with unique challenges, such as individuals with a history of substance abuse.

1. Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: Risk factors and protective factors. Expert Rev Neurother. 2009;9(5):723–44.
2. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet. 2006;367(9522):1618–25.
3. Zeng C, Dubreuil M, LaRochelle MR, et al. Association of tramadol with all-cause mortality among patients with osteoarthritis. JAMA. 2019;321(10):969–82.
4. Volkow ND, McLellan AT. The neurobiology of opioid addiction and the potential for prevention strategies. JAMA. 2016;315(18):1853–4.
5. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–7.
6. El-Boghdadly K, Wolmarans M, Stengel AD, et al. The efficacy of erector spinae plane block for improving peri-operative outcomes: A systematic review and meta-analysis. Anaesthesia. 2021;76(9):1196–206.
7. Tulgar S, Senturk O, Thomas DT, et al. Efficacy of erector spinae plane block in the management of acute pain: A comprehensive review. Scand J Pain. 2020;20(4):677–91.
8. Alford DP, Compton P, Samet JH. Chronic pain and addiction: Does opioid therapy have a role? Am J Med. 2006;119(3):S10–6.
9. Barry DT, Savant JD, Beitel M, et al. Pain and associated substance use among opioid dependent individuals. Drug Alcohol Depend. 2013;132(1-2):68–74.