The Clinical Application Study Of Ultrasound-Guided Erector Spinae Plane Block In Percutaneous Transforaminal Endoscopic Discectomy

PurposeLumbar disc herniation(LDH)is the most common spine disease in modern society,and the main cause of lumbar pain and sciatica.Percutaneous transforaminal endoscopic discectomy(PTED)has become the main method for treating LDH because of its small trauma,quick recovery,good effect and low cost.PTED has small mirror operation visual field,to avoid nerve damage,performer need close monitoring of nerve function,requirement of patients can make response to the doctor’s question and description^therefore the clinical use of local anesthesia this kind of surgery,However,the pain caused by intraoperative foraminal dilation and nerve root release is poorly controlled by local anesthesia.Patients are prone to increased blood pressure,increased heart rate,nausea and vomiting,and even have to give up treatment because of the pain.Ultrasound-guided erector spinae plane block(ESPB)is a new technique for trunk nerve block.Combined with the advantages of ultrasound visualization technology,it can accurately inject local anesthetic into the deep surface of the erector spinal muscle,effectively block the plane of the erector spinal muscle and the peripheral nerves,and obtain good analgesic effect.Therefore,we analyze the safety and effectiveness of ESPB onPTED,and further explore the optimal block concentration of erector spinae plane with ropivacaine on PTED.MethodsOne hundred and twenty patients who underwent elective receive treatment for lumbar disc herniation in our hospital,age ranged 40-75,BMI 18～30 kg/m2,American Society of Anesthesiologist physical status Ⅰ-Ⅱ,The patients were randomly divided into four groups by computer random number table method:group C(local infiltration anesthesia group);D1 group(0.25%ropivacaine ultrasound-guided ESPB);D2 group(0.375%ropivacaine ultrasound-guided ESPB);D3 group:(0.50%ropivacaine ultrasound-guided ESPB);30 cases in each.Group C was treated with 0.15%ropivacaine+0.4%lidocaine+0.9%normal saline with a total amount of 20 ml.At the beginning of the operation,10 ml of the lumbar dorsal fascia layer and 10 ml of the superior articular process were infiltrated by the operator layer by layer.Groups of D1-3 were treated with 20 ml ropivacaine at different concentrations(0.25%,0.375%,0.5%)before preoperative using ultrasound-guided ESPB under L4/5 transverse parallel.The sensory plane was measured by the method of cooling sensation every 3 minutes.When the skin cold sensation disappeared,it was defined as effective blocking,otherwise,it was defined as ineffective blocking.The modified Bromage score was used to evaluate whether the patients had lower limb motion block.Intraoperative oxygen intake was routine for 3 L/min,and the patient returned to the ward after surgery.During PTED the whole treatment process,the penetration needle should not enter the intervertebral foramen and the spinal canal for anesthesia,and the annulus fibrosus should not be anesthetized.All operations were performed by the same surgeon.The onset and duration time of nerve block,sensory block plane,and the success rate of adjacent spinal nerve block areas in group D1-3 were recorded;Mean arterial pressure(MAP),heart rate(HR),Visual analogue scale(VAS)in resting state and Ramsay sedation score in the four groups were recorded before anesthesia operation(T0),surgical puncture(T1),lumber foraminoplasty(T2),annulus fibrosus operation(T3),immediately after surgery(T4),2hafter operation(T5)and 4hafter operation(T6).When the intraoperative VAS≥4,5 μg sufentanil was given intravenously,and The Times and dosage of analgesic drugs were counted.Finally,the anesthesia satisfaction evaluation and perioperative adverse reactions(such as rapid heart rate,nausea and vomiting,respiratory depression,dizziness,lower limbs distal paralysis,transient lower limb muscle weakness,etc.)in the four groups were recorded.Results(1)No significant differences were observed in the age,BMI,duration of surgery or operation segment between the four groups(P>0.05).(2)The onset and duration time of nerve block and the success rate of spinal nerve block area in the three groups Compared with group D1,the onset time of nerve block in groups D2 and D3 was significantly shorter(P<0.05).Compared with group D2,the onset time of nerve block in group D3 was significantly shorter(P<0.05);There were no significant difference in the duration of block and sensory block plane among the three groups(P>0.05).The success rate of ESPB was relatively high in L2-S1 spinal innervation region.Most of the block planes can spread to 2-4 innervation segments.(3)Changes of hemodynamic at each time point in the four groups Compared with group C,level of MAP at T2 and T3 decreased significantly in group Di,D2 and D3(P<0.01),and HR level at T2 and T3 increased significantly in group D1,D2 and D3(P<0.01),compared with group D1,level of MAP at T2 and T3 decreased significantly in group D2 and D3(P<0.05),and HR level at T2 and T3 increased significantly in group D2 and D3(P<0.05).(4)Changes of VAS pain score at each time point in the four groups Compared with T0,the VAS score of group C at T2-4 was significantly increased(P<0.05),and that of group D1 at T2-3 was significantly increased(P<0.05).Compared with group C,the VAS scores at T2-5 decreased significantly in groups D1,D2 and D3(P<0.05).Compared with group D1,the VAS scores at T2-5 decreased significantly in groups D2 and D3(P<0.05).(5)Changes of Ramsay sedation score at each time point in the four groups Compared with group C,Ramsay scores at T2 increased significantly in groups D1,D2 and D3(P<0.05);Ramsay scores at T3 increased significantly in groups D2 and D3(P<0.05);Compared with group D1,Ramsay scores at T2 and T3 in groups D2 and D3(P<0.05).(6)Comparison of intraoperative times and amount of sufentanil in the four groups Compared with group C,the number and amount of perioperative sufentanil supplementation decreased significantly in groups D1,D2 and D3(P<0.05);compared with group D1,the number and amount of perioperative sufentanil supplementation decreased significantly in groups D2 and D3(P<0.05).(7)Comparison of the incidence of adverse reactions and satisfaction with anesthesia in four groups Compared with group C,the incidence of adverse reactions in groups D1,D2 and D3 were decreased(P<0.05),Compared with group D1,the incidence of adverse reactions in groups D2 and D3 were decreased(P<0.05),while there was no significant difference between groups D2 and D3(P>0.05).Compared with group C,anesthesia satisfaction in groups D1,D2 and D3 was significantly increased(P<0.05);compared with group D1,anesthesia satisfaction in groups D2 and D3 was significantly increased(P<0.05),there was no significant difference in anesthesia satisfaction between groups D2 and D3(P>0.05).ConclusionsUltrasound-guided ESPB,can improve effective analgesic effect in PTED,and the satisfaction is better than that of local anesthesia alone.In different concentration ropivacaine of ultrasound-guided ESPB in PTED,both 0.375%and 0.5%concentration ropivacaine are can obviously improve pain,improve perioperative anesthesia satisfaction and comfort,reduce perioperative opioids usage amount.but considering for high concentration of local anesthetics increases the risk of poisoning in clinical practice,0.375%concentration of ropivacaine is safer and more suitable for clinical use.