Adjuvant Pain Management Using Regional Anesthesia (ESPB) in Posterior Spinal Fusion for Adolescent Scoliosis Patients: Comparative Pilot Data and Initial Results of a Randomized Study

OBJECTIVEThe authors sought to investigate the efficiency of percutaneous endoscopic discectomy (PED) in adolescent patients with lumbar disc herniation (LDH), compare PED outcomes in adolescent patients with those in young adult LDH patients as controls, and discuss relevant technical notes.METHODSThis was a retrospective study involving 19 adolescent LDH patients (age > 13 and < 18 years, 20 discectomies) and 38 young adults (age < 40 years, 38 discectomies) who also had LDH and were matched to the adolescent group for sex and body mass index. The combined cohort included 51 male patients (89.5%) and 6 female patients (10.5%), with an average age of 26.7 years (range 14-39 years). The operated levels included L3-4 in 1 patient (1.7%), L4-5 in 22 patients (37.9%), and L5-S1 in 35 patients (60.4%). Two adolescents (10.5%) exhibited apophyseal ring separation and one (5.3%) had had previous PED. All patients underwent PED under local anesthesia. Outcomes were evaluated through a visual analog scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the modified MacNab grading system.RESULTSThe mean duration of follow-up was 41.7 months (range 36-65 months). The outcomes in adolescents were satisfactory and comparable with previously reported outcomes of microsurgical discectomy (MD) and conventional open discectomy (COD). The adolescent patients had a faster and better recovery course than the adult patients (p < 0.01). One adolescent patient (5.3%) exhibited recurrence and 2 adults (5.3%) experienced transient dysesthesia; the complication rates were comparable in the 2 age groups (p = 0.47). Prolonged duration of symptoms (p < 0.01) and disc degeneration (p = 0.01) were correlated with lower postoperative JOA values; patients with extrusions had higher postoperative JOA values than those with protrusions (p = 0.01).CONCLUSIONSPED may yield favorable results in the treatment of adolescent LDH in terms of short- to medium-term follow-up; restricted discectomy and a conservative rehabilitation program might be advisable. Further long-term studies are warranted to address this rare disease entity.

Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia (SMD -2.03; 95% CI -2.88--1.17). However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption (SMD -0.76; 95% CI -1.25--0.26) and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group (SMD 0.83; 95% CI 0.47-1.20). The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain.

Anaesthesia for major orthopaedic surgery in the elderly

To compare outcomes between posterior spinal fusion of juvenile idiopathic scoliosis and adolescent idiopathic scoliosis patients with a minimum of 2-year follow-up. The juvenile idiopathic scoliosis patients were fused to the stable vertebra and adolescent idiopathic scoliosis to the touched vertebra. We hypothesized that extending the spinal fusion to the stable vertebra in juvenile patients would provide similar outcomes compared with fusion to the touched vertebra in adolescents. A prospective comparative study of 21 consecutive children with juvenile (Risser 0) and 84 adolescent (Risser ⩾2) idiopathic scoliosis (1:4 ratio) undergoing bilateral segmental pedicle screw instrumentation and direct vertebral derotation with a minimum of 2-year follow-up. Juvenile patients had a significantly larger main curve (58° vs 53°, p = 0.003), more fused levels (p = 0.012) and posterior column osteotomies (p = 0.014) than adolescent patients. Distal adding-on (>10°) was observed in one (4.7%) juvenile and three (3.6%) adolescent patients (p = 0.80), without the need for revisions. Scoliosis Research Society 24 total score averaged 101 in juvenile and 97 in adolescent group at 2-year follow-up (p = 0.047). Posterior spinal fusion with bilateral segmental pedicle screw instrumentation to the stable vertebra provides similar clinical and radiographic outcomes in juvenile patients as compared with adolescents with fusion to the touched vertebra in idiopathic scoliosis. Health-related quality of life as measured using the Scoliosis Research Society 24 questionnaire at the end of follow-up was better in the juvenile as compared with the adolescent group.

Introduction. Progressive systemic atherosclerosis affects not only the peripheral extremities but also the coronary, cerebral, and renal vessels. This requires the anesthesiologist to understand the pathophysiology of the disease, comorbidities, perioperative complications, and surgical methods of lower limb revascularization. Aim. To study the effectiveness of different anesthesia regimens and pain management strategies in surgical revascularization of the lower extremities. Materials and methods. Bibliosemantic, comparative and systematic analysis method. Results and discussion. Appropriate methods of anesthesia in surgical revascularization of the lower extremities include local anesthesia with sedation, regional, and general anesthesia. Multilevel multivariate analysis showed that neuraxial anesthesia was associated with a lower probability of 30-day mortality, the number of complications and rehospitalizations, and cost savings. Individual studies have shown specific benefits of regional anesthesia: these include attenuation of the neuroendocrine response to surgery, reduction of blood loss, improvement in pulmonary function, reduction of myocardial ischemia, increased lower limb blood flow, and reduction in the incidence of graft thrombosis and the thrombotic response to surgery. Lower limb peripheral nerve blocks provide anesthesia with minimal hemodynamic effects, without reducing regional lower limb blood flow. They may serve as an alternative to neuraxial anesthesia in patients at high anesthetic risk. Regional anesthesia has gained attention in recent years, but there is still no clear evidence favoring regional (spinal, epidural, or peripheral nerve block) or general anesthesia over the other. Regardless of whether a regional or general anesthetic approach is chosen, a multimodal analgesic strategy is used, including nonopioid analgesics and regional anesthesia, tailored to the expected duration of pain and the postoperative course. Conclusions. Effective regional anesthesia during lower extremity angioplasty can be achieved with either spinal or epidural anesthesia, combined spinal-epidural anesthesia, or nerve trunk block in patients with chronic lower extremity ischemia.

Adolescent idiopathic scoliosis is a multifactorial disorder including neurological factors. A dysfunction of the sensorimotor networks processing vestibular information could be related to spine deformation. This study investigates whether feed-forward vestibulomotor control or sensory reweighting mechanisms are impaired in adolescent scoliosis patients. Vestibular evoked postural responses were obtained using galvanic vestibular stimulation while participants stood with their eyes closed and head facing forward. Lateral forces under each foot and lateral displacement of the upper body of adolescents with mild (n = 20) or severe (n = 16) spine deformation were compared to those of healthy control adolescents (n = 16). Adolescent idiopathic scoliosis patients demonstrated greater lateral displacement and net lateral forces than controls both during and immediately after vestibular stimulation. Altered sensory reweighting of vestibular and proprioceptive information changed balance control of AIS patients during and after vestibular stimulation. Therefore, scoliosis onset could be related to abnormal sensory reweighting, leading to altered sensorimotor processes.

Ankylosing spondylosis is always a challenge when patient has severe deformities to choose between general anaesthesia versus regional anaesthesia. Regional anaesthesia is always a choice either at institutionally or at smaller private hospital set ups. Schewley and colleagues compared regional versus general anaesthesia over 10 years and shown that regional anaesthesia is equally good choice.[1] There are many case reports which suggest that regional anaesthesia could be a safer option in severe Ankylosing spondylosis patients.[2] Author has managed to achieve neuraxial access by using fluoroscopy. However, interpretation of images by fluoroscopy could be difficult for anaesthetists without chronic pain management background. Also, availability of fluoroscopy could be variable as it may be busy in other theatres to be available later for surgery. Use of ultrasound to view spaces could be useful in cases with difficult neuraxial access to find the space. Most of the anaesthetists practising regional anaesthesia have expertise in using ultra-sound and also are comfortable to interpret the images. USG could also be helpful in pre-operative setting to identify and plan for central neuraxial blockade. [4] There are many case reports of use of USG guidance for neuraxial anaesthesia in such cases. [3] However, central neuraxial blocks in these patient comes with risks. The placement of epidural anaesthesia is technically difficult and is associated with an increased risk of an epidural haematoma. Wulf reported five out of 51 patients with spinal haematoma occurred in patients with AS in a comprehensive review of spinal haematoma associated with epidural anaesthesia over a 30?year period. These were related to difficult or traumatic insertion. In this his review article, he also mentions Ankylosing spondylosis as one of the risk factor for spinal or epidural haemoatoma. [5] Li et al also present a case report where patient developed epidural haematoma after epidura

Regional and Local Anesthesia in Pediatric Orthopaedic Surgery

Postoperative pain management typically relies on numerical (NRS) or analogue rating scales. However, exclusive focus on nociception may overlook broader aspects of patient experience, especially under regional anaesthesia (RA). This post hoc analysis of the COMFORT trial (NCT05234216) examined whether replacing the NRS with a comfort-focused scale affects patient-reported experience, opioid use, and related outcomes. We analysed data from a cluster-randomised trial in 29 French centres. Adults undergoing elective non-cardiac surgery managed in the post-anaesthesia care unit (PACU) were included. The intervention (comfort scale) and comparator (pain NRS) were applied in the PACU. Patient-reported experience was measured with the EVAN-G/LR scales, self-completed on the ward/day-care unit ≥4 h postoperatively. Participants were divided into RA and general anaesthesia subgroups. Of 885 randomised patients, 786 had evaluable EVAN data. After regional anaesthesia (RA; n = 305), comfort‑focused assessment was associated with higher EVAN Pain (median 88 [IQR 75-94] vs. 75 [69-88]; p = 0.034), Waiting (100 [75-100] vs. 75 [50-100]; p = 0.012), and Global Index (81 [72-91] vs. 77 [68-90]; p = 0.044). After general anaesthesia (GA; n = 481), EVAN scores were similar between groups. Nefopam use was lower with the comfort approach in RA (7% vs. 18%; p = 0.005). Antiemetic use was lower with the comfort approach in GA. Replacing the NRS with a comfort-focused approach did not improve global patient experience after surgery. In patients receiving regional anaesthesia, however, using a comfort scale was associated with better patient-reported experience in the EVAN "Pain" dimension, while no benefit was observed after general anaesthesia.

The history of Regional Anesthesia is a beautiful narrative of man’s quest to conquer pain from a disease or surgery. From its ancient beginnings, to the discovery of cocaine as an anesthetic and to the evolution of modern technology, Regional Anesthesia has revolutionized not only how pain is treated but also how surgeries are performed. It has also promoted a culture of safety that translates to better patient care, outcome, and satisfaction. The beginnings of Regional Anesthesia date back to the ancient civilizations. The Greeks and Egyptians pioneered the use of opium, alcohol, and scopolamine to alleviate pain. The Chinese used acupuncture. The Indian culture used both herbal medicine and yoga.1 However, most historians consider the official birth of Regional Anesthesia in 1884 when Carl Koller discovered the local anesthetic properties of cocaine. His tongue became numb after accidentally licking a few grains of cocaine. He then translated this discovery into using a solution of cocaine as an anesthetic for the eye.2 In the following year, the first documented nerve block was performed by two surgeons - William Stewart Halsted and Richard Hall. They blocked the inferior alveolar nerve and the antero-superior dental nerve using cocaine as an anesthetic. This anesthesia technique has made a big impact in the practice of odontology since its introduction in 1885, because it offered dentists a way of performing maxillary procedures without pain.3 As cocaine is highly addictive, toxic, and has many adverse effects, the next century saw the development of local anesthetics that are longer-lasting and have better safety profiles such as lidocaine, tetracaine, bupivacaine, and ropivacaine.4 The 20th century also saw the introduction of the nerve stimulator. It allowed anesthesiologists to locate nerves more accurately, thus improving the efficacy and safety of nerve blocks. However, this technique was still at risk of failure and did not prevent injuries involving direct puncture on blood vessels and nerves.5 In the past 50 years, Regional Anesthesia has since advanced exponentially, especially after the introduction of ultrasoundguided regional anesthesia. La Grange and his colleagues described and documented the first ultrasound-guided nerve block in 1978 wherein they used a Doppler device in performing supraclavicular blocks for upper extremity procedures.6 With the invention of modern ultrasound machines that provide clearer imagery of nerves and the structures surrounding them, the practice of Regional Anesthesia has become safer and more effective. The history of Regional Anesthesia in the Philippines mirrors its global history – from its rudimentary beginnings to the advanced clinical practices that are uniquely intertwined with the challenges of the healthcare system of a developing country. Long before the advent of modern medicine, indigenous Filipino communities had already been using various plant extracts, folk medicine, and traditional methods to relieve pain.7 The Spanish colonial period introduced Western medical practices to the Philippines, but it was only during the American occupation, after World War II, that significant medical advancements in anesthesia trickled into our country. During this time, Filipino anesthesiologists trained abroad, returned home, and became pioneers in providing safer anesthesia techniques including knowledge and skills in Regional Anesthesia. One of them was Dr. Quintin J. Gomez, considered as the Father of Philippine Anesthesia. With his army-type portable to-and-fro Heidbrink anesthesia machine, he introduced and transformed the practice of modern anesthesia in the country, making it safer, more effective, and accessible.8 The next five decades that followed the war were a time of growth for Philippine Anesthesia. Regional Anesthesia then was performed mainly using anatomical landmarks and at times through the help of a nerve stimulator. Dr. Benigno Sulit Jr. and Dr. Wilfredo Alarcon stand as prominent figures among the pillars of Regional Anesthesia during this period, having championed the early advancements and training in the discipline.9 During this period, the Philippine Society of Anesthesiologists (PSA) and the Philippine Board of Anesthesiologists (PBA) were also established. They played a key role in advancing the anesthesia practice by overseeing anesthesia training, research, and policy development.10 The start of the 21st century brought with it new challenges and opportunities for Regional Anesthesia in the Philippines. This period is characterized by a rapid development in the Regional Anesthesia practice. Driven by the global trend towards safer and more effective pain management techniques that allowed for faster patient recovery and reduced hospital stay, Filipino anesthesiologists trained abroad in major regional anesthesia training centers in Europe, North America, and Asia. Upon returning home, they introduced the technique of performing neuraxial, peripheral nerve, and fascial plane blocks under ultrasound guidance. They also organized and conducted workshops, local and international conferences, journal clubs, lectures, and simulations all over the Philippines, attended by both local and foreign speakers, facilitators, and delegates.9 To further promote the common interests of regionalists, to continue the spread of knowledge, to teach the skills, and to further advance the safe practice of regional anesthesia, two organizations were established – Regional Anesthesia Society of the Philippines (RASPhil) in 2017 and the Manila Academy of Regional Anesthesiologists (MARA) in 2019. In recognition of the need for formal training in Regional Anesthesia, the last decade has also seen the establishment of Regional Anesthesia Fellowship Programs in several training institutions in our country, including our very own Regional Anesthesia Fellowship Training Program at the University of the Philippines - Philippine General Hospital which started accepting trainees in 2019. Last year, the Philippine Board of Anesthesiologists conferred the title of Specialists in Regional Anesthesia to 88 Anesthesiologists.9,11 Thus, the seed that Dr. Sulit and Dr. Alarcon have planted has grown into a full-fledged and well-organized subspecialty. Looking forward, the future of Regional Anesthesia in the Philippines is very promising, but will still require continuous effort in several key areas. Right now, access to the technology of modern imaging equipment is limited to the major tertiary centers of the country. There should be continued investment in healthcare infrastructure, training, safety protocols, and technology. More Regional Anesthesia specialists should also be trained and deployed in the remote and underserved areas of the country. In conclusion, the story of Regional Anesthesia in the Philippines is a testament to the strength and adaptability of the anesthesia community. From its indigenous roots to the modern era, the history of Philippine Regional Anesthesia is a story of progress and perseverance to further elevate, innovate, and provide better health care for the Filipino.

Compartment syndrome is a serious complication of fractures of the tibial shaft and its clinical presentation and evaluation have been well documented (Holden 1975; Kikuchi, Hasue and Watanabe 1978). The most important diagnostic feature is the presence of inappropriate pain even after stabilisation of the fracture by a cast or by external or internal fixation. Pain is made worse by passive stretching of the muscles involved and there is an associated sensory disturbance. The prognosis is directly related to the speed at which the diagnosis is made and treatment begun. It has been shown that muscle can tolerate only four hours of ischaemia without injury (Heppenstall et al 1988; Heckman et al 1993). We describe a patient with a fracture of the tibial shaft in whom the diagnosis of compartment syndrome was delayed because of the use of a local nerve block given in the operating theatre after intramedullary nailing. Case report. A 28-year-old man presented after a football injury with a closed fracture of the tibial shaft (42-A2.2 according to the AO classification (Muller et al 1990)). Before operation there were no signs of neurovascular compromise or of a compartment syndrome. The fracture was initially stabilised in a plaster back slab and closed, unreamed locked intramedullary nailing then performed. At the end of the operation, the patient was given a triple nerve block (femoral, obturator, lateral cutaneous nerve of thigh) using bupivacaine 0.5% for pain control. After operation, he was entirely free from pain, although he did complain of areas of altered sensation in his foot and leg, but these varied in site and were initially thought to be a result of the nerve block rather than a symptom of a developing compartment syndrome. Pressure measurements were made 48 hours after operation because symptoms persisted and there was inability actively to extend the big toe. They showed a pressure of 108 mmHg in the anterior compartment. We performed fasciotomy urgently but all the muscles in the anterior compartment were dead. No other compartment was involved. The whole of the anterior tibial compartment was debrided 48 hours later as there was no sign of recovery. The patient now walks with an orthosis. Discussion. The treatment of postoperative pain in patients whose tibial fractures have been stabilised is usually by elevation of the injured leg and the use of oral or intramuscular analgesics, especially non-steroidal anti-inflammatory agents. Local anaesthetic nerve blocks are now also commonly given to patients with fractures of the lower limb; they are effective and especially useful after fracture of the femoral shaft. A nerve block using bupivacaine persists for about eight hours (Macrae and Davies 1993), but recovery from the block may be patchy and erratic over a period of several hours. The diagnosis of compartment syndrome is essentially

Local and Regional Anesthesia

Regional anesthesia is commonly used for adolescent anterior cruciate ligament reconstruction, but its effect on functional recovery is uncertain. We examined whether the use or type of nerve block influenced recovery. 15 institutions contributed to a prospective observational registry of patients aged 12-17 years undergoing anterior cruciate ligament reconstruction. Functional recovery was assessed using the Lysholm Knee Score (range 0-100; higher scores indicate better function) at postoperative day 1, day 3, week 6 and month 6, and the Limb Symmetry Index (percentage of operative to non-operative limb performance; values ≥90% indicate readiness to return to sport) at 6-9 months. A total of 519 patients were enrolled. Lysholm Scores improved over time in all groups. At week 6, patients who received both anterior and posterior blocks had a median Lysholm Score of 83 (good function) compared with 78 for those with no block or anterior block alone (p=0.041). By month 6, scores were similar across groups, with most patients reaching the good to excellent range. Younger patients (12-15 years) reported higher scores than older adolescents (median 89 vs 86, p<0.05), while females reported lower scores than males at several time points. High early postoperative pain (numerical rating scale ≥7) predicted lower function through week 6. Positive temperament and lower preoperative anxiety/depression scores predicted better outcomes. At 6-9 months, 67% achieved a Limb Symmetry Index ≥90%. Younger age increased the odds of a suboptimal Limb Symmetry Index (<90%) (OR 2.54, p=0.03). Nerve block type was not associated with Limb Symmetry Index. Regional anesthesia did not impair functional outcomes after adolescent anterior cruciate ligament reconstruction. Most patients regained good knee function by 6 months, and two-thirds achieved readiness for return to sport by 9 months. Recovery was more strongly influenced by age, sex, and psychological profile than by nerve block use. NCT04329117.

Background: The selection of anesthesia for procedures involving the lower abdomen is an important decision that balances the need for effective pain control with patient safety and satisfaction. Objective: Finding the factors that influence patient satisfaction following lower abdominal surgery under regional anesthesia as opposed to general anesthesia was the aim of this study. Study Design: Comparative Cross-sectional Study. Settings: Department of Anesthesia &amp; Surgery, Mardan Medical Complex, Mardan, Pakistan. Duration: Six months from September 2023 to February 2024. Methods: A total of 384 patients aged 18-75 years were categorized between General Anesthesia (GA) and Regional Anesthesia (RA). Data on surgical techniques, postoperative complications, patient education satisfaction, gender and ASA status were acquired. Statistical analysis was used to evaluate the association (Chi square Test) between these variables. Results: The RA group experienced a decreased rate of postoperative complications and was statistically significant at (p = 0.002), while the GA group experienced greater rates of vomiting (54.2%), nausea (62.5%) and pain (50.4%). In the RA group, 22.9% of respondents were fully happy, compared to 21.9% in the GA group (p = 0.003). RA highlighted the value of making well-informed decisions by reducing complications and increasing satisfaction. Conclusion: RA has several benefits, including improved pain management, quicker recovery periods, fewer problems and more patient comfort. Subsequent research endeavors ought to centre on the enduring consequences of distinct anesthetic varieties and their influence on certain surgical procedures and tactics to augment patient comprehension.

<h3></h3> The number of spine surgeries being performed has exponentially increased in the last two decades. This rapid growth is mainly attributed to the epidemic of chronic low back pain in developed countries, as well as the introduction of minimally invasive surgical technique that allows more complex spine procedures to be performed safely. Many institutes have protocolized their perioperative management of patients undergoing spine surgery. However, a widely accepted enhanced recovery after surgery (ERAS) pathway for spine surgery has yet to be developed. Early studies suggested ERAS spine protocol enables faster recovery, increase patient satisfaction, reduction of hospital length of stay and healthcare expenditure. There are three major anesthetic considerations for adult patients undergoing complex spine surgery, namely: blood loss, pain management, and position-related complications Complex spine surgery was ranked among the top six most painful procedures. Poor pain control has been shown to be associated with increased risks of wound healing, hospital-acquired infections, length of stay, and delayed mobilization. Pain following spine surgery can result from mechanical irritation, nerve compression, or postoperative inflammatory processes. It can be generated from different structures such as vertebrae, discs, ligaments, muscles, dural sleeves, and capsules of the facet joint. Innervation of these pain generators is from the dorsal rami of spinal nerves. Opioids are commonly used as effective analgesics for the management of severe pain disorders. However, their widespread use is restricted because of their side effects such as nausea, vomiting, and respiratory distress, and acquired tolerance. Preemptive multimodal analgesic regimens that rely on the synergistic action of nonopioid agents given in lower doses have been used to improve postoperative pain management and reduce opioid consumption. Protocols for reducing pain after lumbar surgery recommend the use of regional anesthesia techniques to reduce opioid analgesic use to the minimum. Interfascial plane blocks have the potential to provide extended postoperative analgesia and to reduce opioid consumption and neuraxial-related motor block to a minimum. In order to reduce opioid use, loco-regional and local anesthesia were introduced. In spine surgery, loco-regional techniques were limited to epidural catheters and spinal and epidural morphine. Neuraxial analgesia through spinal opioids or continuous epidural infusion can provide excellent pain control, but these techniques have drawbacks. They can lead to rare but serious complications, such as infection, hematoma, or nerve injury, often cause severe pruritus, nausea, vomiting, and urinary retention, and may cause hypotension in the postoperative period. In addition, the use of central blocks could interfere with neurophysiological monitoring and delay postoperative evaluation of possible neurological complications. Local anesthetic wound infiltration is often performed with unfortunately short-lived effect. With the intention of prolonging the analgesic effect of wound infiltration, the possibility of infiltrating a mixture of local anesthetic, opioid, NSAIDs, and epinephrine in the lumbar region has been postulated. Although the evidence for this practice is limited. In 2020, Jeff L. Xu described a novel regional anesthetic technique in which local anesthetic is deposited around the thoracolumbar dorsal ramus nerve (TDRN) via 4 multiorifice pain catheters placed intraoperatively under direct visualization by the surgeon, Patients who received TDRN block catheters required minimal opiates in the postoperative period and avoided affecting the blockage distribution of ventral ramus nerve and sympathetic chain. This allowed patients to participate in physical therapy as early as on postoperative day 0. This bypassed the potential untoward side effects of epidural analgesia (hypotension, lower extremity weakness, respiratory depression, and urinary retention). In addition, the TDRN block catheters can be used in the upper thoracic spine without fear of respiratory depression and may be used in cases of wide laminectomy or large vertebrectomy. Given the results, the authors believe that a larger study comparing TDRN block catheters with the standard thoracic or lumbar epidural or other regional approaches should be performed in the setting of a multimodal analgesic regimen. The loco-regional technique used in this type of surgery should aim to anaesthetize the dorsal root of the spinal nerves at the appropriate operative level. Dorsal ramus blocks have been shown to be feasible in the treatment of chronic pain. In a recent series of case reports, a bilateral block of the lumbar dorsal ramus nerve showed improved pain scores and reduced morphine consumption after spine surgery A loco-regional technique suitable for back surgery should cover the innervation of the relevant vertebrae and paravertebral muscles and include the dorsal roots of the spinal nerves at this level. The Toracolumbar interfascia plane (TLIP) block was first described by Hand et al. In the TLIP block, local anesthetic agents are injected into the fascial plane lying between the multifidus and longissimus muscles at the level of the third lumbar vertebra, targeting the posterior rami of the thoracolumbar spinal nerves, thus achieving a reproducible area of anesthesia with a predictable spread. The TLIP block can provide effective postoperative analgesia for lumbar spine surgery, decrease postoperative VAS scores, and reduce opioid consumtion after lumbar spine surgery. In addition, the TLIP block significantly reduces the side effects of nausea. However, further studies are needed to testify these benefits, and more high-quality RCTs are still necessary and urgently required for further research. Ultrasound-guided erector spinae plane blockade (ESP) was first developed by Forero in 2016 as an easy, safe way of managing thoracic neuropathic pain.Since that time, this block has gained in popularity and has been used to effectively provide analgesia for a variety of surgeries, including spine surgery. Theoretically, an infiltration between the erector spinae muscle and the transverse process provides anesthesia of the dorsal ramus at the same vertebral level. Since the local anesthetic is injected into a plane, the solution can spread both caudally and cranially via the toracolumbar fascia, resulting in anesthesia of the dorsal ramus of the spinal nerves above and below the injected level. Potential benefits of the lumbar ESP include the ease of performance with clear landmarks for ultrasound anatomy. The technique is inherently safe, as the target site for injection is a muscular plane and there is practically no risk for mechanical nerve contact. Other benefits include the possible reduction in perioperative opioid consumption. The ESP is performed in patients under anticoagulant therapy or with coagulopathies. Furthermore, hemodynamic instability due to sympathetic blockade, as with epidural and spinal anesthesia, occurs rarely. Possible risks consist primarily of local anesthetic systemic toxicity. Since substantial doses are considered necessary, there is a clinically significant risk for local anesthetic systemic toxicity, as with any high-volume fascial block. For this reason, patients need to be monitored according to American Society of Regional Anesthesia guidelines with Intralipid available at all times. Some meta-analysis demonstrates that ESP is effective in reducing postoperative pain intensity and postoperative opioid consumption in spine surgery. Furthermore, ESP is easy to perform and has few complications. Therefore, for the management of postoperative pain following spine surgery, preoperative ESP is a good choice. More studies are still needed in order to explore doce. Both the ESPB and TLIP blocks have shown to provide adequate analgesia after lumbar spinal surgery. Clinicians can choose either the TLIP block or the ESPB for pain control after lumbar spinal surgery based on their clinical experience and choice. Currently there is no consensus as to the superiority of one over the other. Retrolaminar block (RLB) was first reported in 2006 as an alternative approach to PVB. RLB is performed with US imaging or the landmark technique. The needle is inserted at a puncture site 1–1.5 cm lateral to the target spinous process and advanced caudally or cranially until it contacts the lamina. Local anesthetics are injected on the lamina at doses of 20–30 ml. RLB can be performed with the US-guided, in-plane insertion technique. The sagital plane with a linear US probe allows for visualization of the laminae or transversus process, and the needleis advanced using the in-plane technique. The retrolaminar block has been successfully used in spinal surgery, although the large number of publications that we have on the ESP block have left this approach relegated. Although everything indicates that regional techniques will be a fundamental pillar in ERAS protocols for spinal surgery, there is no consensus regarding which is the best technique to control postoperative pain in these patients. More studies are needed to reach definitive conclusions in this regard. <h3>References</h3> Abdulrahman Alboog , Sandy Bae, Jason Chui. Anesthetic management of complex spine surgery in adult patients: a review based on outcome evidence. <i>Curr Opin Anaesthesiol.</i> 2019 Oct;<b>32</b>(5):600–608 Nancy S Lee , Ashley Kydes. Regional Anesthetic Approaches for Postoperative Analgesia Following Vertebral Body Tethering: A Case Series. <i>A A Pract</i>. 2021 Aug 23;<b>15</b>(8):e01510. Alla Spivak , Jeff L Xu .Ultrasound guided paraspinal intrafascial plane blocks for postoperative analgesic on spine surgery. <i>J Spine Surg</i>. 2019 Dec;<b>5</b>(4):601–602. Zhenxin Hu , Jun Han , Binbin Jiao , Jian Jiang , Yuefeng Sun , Zhengshuai Lv , Jianhe Wang , Xilaing Tian^, Hong Wang. Efficacy of Thoracolumbar Interfascial Plane Block for Postoperative Analgesia in Lumbar Spine Surgery: A Meta-analysis of Randomized Clinical Trials. <i>Pain Physician</i>. 2021 Nov;<b>24</b>(7). Ezzat Eltaher , Nihal Nasr , Mohamed E Abuelnaga , Yassmin Elgawish. 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. <i>J Pain Res.</i> 2021 Nov 3;<b>14</b>:3465–3474. Daniele Bonvicini , Rafael Boscolo-Berto , Alessandro De Cassai , Michele Negrello , Veronica Macchi , Ivo Tiberio, Annalisa Boscolo , Raffaele De Caro , Andrea Porzionato. Anatomical basis of erector spinae plane block: a dissection and histotopographic pilot study. <i>J Anesth</i>. 2021 Feb;<b>35</b>(1):102–111. Liu MJ, Zhou XY, Yao YB, Shen X, Wang R, Shen QH. Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis. <i>Pain Ther</i>. 2021 Jun;<b>10</b>(1):333–347. Bahadir Ciftci, Mürsel Ekinci, Erkan Cem Celik, Ahmet Murat Yayik, Muhammed Enes Aydin, Ali Ahiskalioglu. Ultrasound-Guided Erector Spinae Plane Block versus Modified-Thoracolumbar Interfascial Plane Block for Lumbar Discectomy Surgery: A Randomized, Controlled Study. World Neurosurg. 2020 Dec. Jeff L Xu , Victor Tseng , Damon Delbello , Matthew A Pravetz. Thoracolumbar Dorsal Ramus Nerve Block Using Continuous Multiorifice Infusion Catheters: A Novel Technique for Postoperative Analgesia After Scoliosis Surgery. <i>Int J Spine Surg</i> 2020 Apr 30;<b>14</b>(2):222–225. Eiko Onishi , Noriko Toda , Yoshinobu Kameyama , Masanori Yamauchi . Comparison of Clinical Efficacy and Anatomical Investigation between Retrolaminar Block and Erector Spinae Plane Block. <i>Biomed Res Int</i>. 2019 Mar 28;2019.