176. Thoracolumbar interfascial plane (TLIP) block and intrathecal fentanyl injection results in an opioid-free peri- and postoperative recovery and early ambulation after percutaneous lumbar spine surgery

Abstract

BACKGROUND CONTEXT Open lumbar spine fusion surgery usually requires opioid analgesia for several weeks during the postoperative recovery period. Recently, a facet-sparing, full percutaneous transforaminal lumbar interbody fusion (TLIF) has been introduced that uses an endoscopic cannula for placement of an interbody cage in combination with percutaneous transpedicular screws and rods. The Thoraco-Lumbar Interfascial Plain (TLIP) block is a novel, ultrasound-guided local anesthesia technique that targets the sensory component of the dorsal rami of the thoracolumbar nerves. PURPOSE We aim to evaluate the efficacy in avoiding post-operative opioid analgesics and allowing early patient ambulation of a novel inter-disciplinary, spine surgery protocol that combines a perioperative TLIP block, intrathecal fentanyl injection and percutaneous TLIF spine surgery. STUDY DESIGN/SETTING Prospective, nonrandomized sequential case series study. PATIENT SAMPLE A total of 15 consecutive patients underwent TLIP combined with percutaneous TLIF spine surgery between 2018 and 2019. Indication for spine surgery was degenerative disk disease of the lumbar spine with or without spondylolisthesis up to grade 2 and foraminal stenosis. OUTCOME MEASURES Pre- and postoperative visual analogic scale (VAS) for lumbar back and leg pain were quantitatively assessed (range 0 to 10) immediately, at 6 and at 12 hours after surgery and at time of hospital discharge. Oswestry Disability Index (ODI) scores (range 0 to 50) were assessed preoperatively and at time of hospital discharge. The time of first post-operative patient ambulation was registered. Significance between pre- and postoperative scores were analyzed with student's paired t-test. METHODS Intrathecal fentanyl 25 mcgr was administered to the patient in sitting position and ultrasound-guided bilateral TLIP was performed in prone position with bupivacaine 0.25% and dexamethasone 8mgrs (20ml each side) by the anesthesia team. All patients were operated on under general anesthesia (protocol: propofol 2.0-3.0 mcg/ml (TCI) following BIS, ketamine 0.15 mg/Kg/h, rocuronium 0.4 mg/Kg). Percutaneous TLIF was performed by inserting an expandable interbody implant using the facet-sparing, trans-Kambin approach with an endoscopic cannula and complemented with a percutaneous posterior fixation consisting of transpedicular screws and rods. Postoperative analgesia included NSAIDs, acetaminophen and a manually patient-controlled oral sublingual 15 mcgr sufentanil microtablet analgesic system (Zalviso®), while its use was monitored. RESULTS Fifteen patients with a mean age of 64.1 years (range, 34 to 82 years) were evaluated. A median of two levels (range, 1 to 4 levels) per patient were instrumented and a median of one interbody cage (range, 1 to 2 cages) was placed in the lumbar spine. No intravenous fentanyl administration was necessary during surgery. The median time of surgery was 3.5 hours. Mean preoperative VAS scores for lumbar back and leg pain were 6.3 and 5.8, respectively. Mean postoperative VAS back scores at 0h, 6h, 12h and at discharge improved to 1.2, 1.8, 2.4 and 2.7 (P CONCLUSIONS The combination of perioperative TLIP, intrathecal fentanyl injection and percutaneous TLIF surgery prevents peri- and postoperative opioid administration and improves the quality of peri- and postoperative analgesia, allowing early patient ambulation and fast hospital discharge. This interdisciplinary analgesia protocol is a promising solution to avoid opioid analgesia in spine surgery and could be particularly interesting in the context of an outpatient spine surgery setting. FDA DEVICE/DRUG STATUS Fentanyl (Approved for this indication), Zalviso (Approved for this indication), Bupivacaine (Approved for this indication), Globus RISE (Approved for this indication)