Intraoperative erector spinae plane block guided by O-arm navigation in transforaminal lumbar interbody fusion (TLIF): a novel technique

Introduction

Postoperative pain following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) remains a significant clinical challenge, frequently necessitating the use of substantial opioid doses, which carry risks of side effects and dependence. To address this issue, this technical note introduces a novel intraoperative technique for erector spinae plane (ESP) block guided by O-arm navigation. This innovative approach combines the proven benefits of ESP blocks with the precision afforded by O-arm navigation to improve postoperative pain outcomes. This article is presented in accordance with the SUPER reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-19/rc).

Preoperative preparations and requirements

This section details the procedural steps for performing an intraoperative ESP block guided by O-arm navigation during TLIF surgery. This technique is easily applicable in surgeries that already utilize O-arm navigation, particularly in cases involving the insertion of pedicle screws. Proper preoperative preparation is essential to ensure the effectiveness and safety of the intraoperative ESP block guided by O-arm navigation during transforaminal lumbar interbody fusion (TLIF) procedures. Before surgery, the patient must undergo a thorough preoperative evaluation to assess their medical history, surgical indications, and any potential contraindications to regional anesthesia techniques. The operating room should be equipped with an O-arm imaging system and a compatible navigation system to allow for precise visualization and guidance. All surgical and anesthetic equipment, including a 22-gauge spinal needle, local anesthetics such as 0.5% marcaine or 2% xylocaine, and adjuvants like 10 mg of dexamethasone, must be readily available. Sterile supplies and drapes should be prepared to maintain aseptic technique during the procedure. The navigation system must be calibrated in advance to ensure accurate synchronization with the O-arm images. Adequate communication between the anesthesiology and surgical teams is crucial to plan the timing and administration of the ESP block within the surgical workflow.

Additionally, the patient should be properly informed about the procedure, including its purpose, benefits, and potential risks, as part of the informed consent process. Comprehensive preparation ensures a smooth procedure, minimizes complications, and enhances patient outcomes. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this article and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Step-by-step description

Patient positioning and preparation

The patient is positioned prone on the operating table. The surgical site [typically L1-S1, depending on the level(s) of TLIF] is prepped and draped aseptically.

O-arm imaging

The O-arm is used to obtain images to identify the target anatomical landmarks transverse processes. This provides a roadmap for subsequent needle placement. The specific level(s) for ESP block administration will depend on the surgical plan; for a single-level L4-L5 fusion, an ESP block at either L4 or L5 may suffice.

Navigation system setup

The navigation system is calibrated and aligned to facilitate the needle trajectory. A dilator tracker, devoid of a navigated dilator (Figure 1), is employed to ensure proper navigation toward the needle placement path (Figure 2). In the scout image’s coronal view, the trajectory is adjusted from linear to circular, aligning with the target transverse process while keeping the dilator tracker steady (Figures 3,4).

Figure 1 A dilator tracker and 22-gauge spinal needle are shown for procedural setup.

Figure 2 A 22-gauge spinal needle being inserted through the dilator tracker.

Figure 3 The dilator tracker provides needle guidance for accurate placement without navigated assistance.

Figure 4 In the coronal view from the navigation station, adjust the trajectory from linear to circular to align with the target transverse process while maintaining dilator tracker position. The blue dot in the figure indicates that the navigation trajectory is perpendicular to the transverse process and is ready for the needle to be introduced via the dilator tracker.

Needle placement

A 22-gauge spinal needle is advanced in-plane towards the identified target, ensuring accurate positioning relative to the bone structure. Post-placement, an AP (anterior-posterior) radiograph is captured to confirm the proper placement of the needle (Figure 5). This step is crucial to ensure the needle is correctly situated within the plane before injection (Figure 6).

Figure 5 Post-needle placement confirmation: an AP radiograph is obtained using O-arm imaging to verify proper needle placement. AP, anterior-posterior.

Figure 6 A 22-gauge spinal needle is advanced in-plane relative to the bony anatomy for precise placement at the target site.

Injection

Once the needle tip’s location is verified, 10–20 mL of local anesthetic (e.g., 0.5% marcaine, 2% xylocain, dexamethsone 10 mg) is injected slowly. Slow injection minimizes rapid pressure changes and potential nerve injury. Ensure that the needle does not advance too far. If docking the needle on the transverse process is not possible, use X-ray imaging to confirm the needle’s placement. Additionally, during the injection, verify that the needle is correctly positioned on the bone to prevent the medication from entering the foramen, which could result in temporary postoperative weakness.

TLIF procedure

Following successful ESP block placement, the TLIF procedure is performed using standard surgical techniques.

Postoperative considerations and tasks

Postoperative analgesia

Standard postoperative pain management protocols are implemented, potentially augmented by the analgesia provided by the intraoperative ESP block.

Tips and pearls

The intraoperative ESP block guided by O-arm navigation during TLIF represents a novel technique. Previous publications have primarily focused on the use of ultrasound and fluoroscopic guidance for ESP blocks (1-3). In this procedure, the author selected a spinal needle instead of a peripheral nerve needle due to the absence of a line connector on the spinal needle, as the presence of such a connector on the needle could become dislodged and disturb the navigated procedure (4). Since the spinal needle may shift during the procedure, the author recommends verifying the final placement with an X-ray before administering the injection. Additionally, it is crucial to ensure that the needle remains in contact with the bone throughout the procedure, specifically positioned on the transverse process.

Discussion

The incorporation of O-arm navigation into intraoperative ESP block administration has shown substantial advantages, particularly in improving needle placement accuracy. O-arm navigation significantly enhances precision by providing detailed anatomical information, reducing the risk of misplaced injections and associated complications (5-7). Evidence from the first six cases performed demonstrates that the procedure resulted in no instances of needle misplacement, highlighting the reliability of this approach. Accurate needle placement not only improves procedural efficiency but also contributes to better overall patient outcomes.

The ESP block has also proven effective in providing enhanced analgesia (8,9). By reducing intraoperative opioid requirements and delivering improved postoperative pain control, this technique addresses critical challenges in spinal surgery (6,7,10-12). The reduction in opioid consumption may also lower the risk of dependency and postoperative complications associated with opioid use. Additionally, the procedure is minimally invasive and carries a low risk of adverse events. In the first six cases performed, there were no reported complications during the procedure (13-16). This safety profile, combined with a relatively fast learning curve, makes the technique accessible to surgeons experienced in O-arm navigation, enhancing its feasibility in clinical practice.

However, limitations remain. Unlike ultrasound-guided techniques, O-arm imaging does not provide real-time visualization of the ESP plane being lifted during injection, which may complicate needle guidance (17). To address this limitation, care must be taken to ensure the needle remains consistently positioned on the transverse process throughout needle placement, avoiding inadvertent advancement.

Future directions should focus on conducting larger-scale clinical trials to compare the safety, efficacy, and postoperative outcomes of O-arm-guided intraoperative ESP blocks with traditional methods, such as ultrasound-guided ESP blocks. These studies should encompass diverse patient populations to improve the generalizability of findings and establish the broader applicability of this innovative technique. Comprehensive clinical trials will help refine this method and strengthen its position as a valuable addition to perioperative pain management strategies.

Conclusions

This novel technique for intraoperative ESP block guided by O-arm navigation during TLIF surgery offers a promising approach to enhancing postoperative pain management. The integration of O-arm navigation technology with ESP blocks improved accuracy in needle placement, reduced procedural time by approximately 3 minutes, and its minimally invasive nature, this technique may lead to better patient outcomes and decreased opioid consumption. Although it faces limitations such as the lack of real-time visualization compared to ultrasound techniques, preliminary evidence suggests it represents a significant advancement in TLIF pain management. Further research, including larger clinical trials, is essential to fully assess its effectiveness and safety against traditional methods. The technique’s minimally invasive nature and relatively straightforward learning curve make it an attractive option for spine surgeons seeking to optimize their patients’ postoperative pain management strategies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-19/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-19/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-19/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this article and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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