Erector Spinae Plane Block in Lumbar Spine Surgery: Dual Network Meta-Analysis of Comparative Effectiveness and Delivery Modality.

Abstract

Erector spinae plane block (ESPB) is increasingly used to improve perioperative analgesia after lumbar spine surgery, but its comparative effectiveness versus alternative strategies and different delivery modalities remains uncertain. To compare ESPB with analgesic comparators evaluated in eligible ESPB-containing studies and to assess whether analgesic efficacy differs by ESPB delivery modality. Systematic review and dual network meta-analysis. Adults undergoing lumbar spine surgery receiving ESPB, modified thoracolumbar interfascial plane block (mTLIP), wound infiltration, sham ESPB, or control/usual care. Primary outcomes were 0-24 h opioid consumption (intravenous morphine equivalents), 24 h postoperative pain scores, and postoperative nausea/vomiting (PONV); secondary comparisons evaluated ultrasound-guided, fluoroscopy-guided, and freehand ESPB techniques. Electronic databases were searched for eligible trials and two complementary network meta-analyses were performed: a treatment-comparison network including ESPB, mTLIP, wound infiltration, sham, and control, and a modality-comparison network contrasting ultrasound-guided, fluoroscopy-guided, and freehand ESPB with sham, wound infiltration, and control. Random-effects models generated comparative treatment effects alongside frequentist network estimates and Bayesian ranking metrics. ESPB reduced 0-24 h opioid consumption versus control/usual care and was superior to wound infiltration and sham. Modified thoracolumbar interfascial plane block (mTLIP) often ranked highest for opioid sparing, although inferences were limited by sparse direct evidence. ESPB showed favourable effects on 24 h pain and reduced PONV versus control, with no clear differences versus mTLIP or sham for PONV. Modality analyses indicated broadly similar reductions in opioid use and pain with ultrasound- and fluoroscopy-guided ESPB. ESPB is an effective opioid-sparing adjunct after lumbar spine surgery and appears superior to sham and wound infiltration for several outcomes, while apparent advantages of mTLIP require cautious interpretation; ultrasound- and fluoroscopy-guided ESPB demonstrate comparable analgesic performance, supporting modality choice based on local expertise and resources.