Original Article

Comparison of spinal anaesthesia and erector spinae plane

block in unilateral inguinal hernia: Randomised clinical trial
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Mustafa Kaçmaz1, Hacı Bolat2, Alirıza Erdoğan2

Department of Anesthesiology, Faculty of Medicine, Ömer Halisdemir University, Niğde, Turkey, 2Department of General Surgery,
1
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Faculty of Medicine, Ömer Halisdemir University, Niğde, Turkey

Abstract Introduction: The objective of our study was to compare erector spinae plane block (ESP) with spinal
anaesthesia (SA) for inguinal hernia repair with respect to anaesthetic efficacy, post‑operative analgesia,
mobilisation, discharge, complication and side effects.
Patients and Methods: The study included 52 patients over 50 years of age, with the American Society of
Anaesthesia physical status Class I‑III. Group ESP (n = 26) was applied 30 ml of mixed local anaesthetic
mixture applied at the L1 level to the plane of the erector spinae and 10 ml of tumescent when necessary,
while Group SA (n = 26) was applied 3 ml of 0.5% bupivacaine at the L3–L4/L2–L3 level.
Results: Intraoperative Visual Analogue Scale (VAS) value was lower in Group S, whereas the 6th‑h VAS value
was lower in Group ESP (P < 0.05). There was no significant difference between the VAS values at hour
12 and 24 (P > 0.05). Reaching post‑anaesthesia discharge criteria 9 and time to mobilisation and oral
feeding was shorter in Group ESP, whereas post‑procedure waiting time was shorter in Group S (P < 0.05).
While the need for post‑operative analgesics was higher in Group S (P < 0.05), there was a high level of
patient satisfaction in Group ESP (P = 0.05). Intraoperative midazolam requirement was lower in Group S,
post‑operative diclofenac requirement was lower in Group ESP (P < 0.05), post‑operative urinary retention
and tremor were higher in Group S (P = 0.05).
Conclusion: ESP block provides adequate surgical anaesthesia compared to SA (non‑inferiority) for inguinal
hernia repair. It is associated with less analgesic requirement, low post‑operative pain, less complication
rate and high patient satisfaction in the post‑operative period.

Keywords: Erector spinae plane block, inguinal hernia, spinal anaesthesia

Address for correspondence: Dr. Mustafa Kaçmaz, Department of Anesthesiology, Faculty of Medicine, Ömer Halisdemir University, Niğde, Turkey.
E‑mail: muskac51@gmail.com
Submitted: 31‑Dec‑2022, Revised: 06‑Apr‑2023, Accepted: 19‑Apr‑2023, Published: 05-Jul-2023

INTRODUCTION Since ESP is associated with fewer complications such as

direct spinal cord injury, epidural haematoma and central
Erector spinae plane block (ESP) was first described in nervous system infection, which are seen in neuraxial
2016 as a regional block technique for thoracic neuropathic blocks, it has recently been used as an alternative analgesic
pain. Since then, the interfascial plane block has been and a safer anaesthesia technique.[2]
successfully used as an alternative to neuraxial block in
various surgeries.[1]
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DOI: How to cite this article: Kaçmaz M, Bolat H, Erdoğan A. Comparison of

10.4103/jmas.jmas_367_22 spinal anaesthesia and erector spinae plane block in unilateral inguinal
hernia: Randomised clinical trial. J Min Access Surg 0;0:0.

© 2023 Journal of Minimal Access Surgery | Published by Wolters Kluwer - Medknow 1

 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block
ESP block has emerged as an effective regional anaesthesia
technique for thoracic, abdominal and other regions.
ESP is easy to administer and has a low risk of serious
complications. Therefore, it is gaining popularity.[3] Today,
ESP is used to provide analgesia in procedures such
as pyeloplasty, lipoma excision, breast reconstruction,
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malignant mesothelioma and hip reconstruction, and there
are reports of its use in paediatric inguinal hernia repair.[4]
Although there are many case reports on ESP, controlled
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clinical studies on this subject are not yet sufficient. ESPs
are mostly administered to adult patients from the thoracic
region with a single injection technique. Although generally
used for thoracic analgesia, they are secondarily used for
analgesia and anaesthesia applications in lumbar surgeries.[5]
One‑third of the patients admitted to the hospital due to
gastrointestinal diseases suffer from an abdominal hernia.
Ninety‑six percentage of these patients apply for inguinal
hernia.[6] Repair of inguinal hernia can be performed
under general anaesthesia, regional or local anaesthetics.
Despite various side effects such as post‑spinal headache,
urinary retention, motor deficit of lower extremities,
intraoperative haemodynamic variations, delayed mobility
and hospital discharge, spinal anaesthesia (SA) remains
the most commonly used anaesthesia method in inguinal
hernia repair.[7,8]
Based on the current scientific data supporting the use of
local infiltration and peripheral nerve block anaesthesia,
one may wonder why this technique is used for only 10%
of all operations and not translated into general practice.[9]
The infrequent use of local anaesthetic and peripheral
nerve block methods can partly be explained by traditions
in the practice of anaesthesia. In addition, many surgeons
are probably reluctant to learn the technique of regional
infiltration anaesthesia as well as to learn and practice
peripheral nerve blocks for anaesthesia. They may find
it easier to operate with spinal or general anaesthesia,
although it poses a higher risk in terms of patient comfort
and complications.[7]
Controlled clinical studies with well‑explained and
applicable methods are needed to popularise the use of
peripheral nerve blocks or infiltration anaesthesia against
SA. In this way, ESP may be a suitable alternative, especially
for middle‑aged patients with comorbidities and for whom
SA is thought to increase the relative intraoperative risk.
The primary aim of our study was to compare the lumbar
erector spinae blocks supported with local infiltration
anaesthesia versus SA applied in unilateral inguinal hernia
2 Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023
surgery in middle‑aged and older patients in terms of the
operation time, intraoperative haemodynamic data, onset
time, analgesic requirement and discharge time, while the
secondary aim was to assess patient satisfaction, surgeon
satisfaction and procedure‑related complications such as
nausea, vomiting, urinary retention, headache, tremor and
bleeding.
PATIENTS AND METHODS
After the study was approved with the decision of the ethics
committee of Nigde Omer Halisdemir University, dated
28th August 2020 and numbered 2020/38, and registered
in the ClinicalTrials.gov (NCT05073055) before patient
recruitment. The suitability of 70 cases who were admitted
to the general surgery clinic for surgery with the diagnosis
of unilateral inguinal hernia and were classified under the
American Society of Anaesthesia physical status (ASA)
I‑III class, aged between 50 and 75 years old, was evaluated.
The study was designed as a prospective, randomised
controlled study. Eighteen patients were excluded from
the study due to various reasons at different stages, and
a total of 52 patients were included in the statistical
evaluation [Figure 1].
The study was conducted in accordance with the
principles of the Declaration of Helsinki. The patients
were selected 1 day in advance by the single‑blind and
the closed‑envelope method, and informed consent was
obtained from all patients after the study design was
explained in detail.
Patients who were 20% above their ideal body weight, had
liver disease, were allergic to anaesthetic agents, had local
infection, relapse, strangulated hernia, history of allergy to
local anaesthetics and a history of anaesthesia up to 2 weeks
priorly were excluded from the study. The general surgeon
who performed the inguinal hernia repair surgery did not
take part in patients’ post‑operative follow‑ups.
All patients were administered 0.05 mg/kg of midazolam
for pre‑operative sedation 10 min before the block
application. Before anaesthesia, electrocardiogram (ECG),
heart rate (HR), peripheral oxygen saturation (SpO2)
values were monitored in the preparation room and nasal
administration of 2 lt/min of O2 was started.
Patients were randomised into two groups. Patients who
underwent SA were named Group S, and patients who
underwent erector spinae block and tumescent anaesthesia
were named Group ESP. Group (S) (n = 30): Patients
to undergo SA were placed in a sitting position on the
operating table and entered through the subarachnoid
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block

Assessed for Eligilibility

Enrollment (n = 70)

Excluded (n = 3)
Nor meeting inclusion criteria (n = 4)
Declined to participate (n = 3)
Other reasons (n = 0)
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Randomized (n = 60)
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Allocated to SA arm (n = 30) Allocated to ESP block arm

Allocation (n = 30)
Received allocated intervention
(n = 1) Received allocated intervention
(n = 1)

Lost to follow-up (failed block)

(n = 3) Lost to follow-up (failed block)
Follow-Up
Discontinued intervention (n = 2)
(give reasons)(n = 0) Discontinued intervention
(surgical reason) (n = 1)

Analysed (n = 26) Analysed (n = 26)

Excluded from analysis Excluded from analysis
(n = 0) Analysis
(n = 0)

Figure 1: Consolidated standards of reporting trials statement flow diagram. SA: Spinal anaesthesia, ESP: Erector spinae plane block

space at the level of L3–L4/L2–L3 under sterile conditions
with a 25G cutting quincke spinal needle (Egemen,
Turkey) and were injected 3 ml of 0.5% hyperbaric
racemic bupivacaine (15 mg) in 30 s. The patients were
placed in the supine position right after the spinal block
and the intervention was started after the pinprick test
confirmed that the level of the sensory block was in the T10
dermatome. Surgery was allowed in patients who developed
sensory block at the T10 level. Patients who did not develop
enough sensory block for the intervention despite a waiting
period of 10 min were recorded and excluded from the
study, and an additional anaesthesia method was applied.
Three patients in the SA group and two patients in the ESP
group were excluded due to unsuccessful block.
A total of 40 ml mixture was prepared by mixing 15 ml
of 2% lidocaine hydrochloride (10 mg/ml) with 15 ml
of % 0.5 bupivacaine hydrochloride (5 mg/ml), 5 ml of
serum 8.4% sodium bicarbonate and adrenaline tartrate
(5 μg/mL) complemented to 5 ml with physiological
saline. The mixture was administered to each patient in
Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023
Group (ESP) (n = 30) before the operation to create a
tumescent anaesthesia‑assisted erector spinae block in
patients undergoing erector spinae block with infiltration
anaesthesia.
After haemodynamic stability, the patients were placed
in a sitting position and infiltration anaesthesia was
administered with 2% lidocaine. Following aseptic
preparation of the skin and probe, a medium‑frequency
curvey ultrasound (USG) transducer was first placed in
the midline to visualise the transverse projection of the
first lumbar (L1) vertebra. L1 vertebra was determined
as the first vertebra of the transverse process (TP) that
does not continue with the rib and then it was moved
2.5 cm laterally in the parasagittal plane, after imaging
the TP, in‑plane spreading was injected. Hydrodissection
was achieved on the TP of L1 by using a 5 cm, 21G
peripheral nerve block needle (Pajuk®, stimupleks
HNS12 Germany) just below the erector spinal muscle
with real‑time imaging of the substance. Afterwards, a
unilateral injection was completed from the same side of
3
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block
the inguinal hernia at L1 level, with an additional 25 ml
from the same insertion point Figure 2.
After the needle was removed, the injection site was
applied pressure for 1 min, and then, the level of sensory
block in the inguinal region was checked periodically. The
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patient was taken to the operating room after sufficient
sensory block was formed and the operation was started.
A maximum of 5 ml of local anaesthetic mixture, if
needed during the operation, was applied to the patient
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using the step‑by‑step technique, subcutaneously and
to the subcutaneous area around the incision, while a
maximum of 5 ml was applied under the fascia, around
the funiculus (spermatic cord) and to the tissues at the base
of the hernia sac. The total amount of anaesthetic used
was recorded. Patients who did not have sufficient sensory
block despite the application were excluded from the study
and general anaesthesia was administered.
In both groups, patients’ intraoperative sedation levels
were monitored by Ramsey sedation score (1: Agitated,
anxious, 2: Cooperative, 3: Responsive to verbal
commands, 4: Brisk response to light glabellar tap or loud
auditory stimulus, 5: Sluggish response to light glabellar
tap or loud auditory stimulus and 6: No response). If the
Ramsey sedation score was <3, sedation was provided
with 2 mg of midazolam and additional doses of 2 mg
were administered when necessary. Fifty of µg fentanyl
was administered in case of intraoperative pain while an
additional dose of 50 µg fentanyl was applied providing
that inadequate analgesia development was reported by the
surgeon. 10 ml/kg of crystalloid infusion was administered
to all patients in the S group before the operation to
prevent intraoperative hypotension, and 10 ml/kg/h of
crystalloid fluid infusion was administered to all patients
throughout the operation.
The patients were followed up in the operating room
until the end of the operation by routine monitoring
with ECG, SPO 2 and non‑invasive blood pressure.
a b
Figure 2: Ultrasonographic image of the ESP. (a) Anatomical
localization of the erector spina plane at L1 level, (b) distribution of local
anaesthetic after injection. ESP: Erector spina plane block
4 Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023
Intraoperative mean arterial pressure (MAP) and peak HR
were recorded at 15‑min intervals. Height, weight, gender,
ASA, anaesthesia and surgery time and pain scores of both
groups were evaluated with the help of Visual Analogue
Scale (VAS), with the lowest 0 being the highest,[10] and
intraoperative pain scores were recorded at the 6th, 12th h
and 24th h [Figure 3].
All the patients underwent Lichtenstein tension‑free
mesh repair as surgical method. All patients’ operation
time from surgical incision to last skin suture, pain‑free
mobilisation time and oral feeding initiation time,
post‑operative total amount of analgesics, time for
rescue analgesics and surgeon satisfaction level were
recorded. 50 mg of diclofenac was administered to
the patient intramuscularly given that a VAS value
of 4 and above was measured at any time during the
post‑operative period. If pain persisted, additional
50 mg of diclofenac was administered intramuscularly.
Intravenous metoclopramide ampoule was administered
in case of nausea or vomiting.
Time to reach discharge criteria was evaluated by the
post‑anaesthesia discharge criteria (PADSS).[10] Time to
reach discharge criteria was accepted as PADSS ≥9.
Post‑operative satisfaction level, post‑operative wound
haematomas, hypotension, nausea, vomiting, urinary
retention, headache, tremor, bleeding and wound infection
were recorded.
Satisfaction scores were evaluated as 1: Not at all satisfied,
2: Not satisfied, 3: Satisfied, 4: Very satisfied.
Statistical analyses
Statistical analyses were performed using the IBM SPSS
Figure 3: Variation of VAS values over time between groups. VAS:
Visual analog scale
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block

(IBM SPSS Statistics, Software version: 22.0, Operating Table 1: Distribution of demographic features of the groups
systems: Windows, Chicago, IL, USA) for Windows (n=26)
Group ESP Group S P
version 21.0 package program. Numerical variables were
Age* (years) 62.42±8.81 61.65±9.34 0.761
expressed as mean ± standard deviation. The normality of Height* (cm) 170.65±5.38 172.96±5.37 0.107
numeric variables was evaluated using the Kolmogorov– Male/female¶ 26/0 26/0 0.592
Smirnov test. The independent’s t‑test was used to compare Weight** (kg) 76.31±13.85 77.27±9.72 0.773
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MAP* (mm/Hg) 98.58±9.07 94.77±9.05 0.136

normally distributed variables between the groups. Pulse* 74.69±12.79 74.65±12.37 0.978
Mann–Whitney U‑test was used for the variables in which ASA¶ (I/II/III) 1/14/11 1/19/6 0.328
normality was not achieved. Chi‑square test and Fisher’s SpO2** (%) 95.27±2.20 95.77±1.33 0.402
Side (right/left)§ 15/11 11/15 0.267
exact test were used to evaluate the statistical significance
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*Student’s t‑test, **Mann–Whitney U‑test, ¶Pearson’s Chi‑square test,

between categorical variables. The significance level was §
Fisher’s exact test. Data presented as mean±SD or number of patients
accepted as P < 0.05. (%). Statistically significant between‑group differences (P<0.05). Group
ESP: Erector spinae plane block, Group S: Spinal block, ASA: American
Society of Anesthesiologists, MAP: Mean arterial pressure, SpO2: Oxygen
G power (Software version: 3.1, Heinrich-Heine-Univ. saturation, SD: Standard deviation
Düsseldorf, Germany) test was used to determine the
sample size. Based on post‑operative analgesic consumption Table 2: Post‑operative visual analogue scale values among
in the study of Kamel AA et al., the[11] α error was calculated groups (n=26)
as 0.05, the power as 0.70, the effect size as 0.8 and the Hour Mean±SD P
minimum sample size required in both groups as 52. Group ESP (n=26) Group S (n=26)
0 1.31±0.92 0.85±1.59 0.017
RESULTS 6th 2.54±1.83 4.69±1.89 <0.001
12th 2.08±2.05 2.96±2.28 0.156
24th 1.23±1.53 1.58±1.50 0.323
There was no statistically significant difference between the Mann–Whitney U‑test. Group ESP: Erector spinae plane block, Group
groups in terms of age, weight, height and gender (P > 0.05). S: Spinal block, SD: Standard deviation
There was no statistically significant difference between the
groups in terms of the operated side and pre‑operative Table 3: Durations of mobilization, satisfaction level, waiting,
ASA values (P > 0.05). There was no statistically significant analgesic need (n=26)
difference in terms of intraoperative SPO2, MAP and pulse Mean±SD P
Group ESP Group S
values (P > 0.05) [Table 1].
Mobilization and feeding start 1.88±0.55 6.58±2.88 <0.001
time (h)
While the intraoperative VAS value was significantly Surgical time (min) 35.46±7.96 39.58±10.34 0.125
lower in Group S, the VAS value measured at hour 6 was Rescue analgesic time (h) 6.82±2.63 7.13±4.50 0.951
significantly lower in Group ESP (P < 0.05). Although Post‑processing waiting time (min) 29.12±6.16 6.27±1.61 <0.001
Time to reach PADSS 9 (h) 5.31±1.01 19.85±4.05 <0.001
VAS values at hours 12 and 24 were lower in Group ESP, Patient satisfaction level 3.69±0.47 3.15±0.73 0.005
there was no statistically significant difference (P > 0.05) Surgeon satisfaction level 3.73±0.45 3.69±0.47 0.762
Table 2. Analgesic need, n (%)
Yes 11 (42) 23 (88) <0.001
No 15 (58) 3 (12)
In the post‑operative period, time to mobilisation, oral Mann–Whitney U‑test. Group ESP: Erector spinae plane
feeding and reaching PADSS 9 was significantly shorter in block, Group S: Spinal block, SD: Standard deviation, PADSS:
Post‑anaesthesia discharge criteria
Group ESP, while the waiting time until surgery after the
procedure was significantly shorter in Group S.(P < 0.05)
Post‑operative requirement for rescue analgesics was Group ESP (P < 0.05). There was no significant difference
statistically significantly higher in Group S (P < 0.05). between the amount of intraoperative fentanyl use
Patients in group ESP exhibited a statistically significant (P > 0.05). In the intraoperative period, the patients
high level of patient satisfaction (P < 0.05). There was no in Group ESP required a mean of 5.54 ± 3.71 mg of
statistically significant difference between the groups in local anaesthetics. In Group S, no local anaesthetics
terms of operation time, surgeon satisfaction level and were administered to any of the patients developing
time of first analgesic administration to patients requiring blocks successfully. Urinary retention and shivering,
analgesics (P > 0.05) [Table 3]. which were recorded as post‑operative complications,
were significantly more common in Group S (P < 0.05).
Intraoperative requirement of midazolam for sedation No statistically significant difference was found
was significantly lower in Group S, while post‑operative between the groups in terms of headache, nausea and
requirement of diclofenac was significantly lower in bleeding (P > 0.05) [Table 4].
Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023 5
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block

Table 4: The amount of analgesic and anaesthetic use and The nerve divides into genital and femoral branches. The
complications (n=26) lateral femoral cutaneous nerve originates from the L2 and
Group ESP Group S P
L3 spinal nerves.[16]
Diclofenac (mg)** 21.15±25.19 71.15±42.83 <0.001
Fentanyl (µg)** 21.15±28.89 17.31±24.25 0.703
Midazolam (mg)** 2.46±1.02 1.81±1.05 0.040 In our study, we aimed to diffuse the local anaesthetic
Tümescent local anaesthetic (mL) 5.54±3.71 0.00±0.00 <0.001 between T12 and L3 levels by applying a single injection
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Urinary retention*
at the L1 level and a volume of 30 ml for ESP block. In
Yes 0 4 (15) 0.037
No 26 (100) 22 (85) this way, we aimed to provide strong somatic and visceral
Headache* anaesthesia by blocking the ilioinguinal, iliohypogastric,
Yes 0 2 (8) 0.149
genitofemoral and lateral cutaneous femoral nerves that
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No 26 (100) 24 (92)
Nausea* innervate the inguinal region.
Yes 2 (8) 5 (19) 0.223
No 24 (92) 21 (81)
Shivering*
The local anaesthetic mixture we used in the ESP group
Yes 0 6 (23) 0.042 consisted of lidocaine hydrochloride, bupivacaine
No 26 (100) 20 (77) hydrochloride, sodium bicarbonate, adrenaline tartrate and
Bleeding*
Yes 1 (4) 0 0.313
physiological saline. By opting for a mixture instead of a
No 25 (96) 26 (100) single local anaesthetic, we aimed to; increase the analgesic
*Pearson’s Chi‑square test, **Mann–Whitney U‑test. Data presented as effect of the local anaesthetic with sodium bicarbonate
mean±SD or number of patients (%). Group ESP: Erector spinae plane
block, Group S: Spinal block, SD: Standard deviation
acting as a buffer,[17] prolong the effect of local anaesthetics
by creating epinephrine‑induced regional ischaemia and
DISCUSSION reduce systemic toxicity by preserving it at the injection
site,[18] shorten the onset of anaesthesia by using lidocaine,
ESP block requires relatively large volumes of local which is a medium‑acting local anaesthetic and long‑acting
anaesthetics (0.3–0.5 mL kg − 1) under USG guidance. bupivacaine together.[19]
It has been shown to diffuse from the injection site to
vertebral levels 3–6 in the cranial and caudal directions, In our study, all patients in the EPS group and control
while its diffusion in the mediolateral direction is limited.[12] group were over 50 years old, with a mean age of
It provides somatic and visceral analgesia and anaesthesia 61.53 ± 9.87 years. The reason why we included patients
in the site of innervation of the nerve it affects due to the over middle age is because we think that ESP block is
spread of local anaesthetic limited to the erector spinae especially preferred in middle and advanced aged patients
muscle, which encompasses the rib edges and surrounds with comorbidities. In our study, the patients in the ESP
the thoracolumbar fascia. The spread of local anaesthetic and spinal anaesthesia groups exhibited similarities in terms
injected from T10 in a volume of 30 ml up to T5 and T12 of other demographic data, intraoperative haemodynamic
was demonstrated by magnetic resonance imaging.[13,14] measurements and surgical side.

Inguinal hernia repair surgeries are fairly common but
relatively complex procedures. In inguinal hernia repair,
innervation of the surgical incision area is mostly provided
by the ilioinguinal and iliohypogastric nerves and the
anatomical variations in their routes. In addition, some
branches of the genitofemoral and lateral cutaneous femoral
nerves are also observed to be involved in the innervation
of the inguinal region.[15] Motor block formation is not
required for the administration of anaesthesia in inguinal
hernia repair. Blocking the nerves mentioned above with
local anaesthesia can provide necessary intraoperative
anaesthesia.
The iliohypogastric nerve originates from the spinal T12
and L1 levels. The ilioinguinal nerve originates from a
branch of the L1 spinal nerve. The genitofemoral nerves
arise from the upper part of the L1 and L2 spinal nerves.
6 Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023
It has been reported that SA induces intraoperative
hypotension, for which pre‑operative fluid loading provides
prevention.[20] In our study, 10 ml/kg of crystalloid was
administered pre‑operatively to patients in Group S.
Therefore, we think that there is no significant difference
between the MAP values of the patients in both groups.
The reason why we preferred pre‑operative fluid loading
was to prevent the problems associated with hypotension
in the SA group from affecting the results in a false positive
way by acting on the intraoperative and post‑operative
results of our patients in the ESP and S groups.
To date, no formal dose studies have been published for
ESP block, but the most common doses are 20–30 ml or
0.2–0.3 ml/kg. The diffusion of local anaesthetics in ESP
block is likely to be correlated with volume.[21] For this
reason, we used a volume of 30 ml in our study.
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block
We evaluated the VAS score at 6‑h intervals in the
post‑operative period. Various case reports show that the
ESP block can be used in abdominal surgeries and provides
effective analgesia in the post‑operative period. However,
most of these studies are not randomised and controlled[22]
On the other hand, Tulgar et al.[23] reported that ESP
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block significantly improved analgesia and reduced opioid
consumption following laparoscopic cholecystectomy.
Chin et al.[24] showed that ESP block is effective in relieving
visceral abdominal pain following gastric bypass surgery
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in their 3‑case report.
In our study, the intraoperative VAS score was higher in
the ESP block group, with a mean score of 1.31 ± 0.92
at the beginning of the operation. We preferred to use
local anaesthetics when necessary to prevent discomfort
that may occur during the incision. The mean use of local
anaesthetic per case was 5.54 ± 3.71 ml. Six of the patients
in the ESP group did not need to use local anaesthesia.
We think that this value can be considered as rather low. It
has also been reported that there may be some variations
in the innervation of the inguinal region.[15] The relatively
higher intraoperative VAS value in ESP block compared
to Group S and the need for local anaesthetic use, albeit
in low volume, make us think that in some cases, the
spread of local anaesthetic may be insufficient to block
some branches of the genitofemoral or lateral cutaneous
femoral nerves.
The VAS value at the 6th‑h was significantly lower in the
ESP group. There was no significant difference between
the two groups in terms of VAS values measured at hour
12 and 24. The VAS score in the ESP group was never
measured above a mean of 2.54 ± 1.83 in any time period.
These results show that ESP block significantly reduces the
level of pain in the post‑operative period.
It has also been reported that ESP block can be applied
easily and safely at the lower lumbar level for pain control
in complex regional pain syndrome, and it significantly
reduces NRS score and tramadol use.[25] Our study included
patients with unilateral hernias and we preferred to use
non‑steroidal anti‑inflammatory drugs instead of opioid
analgesia in the post‑operative period since the surgery
was less invasive and the surgical incision was smaller. No
analgesic requirement emerged in 58% of our patients in
the ESP group. This rate was only 12% in the SA group.
Although the time of rescue analgesics was similar, the
total amount of diclofenac use in the post‑operative
period was significantly lower in the ESP group. These
results show us that ESP block significantly reduces the
need for analgesics.
Journal of Minimal Access Surgery | Volume XX | Issue XX | Month 2023
One of the main disadvantages of SA in inguinal hernia
surgery is delayed mobilisation and delayed oral feeding due
to prolonged motor block time and discharge time. Singh
et al.[26] reported a significant time of 196.4 ± 21.2 min of
motor block time, prolonged first urination time, nausea
and vomiting in their study where they used 3 ml of 0.5%
hyperbaric racemic bupivacaine in 50 patients undergoing
inguinal hernia repair. These factors play an especially
important role on the level of patient satisfaction. Since
we compared SA with ESP block in our study, we did not
measure the duration of motor and sensory blockade. In
the ESP group, time to mobilisation and initiation of oral
feeding and time to reach PODSS 9 were significantly
shorter, while the level of patient satisfaction was higher.
Operation time, which is one of the most important
factors of surgeon satisfaction, was similar in both groups,
and there was no significant difference between surgeon
satisfaction levels. In addition, the patients in the ESP group
had to wait longer for adequate anaesthesia to occur after
the block was applied. We tried to reduce this disadvantage
by keeping the patients in the ESP group waiting in the
pre‑operative preparation room and transferring them to
the operating room after sensory blockade.
Khetarpal et al.[27] conducted a study in which they compared
paravertebral block (PVB) and SA in inguinal hernia repair
with a group of patients similar to our study, and reported
that it was associated with less post‑operative analgesic
requirement, shortened mobilisation time and discharge
time, as well as longer block time and surgical anaesthesia
in the PVB group without any effect on operation time
and MAP levels. These results are consistent with the
results we obtained from the ESP group in our study. In
addition, urinary retention, headache, nausea and vomiting
were more common in the SA group. In our study, urinary
retention was significantly higher in the S group, but there
was no significant difference in terms of nausea, bleeding
and headache.
Spinal anaesthesia inhibits vasoconstriction, which plays an
important role in temperature regulation. It also causes a
redistribution of core heat to peripheral tissues below the
block level. This has been reported to predispose patients to
hypothermia and shivering.[28] In our study, it was observed
that post‑operative shivering was significantly higher in
Group S. We did not observe post‑operative shivering in
any of the patients in the ESP group.
Post‑dural puncture headache (PDPH) is especially one
of the most unpleasant complications of SA. Xu et al.[29]
reported the rate of PDPH as 6.6% in patients in whom
Quincke spinal needles were used. In our study, no patients
7
 Kaçmaz, et al.: Spinal anaesthesia versus erector spinae plane block
in the ESP group reported headaches while two patients
in the S group reported headaches, but there was no
statistically significant difference. This ratio is consistent
with the ratio reported by Xu et al.[29]
Rani et al.[30] compared SA using 12.5 mg of 0.5% hyperbaric
Downloaded from http://journals.lww.com/jmas by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
bupivacaine with PVB, and reported high intraoperative
fentanyl use in the PVB group. In our study, there was no
difference between the amount of intraoperative fentanyl
use. We think that this is due to the fact that there was no
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/29/2023
need for additional intravenous analgesics in the ESP group
due to the relief of pain with the local anaesthetics we
used, which may occur in some patients due to anatomical
variations in the ESP group. Midazolam use was more
common in the ESP group. This may be due to the fact
that patients in the ESP group are more likely to experience
anxiety due to the administration of somatic and visceral
analgesia without motor blockade.
This is the first randomised study comparing the effects
of SA versus ESP used for intraoperative anaesthesia in
inguinal hernia repair.
Limitations
The study was conducted with a limited sample group.
Therefore, the power of the study is relatively low. Our
study is a single‑centre study.
CONCLUSION
ESP block supported by low‑dose intraoperative local
anaesthetic infiltration for anaesthesia in unilateral inguinal
hernia surgeries creates a sufficient level of surgical
anaesthesia (non‑inferiority) compared to SA. ESP
block can also provide less analgesic requirement, early
mobilisation, early discharge time, low post‑operative pain
level, less complication rate and high patient satisfaction
in the post‑operative period. More randomised controlled
studies are needed to conclude that ESP nerve block can
be used instead of SA in inguinal hernia repair.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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