Spinal Anesthesia With Use of an Erector Spinae Plane Block Is Associated With Reduced Opioid Use and Improved Clinical Outcomes in Single-Level Transforaminal Lumbar Interbody Fusions: Evolution of Techniques and a Single-Surgeon Retrospective Analysis

Background General anesthesia (GA) has long been the preferred modality of anesthesia for spine surgery, including transforaminal lumbar interbody fusions (TLIFs). However, recent advances in regional anesthesia, including spinal (awake) anesthesia and regional blocks, have demonstrated potential improvements in both surgical outputs and recovery times compared with GA. This study aims to describe the associations between regional anesthesia, clinical outcomes, and opioid utilization among patients undergoing TLIF. Methods The electronic medical records of a single fellowship-trained spine surgeon were analyzed retrospectively, and patients undergoing a single-level TLIF between 2018 and 2024 were included. Pre- and postoperative clinical measures (eg, length of stay, operating time, and readmission rates) and both intra- and postoperative opioid use were collected. All data were analyzed using a multivariable regression model. Results Compared with GA, awake anesthesia was associated with reduced intraoperative opioid utilization (P = 0.007) across all TLIF groups, while the use of an erector spinae plane (ESP) block was associated with a reduced length of stay (P = 0.044) and lower postoperative opioid utilization (P < 0.001). The use of spinal anesthesia combined with the use of an ESP block was associated with significantly lower length of stay and lower postoperative morphine equivalent daily dose (P = 0.030 and P = 0.002, respectively). Conclusions Awake TLIF surgery under spinal anesthesia and the use of an ESP block were independently associated with reduced opioid usage, while the combined use of these techniques was associated with decreased length of stay and reduced postoperative opioid usage. Additional investigation and prospective studies are needed to further elucidate these complex relationships. Clinical Relevance The relationship between regional anesthesia and patient outcomes has not been comprehensively characterized in the TLIF patient population despite the growing utilization of these techniques in spine surgery. Once established, these findings have potential implications for the integration of regional anesthesia into TLIF procedures as a new standard of care. Level of Evidence Preliminary evidence suggests that regional anesthesia offers multiple benefits over GA, including health and mortality outcomes, time to ambulation and recovery, and incidence of postoperative complications. However, little is known about the applicability of these findings to patients undergoing TLIF.