Comparison of Lumbar Erector Spinae Plane Block and Spinal Anesthesia in Hip and Proximal Femur Surgery

Hip and proximal femur surgeries are frequently performed in elderly patients and require anesthetic techniques that provide sufficient surgical anesthesia while limiting the need for additional intraoperative opioid administration. In this patient population, selecting an appropriate anesthetic approach is particularly important due to age-related physiological changes and the presence of comorbidities.

This study was designed as a prospective, randomized, single-blind clinical trial comparing ultrasound-guided lumbar erector spinae plane (ESP) block performed at the L4 vertebral level with spinal anesthesia in patients undergoing hip and proximal femur surgery. After obtaining written informed consent, eligible adult patients were randomly assigned to one of the two anesthetic techniques using a computer-generated randomization sequence. Intraoperative assessments were performed by an investigator who was blinded to group allocation.

All patients received standardized premedication consisting of intravenous midazolam 2 mg and fentanyl 100 µg prior to the anesthetic procedure. In the spinal anesthesia group, spinal anesthesia was performed at the L4-L5 interspace according to institutional routine practice. In the ESP block group, an ultrasound-guided erector spinae plane block was performed at the L4 level using a total volume of 30 mL of local anesthetic solution, composed of 15 mL of 0.5% isobaric bupivacaine, 7.5 mL of 2% lidocaine, and 7.5 mL of normal saline.

Standard intraoperative monitoring, including electrocardiography, non-invasive blood pressure measurement, and peripheral oxygen saturation, was applied to all patients throughout the surgical procedure. The adequacy of anesthesia was evaluated intraoperatively based on clinical signs and the requirement for additional opioid administration. Intraoperative opioid use was recorded as present or absent and documented.

When inadequate anesthesia or analgesia was observed, rescue opioid analgesia was administered according to a standardized institutional protocol. Patients in whom adequate anesthesia could not be achieved with the assigned technique and who required conversion to general anesthesia were excluded from the final analysis.

The primary parameters evaluated in this study included the anesthetic technique applied (lumbar ESP block or spinal anesthesia), intraoperative opioid use and the time to first postoperative rescue analgesic administration. This study aims to provide clinical data on whether lumbar ESP block can be used as an effective and safe alternative to spinal anesthesia in hip and proximal femur surgery.

Inclusion criteria

• Age 18 to 80 years
• American Society of Anesthesiologists (ASA) physical status I, II, or III
• Patients diagnosed with hip fracture requiring surgical intervention
• Patients diagnosed with proximal femur fracture requiring surgical intervention

Exclusion criteria

• Known allergy to local anesthetic agents
• Patients younger than 18 years or older than 80 years
• American Society of Anesthesiologists (ASA) physical status IV or higher
• Lumbar skeletal deformity or history of previous lumbar spine surgery
• Contraindications to regional anesthesia (e.g., coagulopathy, infection at the injection site, severe hypovolemia, patient refusal)
• Pregnancy