Overview
Spine surgery encompasses an extremely broad spectrum — from a single-level lumbar microdiscectomy (often day-case) to multilevel deformity correction with instrumentation (major surgery, large incisions, significant blood loss). PROSPECT addresses this with two separate guidelines: one for laminectomy/discectomy (simpler, more common procedures) and one for complex spine surgery (multilevel fusion, deformity, revision surgery).
Both share a common multimodal foundation but diverge meaningfully in regional technique recommendations and the role of agents like ketamine, reflecting the very different pain trajectories of minor versus major spinal procedures.
Quick distinction: Use the Laminectomy/Discectomy pathway for single/two-level decompression without instrumentation. Use the Complex Spine Surgery pathway for multilevel fusion, deformity correction, revision surgery, or any procedure with substantial instrumentation and expected blood loss.
Laminectomy / Discectomy
For single- or two-level lumbar laminectomy/discectomy without instrumentation. Recommends paracetamol + NSAID/COX-2 as basic analgesia, with wound infiltration as an effective adjunct. Many of these procedures are now performed as day-case surgery.
- Paracetamol 1g PO
- COX-2 inhibitor or NSAID PO
- Gabapentin 300mg — selected patients with radicular pain
- Dexamethasone 8 mg IV
- Wound infiltration by surgeon (LA ± adjuvant)
- Paracetamol 1g IV (if not given pre-op)
- ESP block — emerging evidence, growing adoption
- Routine epidural opioids — limited evidence for this procedure
- Paracetamol 1g QDS regular
- NSAID/COX-2 regular ≤5 days
- Opioid PRN rescue
- Early mobilisation — often same-day for discectomy
Based on PROSPECT 2021 (Peene, Le Cacheux, Sauter, Joshi, Beloeil — Eur Spine J 2021;30:2925–2935).
Wound Infiltration
Local anaesthetic wound infiltration by the surgeon at closure has shown benefit specifically for laminectomy and microdiscectomy (though not demonstrated for complex spine surgery). Typically ropivacaine 0.2–0.5% 20–30 mL infiltrated into the paraspinal muscle layers and subcutaneous tissue before closure.
Complex Spine Surgery
For multilevel fusion, deformity correction, and revision spine surgery. Recommends paracetamol + COX-2/NSAID + intraoperative low-dose ketamine infusion + epidural analgesia (LA ± opioid) where surgically feasible. This guideline places significantly more emphasis on systemic adjuvants given the greater surgical trauma and higher pain intensity.
- Paracetamol 1g PO
- COX-2 inhibitor PO (if surgeon agrees re: fusion/bleeding risk)
- Gabapentin — selected chronic pain/opioid-tolerant patients
- Ketamine bolus 0.3–0.5 mg/kg + infusion 0.1–0.3 mg/kg/h
- Epidural LA ± opioid — if surgically placed
- Dexamethasone 8 mg IV
- Paracetamol 1g IV
- ESP block bilateral — emerging, promising but limited PROSPECT evidence
- Methadone — not recommended (limited safety profile vs shorter-acting opioids)
- Paracetamol 1g QDS regular
- COX-2 if NSAID-tolerant (discuss with surgeon re: fusion)
- Continue ketamine infusion 24–48h if started
- Epidural infusion if catheter placed
- Opioid PRN/PCA rescue
- Early mobilisation per protocol
Based on PROSPECT 2021 complex spine surgery guideline (Eur J Anaesthesiol 2021). See PMC8373453.
NSAID caution in spinal fusion: NSAIDs theoretically impair bone healing/fusion via COX-2 inhibition of osteogenesis. Evidence is mixed and largely from animal models; short-course perioperative use (≤5 days) is generally considered low-risk by most spine surgeons, but always discuss with the surgical team before routine use in fusion surgery.
Erector Spinae Plane Block (ESPB)
Emerging technique — promising but not yet a core PROSPECT recommendation. Both PROSPECT guidelines note "insufficient" or "limited" evidence for ESPB at the time of their literature reviews (search concluded ~2020). Since then, multiple meta-analyses (Oh et al. 2022; Liang et al. 2021; Fu et al. 2023) consistently show ESPB significantly reduces opioid consumption and pain scores after lumbar spine surgery. It is rapidly becoming standard practice in many centres despite formal guideline lag.
Mechanism & Rationale
The ESP block deposits local anaesthetic in the fascial plane deep to the erector spinae muscle, superficial to the transverse processes. The mechanism is debated — local anaesthetic spreads along the paraspinal fascial plane to reach the dorsal rami of spinal nerves, and may also reach the paravertebral space and epidural space via foraminal spread, contributing to its broad dermatomal coverage. For spine surgery specifically, the block is performed bilaterally at the level of the surgical incision.
Technique — Ultrasound-Guided, Bilateral
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Position & probe placement
Patient prone (post-positioning for surgery) or lateral. Place linear or curvilinear probe longitudinally, 2–3 cm lateral to the spinous process at the target vertebral level, identifying the transverse process.
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Identify the layers
From superficial to deep: skin, subcutaneous tissue, trapezius (upper levels) or latissimus dorsi, erector spinae muscle, transverse process. The target plane is between erector spinae muscle and the transverse process.
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In-plane needle insertion — cephalad to caudad
Insert needle in-plane, advancing until the tip contacts the transverse process, then walk off slightly to sit in the fascial plane beneath erector spinae. Confirm with hydrodissection — LA should spread linearly along the plane, lifting the muscle off the transverse process.
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Injection — repeat bilaterally
Inject 20 mL per side at the level of surgery (or one level above for multilevel procedures). Repeat on the contralateral side. Total dose must be calculated for both sides combined.
Dosing
| Agent | Concentration | Volume (per side) | Duration | Notes |
|---|---|---|---|---|
| Ropivacaine | 0.4% | 20 mL | 10–16 h | ± dexamethasone 4 mg per side as adjuvant |
| Bupivacaine | 0.25% | 20 mL | 12–18 h | Calculate total dose both sides ≤2 mg/kg |
| Ropivacaine | 0.2% | 20–25 mL | 8–14 h | Lower concentration; safer total dose margin |
Bilateral injection = double the dose. Always calculate total LA dose for both sides combined before injecting. For a 70 kg patient with ropivacaine (max 3 mg/kg = 210 mg): 20 mL × 0.4% (4 mg/mL) × 2 sides = 160 mg — within range but leaves little margin if combined with other LA sources (wound infiltration, etc). Reduce concentration in smaller patients.
Ketamine Infusion — Complex Spine Surgery
Low-dose ketamine infusion is one of the strongest recommendations in the complex spine PROSPECT guideline — reflecting the central sensitisation and significant opioid requirements associated with major spinal procedures. Particularly valuable in opioid-tolerant patients (common in chronic back pain populations undergoing spine surgery).
| Phase | Dose | Notes |
|---|---|---|
| Induction bolus | 0.3–0.5 mg/kg IV | Standard sub-anaesthetic dose |
| Intraoperative infusion | 0.1–0.3 mg/kg/h | Stop 30–60 min before end of surgery to reduce emergence effects |
| Postoperative infusion | 0.05–0.1 mg/kg/h | Continue 24–48h in major cases; monitor for psychomimetic effects |
This is the same evidence-based approach described in detail on the Systemic Analgesia page — spine surgery (particularly complex, multilevel, or in opioid-tolerant patients) is one of the strongest indications for its use.
Epidural Analgesia
Surgically-placed epidural catheter (by the surgeon, under direct vision during wound closure) with local anaesthetic alone or combined with opioid is recommended for complex spine surgery. This differs from a standard preoperative epidural — it is placed intraoperatively at the surgical level.
Typical regimen: low-concentration LA (e.g. ropivacaine 0.1–0.2%) ± fentanyl or low-dose morphine, infused postoperatively for 24–72h depending on surgical extent and ward monitoring capability.
Intrathecal opioid: Not recommended by PROSPECT for complex spine surgery due to limited evidence in this population — distinct from its established role in some other surgical contexts (e.g. hip fracture, caesarean section).
Not Recommended / Insufficient Evidence
Despite some procedure-specific evidence of benefit, methadone is not recommended for complex spine surgery — comparator studies used shorter-acting opioids, methadone has a limited safety profile (QT prolongation, variable pharmacokinetics), and studies did not adequately incorporate non-opioid multimodal analgesia.
Conflicting evidence for spine surgery specifically. One study showed no clinically meaningful difference; not recommended as routine despite its established role in abdominal surgery.
Limited evidence in the complex spine surgery population specifically — not recommended despite use in other surgical contexts.
PROSPECT 2021 found data insufficient to formally recommend bilateral erector spinae plane block or thoracolumbar interfascial plane (TLIP) block for complex spine surgery — though noting "promising" recent publications. Subsequent meta-analyses have strengthened the evidence base considerably (see ESPB section above).
Practical Analgesic Protocols
References
- Peene L, Le Cacheux P, Sauter AR, Joshi GP, Beloeil H; PROSPECT Working Group. Pain management after laminectomy: a systematic review and PROSPECT recommendations. Eur Spine J. 2021;30:2925–2935. PMID 33247353 ↗
- PROSPECT Working Group. Pain management after complex spine surgery: a systematic review and PROSPECT recommendations. Eur J Anaesthesiol. 2021. PMC8373453 ↗
- Oh SK, Lim BG, Won YJ, Lee DK, Kim SS. Analgesic efficacy of erector spinae plane block in lumbar spine surgery: a systematic review and meta-analysis. J Clin Anesth. 2022;78:110647.
- Liang X, Zhou W, Fan Y. Erector spinae plane block for spinal surgery: a systematic review and meta-analysis. Korean J Pain. 2021;34:487–500.
- Fu MY, Hao J, Ye LH, et al. Efficacy and safety of erector spinae plane block for perioperative pain management in lumbar spinal surgery: systematic review and meta-analysis of RCTs. J Pain Res. 2023;16:1453–1475.
- Qiu Y, Zhang TJ, Hua Z. Erector spinae plane block for lumbar spinal surgery: a systematic review. J Pain Res. 2020;13:1611–1619.
- Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–627.
- Singh S, Choudhary NK, Lalin D, et al. Bilateral ultrasound-guided erector spinae plane block for postoperative analgesia in lumbar spine surgery: a randomized controlled trial. J Neurosurg Anesthesiol. 2020.