Erector spinae plane block versus fascia iliaca compartment block for postoperative analgesia in total hip arthroplasty: A systematic review and meta-analysis

Abstract

Total hip arthroplasty (THA) is associated with significant postoperative pain, and while regional anesthesia techniques such as fascia iliaca compartment block (FICB) and erector spinae plane block (ESPB) are employed to manage postoperative pain, their relative efficacy and safety have not been systematically established. This review aimed to compare the efficacy and safety of ESPB and FICB for postoperative analgesia in patients undergoing THA. PubMed, Embase, APA PsycINFO, Cochrane Library, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched from inception to July 30, 2024. Two independent reviewers screened titles, abstracts, and full texts to include randomized trials comparing ESPB and FICB for postoperative analgesia in adult patients undergoing THA. Reference list screening and citation tracking of included studies ensured literature saturation. The primary outcome was 24-hour postoperative opioid consumption measured as morphine equivalents. The secondary outcomes were time to first rescue analgesic requirement, postoperative static and dynamic pain scores, and any block-related adverse effects. A prepiloted data extraction sheet, Risk of Bias 2 tool, GRADE approach, inverse variance meta-analysis, and I 2 statistic were used for data extraction, risk of bias assessment, grading certainty of evidence, meta-analysis, and assessing outcome heterogeneity, respectively. Mean (MD) or standardized mean difference (SMD) and relative risk (RR) or odds ratio (OR) with 95% confidence intervals (CIs) were used for continuous and dichotomous outcomes, respectively. Five studies randomized 280 patients undergoing THA under spinal anesthesia to receive either ultrasound (USG)-guided single shot ESPB (n = 140) or FICB (n = 140). A low to moderate level of evidence indicated no significant difference between ESPB and FICB with respect to 24-hour postoperative oral morphine milligram equivalent consumption (MD 1.23, 95% CI -3.55 to 6.01; P 0.62, I 2 = 86%), pain scores at rest at 2 (SMD -0.22, 95% CI -0.65 to 0.21; P 0.31, I 2 = 49%), 4 (SMD 0.09, 95% CI -0.39 to 0.58; P 0.70, I 2 = 61%), and 24 hours (SMD 0.25, 95% CI -0.01 to 0.51; P 0.06, I 2 = 0%) and on movement at 24 hours (SMD 0.14, 95% CI -0.30 to 0.58; P 0.52; I 2 = 54%), time to first rescue analgesic requirement in hours (MD -0.77, 95% CI -4.07 to 2.53; P 0.65, I 2 = 90%), and postoperative nausea vomiting (Peto’s OR 0.50, 95% CI 0.10 to 2.56; P 0.41). A moderate level of evidence indicated ESPB to be associated with significantly earlier onset of ambulation and reduced quadriceps weakness compared to FICB (Peto’s OR 0.17, 95% CI 0.07 to 0.42; P 0.0002, I 2 = 0%). An NNTH of 4 (95% CI 2 to 7) indicated that one additional patient incurs quadriceps muscle weakness for every four patients receiving FICB rather than ESPB for THA. There was no significant difference between ESPB and FICB for postoperative analgesia in terms of postoperative opioid consumption, pain scores, and time to first rescue analgesic requirement based on the current limited evidence, and either type of block can be used for postoperative analgesia in total hip arthroplasty. However, ESPB was associated with reduced quadriceps weakness and faster onset of ambulation as compared to FICB after THA, but the evidence comes from only two studies. Further well conducted and adequately powered randomized controlled trials comparing the two types of blocks are warranted. CRD42024551027, dated 09 June 2024.