Comparison of spinal anesthesia and erector spinae plane block in terms of pain management, perioperative hemodynamic changes, morbidity and mortality in critically adult patients undergoing surgery due to femur fracture

Introduction and Aim: Hip fractures are commonly encountered in the elderly population and require surgical treatment. They are associated with high mortality rates and often require postoperative intensive care follow-up, placing a significant burden on the healthcare system. Currently, regional anesthesia techniques are widely used in hip surgeries, with spinal anesthesia being a well-established and reliable method. Recently, erector spinae plane block (ESPB) has emerged as an effective regional anesthesia and analgesia technique. Some case series with fewer patient populations have reported the use of ESPB as the primary anesthetic method. This study aims to compare the effects of spinal anesthesia and ESPB, used as primary anesthesia methods, on perioperative hemodynamics, pain control, and mortality in critically ill adult patients undergoing surgery for hip fractures. Materials and Methods: This prospective, randomized clinical study included 40 patients aged ≥ 65 years with hip fractures, ASA score ≥ III, and frailty index ≥5. Participants were randomly assigned to two groups (Group 1: patients who received ESPB; Group 2: patients who received spinal anesthesia). The demographic data, vital signs, and pain scores were recorded preoperatively. Intraoperative and postoperative hemodynamic parameters, sedation levels, complications, pain scores, and analgesic requirements were recorded at specified intervals. Patients were followed-up for mortality on postoperative days 30 and 90. Data were analyzed using SPSS 18.0, and intergroup differences were evaluated using appropriate statistical tests with a 95% confidence interval and significance level of p<0.05. Results: Of the patients, 20 underwent surgery under ESPB and 20 under spinal anesthesia. The demographic variables were similar between the groups. Intraoperatively, diastolic blood pressure at minutes 0 and 45 and mean arterial pressure at minute 45 were significantly lower in the spinal anesthesia group than in the ESPB group (p=0.007, p=0.026, and p<0.05, respectively). The incidence of intraoperative hypotension (p=0.025) and ephedrine requirement (p=0.018) were significantly higher in the spinal anesthesia group, while the requirement for propofol was significantly higher in the ESPB group (p<0.001). In the postoperative intensive care follow-up, the spinal anesthesia group exhibited significantly lower diastolic and mean blood pressure at 6 h, systolic blood pressure at 12 h, and diastolic and mean blood pressure at 18 h than the ESPB group (p=0.032, p=0.032, p=0.028, p=0.027, p=0.020, respectively). The mortality rates within the first 30 days postoperatively and between days 30 and 90 were similar between the groups (p=0.605 and p=0.999, respectively), with no significant difference in the mean day of mortality (p=0.174). Conclusion: Although ESPB was associated with a higher need for sedation (propofol) during the intraoperative period, it provided better hemodynamic stability, demonstrated fewer hypotension-related complications, and showed similar outcomes in terms of postoperative analgesia and mortality compared with spinal anesthesia. Therefore, ESPB can be considered a viable alternative to spinal anesthesia in elderly adult patients with a frailty index of ≥5 undergoing femur fracture surgery.