Comparison of Efficacy and Safety Between Ultrasound-Guided L4 Level 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.