Comparison of Ultrasound Guided Bilateral Erector Spinae Plane Block, Ultrasound Guided Bilateral Quadratus Lumborum Block and Lumbar Epidural for Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy ; a Prospective Randomized Clinical Trial

Background and Rationale:

Gynecological cancers comprise 10-15% of women's cancers, mainly affecting women post-reproductive age but posing threats to fertility for younger patients.

The goal of postoperative pain control is to reduce the negative consequences associated with acute postsurgical pain and help the patient make a smooth transition back to normal function. Traditionally, opioid analgesic therapy has served as the mainstay of treatment for acute postoperative pain. However, the recent rise in morbidity and mortality associated with opioid misuse has led to increasing demands for more investigative efforts into developing pain treatment strategies that place more emphasis on using a multimodal approach. These efforts have proved to be challenging, as the subjective nature of pain perception further complicates the ability to achieve satisfactory pain control. Furthermore, specific patient comorbidities and social factors may predispose patients to have increased pain perception.

Approximately 75 percent of patients who undergo surgery experience acute postoperative pain, which is often medium-high in severity. Less than half of patients undergoing surgery report adequate postoperative pain relief. This percentage presents a significant problem as inadequate postoperative pain control may lead to adverse physiologic effects among patients in the immediate postoperative period and place them at increased risk of developing chronic pain associated with the procedure. Severe persistent postoperative pain affects 2 to 10 percent of adults.

Multiple peer-reviewed publications address the topic of postoperative pain control in gynecologic oncology surgery. Because many of these surgeries require large laparotomy incisions, patients frequently receive intravenous opioids for pain control. Patient-controlled analgesia, or PCAs, are often used as the mechanism of delivery as they allow patients to deliver pain medications based on their perceived needs. Intravenous opioids are associated with undesired side effects, including nausea, pruritus, hallucinations, and delay in the return of bowel function, which may ultimately lead to prolonged hospitalization and extended recovery times. The use of ultrasonographic technology in regional anesthesia practice has not only eased the application of nerve blocks and interfascial blocks but also led to the definition and practical use of many new interfascial blocks. Thoracoabdominal/thoracolumbar blocks - also named as truncal blocks, have gained popularity recently with the number of such defined blocks increasing substantially.