Comparison of liposomal bupivacaine erector spinae plane block versus wound infiltration for postoperative analgesia and quality of recovery in lumbar fusion surgery: a randomized controlled trial

Abstract

Background

This study aimed to compare the efficacy of liposomal bupivacaine ultrasound-guided erector spinae plane block (ESPB) with wound infiltration (WI) on postoperative analgesia and quality of recovery in patients undergoing lumbar spinal fusion surgery.

Methods

Eighty patients scheduled for lumbar fusion surgery were randomized to receive either WI (n = 40) or ultrasound-guided bilateral ESPB (n = 40). Pain intensity in the postanesthesia care unit (PACU) and at 6, 12, 24, 48 and 72 h after surgery was the primary outcome. The secondary outcomes included quality of recovery, intraoperative opioid consumption, use of rescue analgesics within 72 h and postoperative lumbar function. Adverse events were recorded.

Results

Compared with the WI group, the ESPB group demonstrated lower pain scores in the PACU (median [IQR]: 2 [1,2] vs. 2 [2,3]; median difference, −1; 95% confidence interval [CI] −2 to −1; P < 0.001) and at 6 h after surgery (median [IQR]: 2 [1,2] vs. 3 [2,3]; median difference, −1; 95% CI −1 to −1; P < 0.001). There were no significant differences in VAS scores between the two groups beyond 6 h. In addition, the ESPB group had higher Quality of Recovery-15 scale scores at 72 h after surgery (mean ± SD: [119.49 ± 5.01] vs. [116.61 ± 4.33]; P = 0.009). The doses of sufentanil (median [IQR]: 20 [20,22] vs. 25 [23,30]; P < 0.001) and remifentanil (median [IQR]: 680 [560,850] vs 775 [647.5,1005]; P = 0.042) were significantly lower in the ESPB group than those in the WI group. However, there were no differences in the Oswestry Disability Index between the groups at 1 or 3 months after surgery.

Conclusions

For patients undergoing lumbar spinal fusion surgery, compared with WI, ultrasound‑guided ESPB with liposomal bupivacaine provided a slight advantage in improving postoperative analgesia and quality of recovery, and reduced intraoperative opioid consumption. However, these findings probably lack clinical significance.

Trial registration: This study was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR240084425; Registration Date: May 16, 2024).

Background

Lumbar spinal fusion often causes significant postoperative pain because of severe damage to the structure of the spinal anatomy and the paraspinal musculature. Poorly controlled postoperative pain not only leads to delayed postoperative recovery but also increases the length of hospitalization and the risk of persistent pain [1, 2]. Although opioids are the mainstay of postoperative analgesia, they are associated with several adverse effects, such as dizziness, vomiting, and respiratory depression [3]. Multimodal analgesia is currently a highly recommended strategy for postoperative pain management to achieve the goal of enhanced recovery after surgery (ERAS) [4].

Local infiltration analgesia has progressively emerged as a crucial component of multimodal analgesia protocols since it was first proposed by Kerr et al. [5, 6]. Wound infiltration (WI) has been reported to have an effect that is comparable to modified thoracolumbar interfascial plane block in terms of postoperative opioid consumption and VAS scores in patients undergoing lumbar disc surgery [7]. Li et al. [8] also demonstrated that wound infiltration significantly reduced opioid consumption. Furthermore, with the application of ultrasound visualization technology, ultrasound-guided erector spinae plane block (ESPB) has emerged as particularly beneficial for lumbar spine surgery [9, 10]. In a recent randomized controlled trial [11], ESPB significantly prolonged the duration of analgesia and reduced opioid consumption. Therefore, both WI and ESPB play important roles in postoperative pain management. Comparisons of these approaches in lumbar spinal fusion surgery are clinically significant within the multimodal framework.

However, the longer analgesic effect of regional anesthesia cannot be achieved without the help of long-acting local anesthetics. Liposomal bupivacaine has been described as achieving sustained release that extends the duration of analgesia by encasing standard local anesthetics within liposomes [12]. Brown et al. [13] reported that local infiltration of liposomal bupivacaine (266 mg/60 ml) prior to wound closure in elective spinal surgery did not increase the incidence of adverse reactions. In recent years, several studies on the application of liposomal bupivacaine in lumbar spinal fusion have shown decreased opioid usage and effective postoperative analgesia [14, 15]. However, these studies are limited because the patients received bupivacaine liposome injection only before wound closure and not before the skin incision. A previous study indicated that local infiltration before the incision resulted in a decrease in peripheral sensitization [16]. Nesioonpour et al. [17] reported that preoperative wound infiltration with bupivacaine not only alleviated pain but also decreased the incidence of nausea and vomiting during the initial 24-h post-operative period. However, they did not compare ESPB with the current standard practice of WI. In the present study, we aimed to evaluate the effects of liposomal bupivacaine ESPB versus WI on postoperative analgesia and quality of recovery in patients who underwent lumbar fusion surgery. This can help guide clinicians in selecting the most effective analgesia technique and improving patient outcomes.

Methods

This randomized controlled trial was successfully completed between May 2024 and January 2025 at the Third Affiliated Hospital of Anhui Medical University. We recruited patients who met the following criteria: (1) aged 18–70 years, (2) classified as American Society of Anesthesiologists (ASA) physical status I–III, and (3) scheduled for elective transforaminal lumbar interbody fusion (TLIF) or minimally invasive spinal-transforaminal lumbar interbody fusion (MIS-TLIF). The exclusion criteria were as follows: (1) body mass index of 30 kg·m⁻² or higher, (2) resting heart rate less than 50 beats per minute, (3) significant cardiovascular, renal, or hepatic insufficiency, (4) inability to communicate due to severe dementia, hearing impairment, or language barriers, (5) chronic dependence on opioids, (6) allergy to liposomal bupivacaine, (7) failure of the erector spinae plane block, or (8) a history of prior lumbar surgery.

Randomization and blinding

Participants were assigned to either the ESPB group or the WI group using a computer-generated random number sequence in a 1:1 ratio, with allocation conducted in a blinded fashion. The random numbers and group assignments were placed in sequentially numbered, opaque envelopes and stored by a study coordinator. These envelopes were opened following the administration of general anesthesia on the day of surgery. Experienced anesthesiologists performed ESPB before surgery, whereas attending surgeons conducted WI before both the incision and wound closure stages. Although anesthesiologists and surgeons were informed about the study intervention, all the patients, investigators responsible for postoperative evaluations, and other study staff remained unaware of the group assignments.

Anesthesia procedures and interventions

All the patients were subjected to a standardized general anesthesia protocol. Electrocardiography, blood oxygen saturation, heart rate, invasive blood pressure, and respiratory rate were monitored before anesthesia induction. General anesthesia was induced with the administration of etomidate (0.3 mg/kg), esketamine (0.3 mg/kg), and sufentanil (0.3 μg/kg), followed by cisatracurium besilate (0.2 mg/kg). Endotracheal intubation was successfully performed using a video laryngoscope. Mechanical ventilation was subsequently established, with the end-tidal carbon dioxide partial pressure maintained within 35–45 mm Hg.

Patients were placed in the prone position. After precise positioning, the surgeon marked the central incision on the patient’s skin. Wound infiltration was carried out twice by the attending surgeon during the surgical procedure. After disinfection was achieved and before the skin incision, 0.443% liposomal bupivacaine was infused into the skin, subcutaneous tissue, and muscle layers along each side of the marked central incision (according to the incision size, 3–5 sites on one side were selected for equal and uniform injection, each site was 1 cm away, and the total amount of local anesthetic was 30 ml). The anesthetic was infiltrated into multiple layers of the surgical wound before skin closure to ensure that the local anesthetic to covered the entire surgical area (the procedure and dosage being the same as before).

For patients in the ESPB group, a high-frequency Linear ultrasound probe was used to identify the target spinous process. The probe was subsequently repositioned approximately 3–4 cm lateral to the midline to locate the tip of the corresponding transverse process. The probe was placed in a parasagittal position to clearly observe the transverse process and the surrounding muscle structures. A 21-gauge, 80-mm needle was advanced using an in-plane approach until it reached the transverse process. After the correct placement of the needle tip was verified with 2 mL of normal saline, 20 mL of 0.665% liposomal bupivacaine was injected under continuous ultrasound guidance to ensure proper distribution of the anesthetic around the intended region. The same procedure was subsequently performed on the contralateral side.

Anesthesia maintenance was accomplished through the administration of propofol infusion, remifentanil infusion, cisatracurium besilate, and sevoflurane inhalation, ensuring appropriate anesthesia depth and hemodynamic stability. Sufentanil was provided as needed to support intraoperative analgesia. The target anesthesia depth was set within a BIS range of 40 to 60. Thirty minutes before the anticipated conclusion of the surgery, 100 mg of flurbiprofen axetil and 4 mg of ondansetron were administered. Patients were monitored and extubated in the postanesthesia care unit (PACU) after surgery. Pain intensity was assessed with a visual analog scale (VAS) in the PACU. Patients were transferred to the general ward when their VAS score was ≤ 3 and they met the PACU discharge criteria. However, when the highest VAS score exceeded 3, sufentanil (5 μg) was administered for supplemental analgesia. Pain intensity was evaluated again after 5 min. If the VAS score remained > 3, intravenous sufentanil (5 μg) was readministered until the score decreased to ≤ 3. Patients were excluded from the study if sufentanil was administered more than three times. No subjects were provided with a patient-controlled analgesia pump for postoperative analgesia. For the first two days in the hospital ward, 50 mg of flurbiprofen axetil was administered intravenously every day. Additionally, rescue analgesia was delivered via intravenous dezocine (5 mg) whenever the VAS score surpassed 4.

Outcome measures

Baseline data, including patient demographics, comorbidities and American Society of Anesthesiologists (ASA) classification were recorded on the day before surgery. Intraoperative data, including estimated blood loss; durations of anesthesia, surgery, and extubation; and number of surgical segments, were collected on the day of surgery.

The primary outcome was the postoperative pain intensity, which was assessed with a VAS (scores ranging from 0 to 10, with 0 indicating no pain and 10 indicating the worst pain) at predetermined time points (in the PACU and at 6, 12, 24, 48, 72 h postoperatively). The highest VAS score (VAS_max) was recorded. Investigators who performed postoperative follow-up were blinded to the group allocations and were not involved in the administration of anesthesia or surgery. They were trained on a standardized protocol for VAS evaluation. The secondary outcomes were the quality of recovery, intraoperative opioid usage, the need for rescue analgesics within 72 h, and postoperative lumbar function. The quality of recovery was evaluated at 24 h and 72 h after surgery using the Quality of Recovery-15 scale (QoR-15, overall scores range from 0 to 150, with a higher score indicating better postoperative recovery) [18]. Opioid consumption was measured from the beginning of anesthesia until the patient left the PACU. Lumbar function was assessed before surgery and at 1 and 3 months after surgery with the Oswestry Disability Index (ODI; the percentage ranged from 0 to 100%, with a higher percentage indicating more severe spinal dysfunction) [19]. Telephone administration was necessary to obtain outcome data after discharge.

Adverse events were recorded from the beginning of anesthesia until 48 h after surgery. These included: bradycardia, defined as a heart rate (HR) less than 50 beats/min; tachycardia, with an HR exceeding 100 beats/min; hypotension, characterized by a systolic blood pressure less than 90 mmHg or a reduction greater than 30% from baseline; hypertension, indicated by a systolic blood pressure above 180 mmHg or an increase of more than 30% from baseline; respiratory depression, defined as a spontaneous respiratory rate below 8 breaths/min; postoperative nausea and vomiting (PONV); and dizziness.

Statistical analysis

Statistical analysis was carried out using SPSS version 25.0 (IBM, New York, USA). The Shapiro–Wilk test was used to assess the normality of continuous variables. Data following a normal distribution are presented as the mean ± SD and were analyzed using an independent t test. For nonnormally distributed data, data are represented as medians (interquartile ranges, IQRs) and were compared using the Mann–Whitney U test. Categorical variables are reported as n (%) and were evaluated using the chi-square test or Fisher's exact test. The median difference along with its 95% confidence interval (CI) was estimated using Hodges–Lehmann estimators. The generalized estimating equation method was applied to compare the VAS_max at different time points between the two groups. For repeatedly measured variables, including the quality of recovery scores and postoperative ODI, repeated measures analysis of variance was employed for comparison. Statistical significance was set at a two-sided P < 0.05.

Sample size estimation

In our pilot study, the VAS_max score in the PACU was 2.43 ± 1.27 for 10 patients who received wound infiltration and 1.43 ± 1.13 for 10 patients who received ESPB. With the significance level set to α = 0.05 and the power set to 1–β = 90% on a two-sided t test, the required sample size was calculated, using PASS 15.0 software, to be 32 patients in each group. To account for a 20% dropout rate, we ended up with 40 patients in each group.

Results

A total of 88 patients were evaluated for eligibility. Of these, 8 patients were excluded, resulting in 80 patients ultimately being enrolled and randomized. In the WI group, one patient withdrew consent, and one patient from each group was lost to follow-up (Fig. 1). Baseline data were well balanced and the intraoperative data were comparable between the two groups (Table 1).

Fig. 1.

Study flow chart. WI group: the patients received wound infiltration with liposomal bupivacaine; ESPB group: the patients received ultrasound-guided erector spinae plane block with liposomal bupivacaine

Table 1.

Baseline Data and Clinical Characteristics

	WI group (n = 38)	ESPB group (n = 39)	P value
Age (years)	58.3 ± 10.1	54.9 ± 10.8	0.17
Body mass index (kg·m−2)	24.5 ± 3.8	24.1 ± 3.4	0.64
Female sex	18 (47.4%)	16 (41.0%)	0.65
Preoperative comorbidities
Hypertension	14 (36.8%)	12 (30.8%)	0.64
Diabetes	4 (10.5%)	7 (17.9%)	0.52
Coronary artery disease	2 (5.3%)	2 (5.1%)	> 0.99
Atrial fibrillation	1 (2.6%)	0 (0)	0.99
Hyperlipemia	3 (7.9%)	2 (5.1%)	0.98
ASAa classification			0.79
I	3 (7.9%)	2 (5.1%)
II	33 (86.8%)	33 (84.6%)
III	2 (5.3%)	4 (10.3%)
Preoperative ODIb (%)	(50.74 ± 7.22)%	(51.59 ± 7.27)%	0.61
Estimated blood loss (mL)	100 (50,150)	100 (50,170)	0.67
Duration of surgery (min)	126.9 ± 42.8	123.4 ± 38.3	0.71
Duration of anesthesia (min)	157.3 ± 48.2	159.2 ± 37.2	0.85
Duration of extubation (min)	7.9 ± 2.0	7.5 ± 2.5	0.53
Number of surgical segments			0.84
One	26 (68.4%)	29 (74.4%)
Two	10 (26.3%)	8 (20.5%)
Three	2 (5.3%)	2 (5.1%)

Data are mean ± SD, number (proportion), or median (interquartile range)

^aASA American Society of Anesthesiologists, SD standard deviation

^bODI Oswestry Disability Index (percentage ranges from 0 to 100%, with higher percentage indicating more severe spinal dysfunction)

The generalized estimating equation revealed that there was a significant interaction between group assignment and time for VAS_max (P < 0.001). The VAS_max in the PACU was statistically lower in the ESPB group than in the WI group (median [IQR]: 2 [1, 2] vs. 2 [2, 3]; median difference, −1; 95% confidence interval [CI] −2 to −1; P < 0.001). At 6 h after surgery, patients in the ESPB group reported a lower VAS_max than those in the WI group. (median [IQR]: 2 [1, 2] vs. 3 [2, 3]; median difference, −1; 95% CI −1 to 1; P < 0.001). There were no differences in pain scores between groups beyond 6 h postoperatively. Moreover, the VAS_max of the two groups at 72 h after surgery were significantly lower than that at the other four time points (P < 0.001, respectively) (Table 2; Fig. 2).

Table 2.

Primary and secondary outcomes

Outcomes	WI group (n = 38)	ESPB group (n = 39)	Median or mean difference (95% CI)	P value
Primary outcome
VASamax (point)
In the PACU (T0)	2 (2,3)	2 (1,2)	−1 (−2,−1)	< 0.001*
At 6 h (T1)	3 (2,3)	2 (1,2)	−1 (−1,−1)	< 0.001*
At 12 h (T2)	2 (2,3)	3 (2,3)	0 (0,0)	0.560
At 24 h (T3)	2 (1,2.25)	2 (2,2)	0 (0,0)	0.644
At 48 h (T4)	2 (1,2)	2 (1,2)	0 (0,0)	0.830
At 72 h (T5)	1 (1,1)#	1(1,2)#	0 (0,0)	0.950
Secondary outcomes
Qualility of recovery (point)
At 24 h (T3)	104.55 ± 4.84	106.18 ± 5.74	1.627 (−0.788,4.042)	0.184
At 72 h (T5)	116.61 ± 4.33	119.49 ± 5.01	2.882 (0.754,5.010)	0.009*
Use of sufentanil (ug)	25 (23,30)	20 (20,22)	−5 (−7,−4)	< 0.001*
Use of remifentanil (ug)	775(647.5,1005)	680 (560,850)	−110 (−220,0)	0.042*
Use of rescue analgesics within 72 h	6 (15.8%)	4 (10.3%)	NA	0.702
Postoperative ODIb at 1 month (%)	26.89 ± 5.07	27.36 ± 5.29	0.464 (−1.888,2.816)	0.695
Postoperative ODI at 3 month (%)	19.76 ± 3.37	19.10 ± 4.24	0.661 (−2.402,1.080)	0.452

Data are mean ± SD, number (proportion), or median (IQR)

SD standard deviation, IQR interquartile range, CI confidence interval

^aVAS visual analog scale (10-point scale where 0 indicates no pain and 10 indicates the worst pain)

^bODI Oswestry Disability Index

^#P < 0.001 compared to T1, T2, T3 and T4

Fig. 2.

VAS scores in the PACU and at 6, 12, 24, 48, and 72 h after lumbar fusion surgery. The box plots show medians and interquartile ranges. P < 0.05 was considered statistically significant

With respect to the secondary outcomes, the method of repeated measures analysis of variance revealed that there were no significant interactions between group and time after surgery for QoR-15 scores (P = 0.147) or the ODI (P = 0.295). No statistical difference in the QoR-15 scores at 24 h postoperatively was observed between the two groups. However, compared with the WI group, the ESPB group had higher QoR-15 scores at 72 h after surgery (mean ± SD: [119.49 ± 5.01] vs. [116.61 ± 4.33]; mean difference, 2.882; 95% CI 0.754–5.010; P = 0.009). The postoperative ODI did not differ between the two groups at either 1 or 3 months after surgery. In terms of opioid consumption, the doses of sufentanil (median [IQR]: 20 [20, 22] vs. 25 [23, 30]; median difference, −5; 95% CI −7 to −4; P < 0.001) and remifentanil (median [IQR]: 680 [560,850] vs. 775 [647.5,1005]; median difference, −110; 95% CI −220 to 0; P = 0.042) were significantly lower in the ESPB group than those in the WI group. There was no statistical difference between the two groups in the proportion of patients who received rescue analgesia within 72 h (Table 2). No significant differences were observed in safety outcomes between the two groups (Table 3). All adverse reactions were promptly alleviated with routine treatment, and no adverse events related to ESPB or WI were observed.

Table 3.

Safety outcomes

Adverse events	LIA group (n = 38)	ESPB group (n = 39)	P value
Bradycardia	6 (15.8%)	5 (12.8%)	0.710
Tachycardia	2 (5.3%)	2 (5.1%)	> 0.999
Hypotension	6 (15.8%)	8 (20.5%)	0.591
Hypertension	3 (7.9%)	2 (5.1%)	0.976
Respiratory depression	1 (2.6%)	0 (0.0%)	0.990
PONVa	7 (18.4%)	5 (12.8%)	0.498
Dizziness	2 (5.3%)	1 (2.6%)	0.982

Data are number (proportion)

^aPONV postoperative nausea and vomiting

Discussion

Our study found that compared with WI, ESPB with liposomal bupivacaine provided a short-term and slight advantage in postoperative pain relief. Additionally, it was associated with slightly higher QoR-15 scores at 72 h postoperatively and less intraoperative opioid consumption.

ESPB is a relatively novel anesthetic technique for achieving a multidermatomal interfascial plane block, and it has been widely used for postoperative analgesia in thoracic surgery, ventral hernia repair and orthopedic surgeries because of its feasibility, safety, and effectiveness [20–22]. Vergari et al. [23] reported that ESPB improved analgesia and decreased opioid consumption during lumbar spine surgery. Consistent with the above results, our study demonstrated that the ESPB group resulted in lower pain scores during the first 6 h after surgery. In our study, ESPB was conducted by injecting liposomal bupivacaine into the plane between the deep fascia of the erector spinae muscle and the vertebral transverse process. The analgesic effect was likely achieved by blocking the ventral and dorsal rami of the spinal nerve [24]. However, a median 1-point statistical difference in pain scores make it difficult to support clinical significance. Compared with the WI group, the ESPB group showed only a short-term and slight advantage, most likely because of the absence of a control group without regional anesthesia in this study.

In terms of comparisons within the groups, the VAS_max was the lowest at 72 h after surgery in both groups. A previous pharmacokinetic study demonstrated that Liposomal bupivacaine is released in a sustained manner for up to 96 h after surgery [25]. To some extent, the longer-lasting analgesia might be associated with the sustained release of liposomal bupivacaine. However, Hamilton et al. [26] reported that no differences in postoperative recovery or pain were observed between the Liposomal bupivacaine group and the control group after knee replacement surgery. Of note, their administration route of Liposomal bupivacaine differed from ours. A systematic review and meta-analysis compared liposomal bupivacaine with long-acting local anesthetics for peripheral nerve blocks and revealed that liposomal bupivacaine statistically reduced pain scores at 24, 48, and 72 h post-operatively, but this finding was not clinically relevant [27]. Therefore, it is worth further investigating whether liposomal bupivacaine can truly provide a longer-lasting analgesic effect in clinical practice. Our study also demonstrated that using liposomal bupivacaine for ESPB significantly decreased intraoperative opioid usage. This opioid-sparing effect could prevent opioid-induced side effects [11].

The quality of recovery is a crucial aspect of perioperative health status. The Quality of Recovery-15 scale provides a meaningful overall assessment of patients'recovery after surgery and anesthesia [28]. We found that the ESPB group had statistically higher postoperative QoR-15 scores. However, the quality of evidence associated with the clinic was moderate. Lin et al. [29] demonstrated that ultrasound-guided bilateral ESPB provided superior early quality of recovery for patients undergoing posterior lumbar interbody fusion. Notably, their statistical difference compared with the blank control group was significantly higher than ours. A study with a larger sample size is essential for verifying the clinical significance of our current research.

With ultrasonographic guidance, ESPB can be carried out in a simple and safe manner [30]. In our trial, safety outcomes were comparable between the two groups. On the one hand, there was no difference in the postoperative ODI. On the other hand, we did not found any procedure-related adverse events among the participants, such as local anesthetic toxicity, hematoma formation, or nerve injury.

Since the clinical advantages of ESPB were not significant compared to WI in our study, the cost-effectiveness of ESPB is worth considering. The requirement for ultrasound equipment, special needles, trained anesthesiologists, and additional time could be seen as a disadvantage in resource-limited settings. In contrast, wound infiltration is inexpensive and widely accessible, and might be a better analgesic choice for primary hospitals. However, Cui Y et al. [31] highlighted the potential financial benefits of ESPB due to reduced opioid use and improved recovery outcomes. Therefore, it is necessary to balance the upfront costs and the subsequent economic benefits in clinical practice.

Some limitations of our study should be considered. First, owing to ethical considerations regarding potential harm to patients, the control group did not receive a placebo intervention. Second, we did not compare the effects of liposomal bupivacaine with ropivacaine. Therefore, we could not determine whether liposomal bupivacaine can achieve a long-lasting effect as stated in the instructions. Third, the extent of the sensory block was not assessed because ESPB was administered after the induction of general anesthesia. Fourth, taking practical operational issues into account, anesthesiologists and surgeons were aware of trial interventions. Fifth, the lack of a detailed cost-effectiveness analysis impacted routine adoption of ESPB in clinical practice.

Conclusion

For patients undergoing lumbar fusion surgery, compared with WI, ultrasound‑guided ESPB with liposomal bupivacaine demonstrated statistically significant association with improved postoperative analgesia and quality of recovery. However, these findings probably lack clinical significance.

Abbreviations

ASA

American Society of Anesthesiologists

CI

Confidence interval

ESPB

Erector spinae plane block

ERAS

Enhanced recovery after surgery

HR

Heart rate

IQR

Interquartile range

MIS-TLIF

Minimally invasive spinal-transforaminal lumbar interbody fusion

ODI

Oswestry disability index

PACU

Postanesthesia care unit

PONV

Postoperative nausea and vomiting

QoR-15

Quality of recovery-15

SD

Standard deviation

TLIF

Transforaminal lumbar interbody fusion

VAS

Visual analog scale

WI

Wound infiltration

Author contributions

Conceptualization, J.Y. Niu, J.M. Yu and D.P. Yao; investigation, R.N. Ouyang and Q. Zhang; data curation, D. Liu and J.L. Qi; data analysis, G.S.Han, k. Zhang and L. Ma; writing—original draft preparation, J.Y. Niu and Y.D. Yang; writing—review and editing, J.M. Yu and D.P. Yao; project administration, D.P. Yao. All authors have read and agreed to the published version of the manuscript.

Funding

Health Research Program of Anhui (AHWJ2024Bac20079), Health Research Program of Anhui (AHWJ2024Aa20028), and the Key Program of Natural Scientific Research in Higher Education Institutions of Anhui Province (2024AH050677).

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study received approval from the institutional research ethics committee of the Third Affiliated Hospital of Anhui Medical University (The First People’s Hospital of Hefei) (No. 2023-085-01). Written informed consent was obtained from all participants prior to their involvement. The study was conducted in strict adherence to the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.