Journal Pre-proof

The effect of erector spinae plane block on perioperative analgesic consumption and
complications in dogs undergoing hemilaminectomy surgery: a retrospective cohort
study

Diego A. Portela, Marta Romano, Gustavo A. Zamora, Fernando Garcia-Pereira,

Luisito S. Pablo, Bonnie J. Gatson, Alana N. Johnson, Pablo E. Otero
PII: S1467-2987(20)30247-6
DOI: https://doi.org/10.1016/j.vaa.2020.10.005
Reference: VAA 575

To appear in: Veterinary Anaesthesia and Analgesia

Received Date: 15 July 2020

Revised Date: 6 October 2020
Accepted Date: 24 October 2020

Please cite this article as: Portela DA, Romano M, Zamora GA, Garcia-Pereira F, Pablo LS, Gatson
BJ, Johnson AN, Otero PE, The effect of erector spinae plane block on perioperative analgesic
consumption and complications in dogs undergoing hemilaminectomy surgery: a retrospective cohort
study, Veterinary Anaesthesia and Analgesia, https://doi.org/10.1016/j.vaa.2020.10.005.

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© 2020 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American
College of Veterinary Anesthesia and Analgesia.
RESEARCH PAPER

Running head (Authors) DA Portela et al.

Running head (short title) Erector spinae plane block in dogs

The effect of erector spinae plane block on perioperative analgesic consumption and

complications in dogs undergoing hemilaminectomy surgery: a retrospective cohort study

Diego A Portelaa, Marta Romanoa, Gustavo A Zamoraa, Fernando Garcia-Pereirab, Luisito S

Pabloa, Bonnie J Gatsona, Alana N Johnsona & Pablo E Oteroc

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a
Department of Comparative, Diagnostic, and Population Medicine, College of Veterinary

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Medicine, University of Florida, Gainesville, FL, USA
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Veterinary Anesthesia Services LLC, Jacksonville, FL, USA
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c
Department of Anesthesiology and Pain Management, Facultad de Ciencias Veterinarias,
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Universidad de Buenos Aires, Buenos Aires, Argentina

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Correspondence: Diego A Portela, Department of Comparative, Diagnostic, and Population

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Medicine, College of Veterinary Medicine, University of Florida, 2015 SW 16th Av, PO Box
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1000123, Gainesville, FL 32610-0123, USA. E-mail: dportela@ufl.edu

Abstract

Objective To compare the perioperative use of analgesics and complication rates in dogs

administered an erector spinae plane block (ESP) or a traditional opioid-based (OP) treatment as

part of a multimodal analgesic management during hemilaminectomy.

Study design Retrospective cohort study.

Animals Medical records of 114 client owned dogs.

Methods General data included demographics, duration of procedure, number of laminae

fenestrated, perioperative use of steroid and non-steroidal anti-inflammatory drugs. Intra and

postoperative analgesics used in 48 hours and complications rates were compared between

groups. Opioid use was expressed in morphine equivalents [ME (mg kg−1)]. Continuous data was

compared using the Mann–Whitney and incidence of events with a Fisher's exact tests. Multiple

linear regression was used to evaluate association between perioperative ME consumption

(dependent variable) with other independent variables. Data is presented as median (range).

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Differences were considered significant when p < 0.05.

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Results Group ESP comprised 42 dogs and group OP 72 dogs. No differences were observed in
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the general data. Intraoperative ME was 0.65 (0.20–3.74) and 0.79 (0.19–5.60) mg kg−1 in
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groups ESP and OP, respectively (p = 0.03). Intraoperative infusion of lidocaine was
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administered intravenously (IV) to 23.8% and 68% of groups ESP and OP, respectively (p <
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0.0001). Intraoperative infusion of ketamine was administered IV to 21% and 40% of groups

ESP and OP, respectively (p = 0.04). Regression analysis revealed the ESP block as the only
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independent variable affecting the perioperative ME consumption. Pharmacological intervention

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to treat cardiovascular complications was administered to 21.4% and 47.2% of dogs in groups

ESP and OP, respectively (p = 0.008). There were no differences in postoperative complication

rates.

Conclusion and clinical relevance ESP block was associated with reduced perioperative opioid

consumption, intraoperative adjuvant analgesic use and incidence of pharmacological

interventions to treat cardiovascular complications in dogs undergoing hemilaminectomy.

Keywords analgesia, dogs, erector spinae plane block, ESP, hemilaminectomy, locoregional

anesthesia.

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Introduction

The erector spinae plane (ESP) block is an interfascial plane block described in 2016 and used to

treat acute and chronic pain in humans (Kot et al. 2019). Recently, the ESP block has been

described in two canine cadaveric studies evaluating relevant anatomy, technique and spread of a

colorant in relation with the thoracic spinal nerves (Ferreira et al. 2019; Portela et al. 2020).

Controversy exists regarding the ESP block site of action, although the medial and lateral

branches of the dorsal rami of the thoracic spinal nerves are consistently blocked by this

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technique in dogs (Portela et al. 2020). Branches of the dorsal rami of the spinal nerves innervate

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the paraspinal muscles, the dorsal vertebral laminae and the facet joints (Forsythe & Ghoshal
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1984; Evans & de Lahunta 2013); therefore, the ESP block may provide pain relief in dogs
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undergoing hemilaminectomies (Ferreira et al. 2019; Portela et al. 2020). In our institution, the
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ESP block is now part of the preoperative multimodal analgesic approach in dogs undergoing
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hemilaminectomy. However, the benefit of including this block in dogs undergoing spinal

surgery is still unknown. Published studies evaluating whether the ESP block provides any
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clinical benefit compared with the traditional systemic multimodal analgesic approach in dogs
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undergoing spinal surgery are lacking. Therefore, this retrospective study was performed to

analyze the medical records of dogs undergoing hemilaminectomy and administered an ESP

block as part of a multimodal analgesic approach.

The primary aim of this retrospective cohort study was to compare the perioperative use

of opioid and adjuvant analgesic drugs in dogs undergoing unilateral hemilaminectomy when

administered an ESP block or a traditional opioid-based analgesic treatment. The secondary aim

was to compare the rate of perioperative complications. The hypotheses of the study were 1) that

the incorporation of ESP block to the anesthetic management of dogs undergoing

hemilaminectomy reduces the perioperative use of analgesics; and 2) that dogs administered the

ESP block require fewer pharmacological interventions to treat intraoperative bradycardia and/or

hypotension and have lower incidences of postoperative complications such as nausea and

vomiting.

Materials and methods

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Owner consent allowing anonymous use of animals’ medical information for scientific purposes

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is obtained for all patients admitted to the University of Florida Veterinary Hospitals. Medical
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record database of the University of Florida, Small Animal Veterinary Hospital was searched for
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dogs that were anesthetized to undergo thoracic and/or lumbar hemilaminectomy between
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October 2018 and February 2020. Dogs were included in the study if the medical record
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contained complete intraoperative anesthesia and postoperative records. Dogs with incomplete

records, undergoing bilateral hemilaminectomy, or with negative deep pain perception prior to
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surgery were excluded from data analysis. Dogs that were administered a preoperative ESP block
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as part of the multimodal analgesic management were included in group ESP, whereas dogs

administered a traditional opioid-based analgesic management were included in group OP.

Anesthetic and analgesic management

Anesthetic and analgesic drugs and doses had been selected by the attending anesthesiologist

based on clinical presentation, demeanor, pain score, American Society of Anesthesiologists

physical status and presence of co-morbidities. All dogs were administered maropitant (1 mg

kg−1; Cerenia, 10 mg mL−1; Zoetis Inc., MI, USA) preoperatively orally or intravenously (IV).
After induction of anesthesia and orotracheal intubation, anesthesia was maintained with

isoflurane or sevoflurane. Inhalant anesthetic delivery was chosen at the discretion of the

anesthetist based on assessment of anesthetic depth and cardiovascular status.

Intraoperative analgesia was provided by administration of a full µ-agonist with or

without lidocaine and/or ketamine IV infusions. A unilateral ultrasound-guided ESP block was

administered to dogs in group ESP using a previously described technique (Portela et al. 2020).

With the dog positioned in sternal recumbency and using a sterile technique, the dorsal aspect of

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the transverse process of the vertebra immediately cranial to the intervertebral space involved in

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the surgery was ultrasonographically identified as the target injection point. A 20 gauge, 8.75 cm
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Tuohy needle (MILA International Inc., KY, USA) was directed in-plane to the target transverse
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process and bupivacaine (Bupivacaine, 0.5%, Hospira Inc., IL, USA) was slowly injected while
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observing the longitudinal spread between the longissimus muscle and the transverse processes.
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The blocks were performed on the ipsilateral side of the planned hemilaminectomy. The volume

and dose of bupivacaine were decided by the attending anesthesiologist. Intraoperative

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administration of rescue analgesia using additional doses of opioid or adjuvant analgesics

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[lidocaine (Lidocaine, 2%; MWI/Vet One, ID, USA) and/or ketamine (Ketaset, 100 mg mL−1;

Zoetis Inc.) infusions] was performed at the discretion of the anesthetist of the case. After

extubation, dogs were transferred to the intensive care unit or the progressive care ward when the

body temperature was ≥ 36.7 ºC and clinical signs of pain or dysphoria were absent.

Postoperative pain was scored using the Colorado State University canine acute pain scale every

2–4 hours performed by trained veterinary nurses, as standard practice at our institution.

Postoperative pain management consisted of the IV administration of a full µ-agonist and

oral adjuvant analgesics, including gabapentin and/or tramadol. Postoperative opioid doses were
adjusted at the discretion of the clinician responsible for postoperative pain management. Food

was offered 4 hours after extubation and every 6 hours thereafter. Water was left available in the

kennel throughout the postoperative period starting 4 hours after extubation.

Data collection and comparisons

Data from the medical records were analyzed to investigate the dose of intraoperative and

postoperative opioid and adjuvant analgesic administered (primary outcome) and the incidence

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of intra and postoperative anesthetic complications (secondary outcome). A preliminary analysis

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of 30 anesthesia records of dogs undergoing hemilaminectomy was performed to determine the
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mean and standard deviation of perioperative analgesics consumption (primary outcome). A
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sample size calculation revealed that at least 36 records per group should be included to obtain a
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30% mean difference in the perioperative analgesics consumption with a power of 80% and a
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probability of error type I of 5% (G*Power 3.1.7; Heinrich Heine University Düsseldorf,

Germany).
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Demographic data obtained from both groups included breed, sex, age and weight.
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Duration of anesthesia and surgery was compared between groups. The anesthesia time also

included the time to perform magnetic resonance imaging (MRI) or computed tomography (CT)

when appropriate. Surgical site (spinal level), number of dorsal laminae fenestrated per surgery

and perioperative use [Yes (Y) or No (N)] of steroids or non-steroidal anti-inflammatory drugs

(NSAIDs) was compared between groups. Volume and dose of bupivacaine and the use of

dexmedetomidine (Dexdomitor, 0.5 mg mL−1; Zoetis Inc.) as adjuvant to perform the ESP block

were noted. During recovery from general anesthesia, the following information was collected:
extubation time measured as the elapsed time between discontinuation of anesthetic delivery and

extubation, body temperature at extubation and occurrence of dysphoria.

Total intraoperative consumption of analgesic drugs, defined as any analgesic

administered preemptively and as rescue analgesia, was compared between the groups.

Preemptive analgesia was defined as the analgesic drugs administered in premedication plus

analgesic drug started before and independently of the surgical stimulation. Analgesics drugs

administered by the referral service within 2 hours before arrival to the anesthesia unit were also

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included as part of the premedication drugs. Rescue analgesia was defined as any analgesic drug

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administered after the start of the surgical procedure. The percentage of dogs requiring rescue
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analgesia was compared between the groups. In each group, the incidence of dogs requiring
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intraoperative rescue analgesia was compared between animals that had surgery performed
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cranial to the first lumbar (L1) vertebra (thoracic/thoracolumbar spine) and those that underwent
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lumbar hemilaminectomy caudal to L2. The cumulative doses of opioid and adjuvant analgesic

given from extubation to 24 and 48 hours postoperatively, were compared between groups.
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Because full µ-agonists with different potencies were used, comparison of the administration of
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opioids was performed by normalizing the opioid dose according to equivalent potencies to

morphine (morphine equivalents; ME) in mg kg−1 using the opioid equivalency table published

by The Hopkins Opioid Program (Floriano et al. 2019; Appendix A).

Intraoperative pharmacological interventions to stabilize the cardiovascular system

including the use of IV fluid boluses, anticholinergics (atropine or glycopyrrolate) and/or

sympathomimetics (dopamine, dobutamine, norepinephrine, phenylephrine or ephedrine) were

compared between groups. Pharmacological interventions performed during MRI or CT were not

included in the analysis. The postoperative records of 48 hours post extubation were compared
for the incidence of regurgitation and vomiting, and the time to the first voluntary meal. Any

additional intraoperative and/or postoperative complications marked in the medical record and

the use of drugs to treat specific complications were also noted.

Statistical analysis

Shapiro–Wilk test was used to test normal distribution of data. Continuous non-normally

distributed data were compared using the Mann–Whitney test for unpaired variables. Fisher's

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exact test was used to compare the incidence of events observed between the groups. For

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variables whose outcome was Y or N, the odds ratio (OR) and 95% confidence interval (CI) was
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calculated to quantify the strength of association between the events. Multiple linear regression
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was used to evaluate the association between intraoperative and postoperative ME consumption
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(dependent variable) and age, weight, duration of the surgery, number of spaces fenestrated,
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temperature, perioperative use of dexmedetomidine, ketamine, lidocaine, steroids, NSAIDs or

the ESP block (independent variables). Differences were considered significant when p < 0.05.
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Nonparametric distributed data was presented as median (range). Statistical analyses were
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performed using GraphPad Prism Version 8.0 (GraphPad Software Inc., CA, USA).

Results

A total of 130 medical records of dogs undergoing hemilaminectomy were reviewed to account

for potential data loss. There were 16 records excluded: 15 for dogs with no deep pain sensation

prior to anesthesia and one because the anesthesia record was missing one page. Therefore, a

total of 114 records were used for the comparison, and included 42 records for group ESP and 72

for group OP.

 Demographic data, hemilaminectomy spinal level, number of laminae fenestrated,

extubation time, duration of anesthesia and surgery are listed in Table 1. Perioperative steroids

were used in 21.4% and 30.6% of dogs in the ESP and OP group, respectively (p = 0.38). Time

to the first voluntary meal was 15 (3–55) and 21 (4–72) hours in groups ESP and OP,

respectively (p = 0.04).

Analgesic management

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The ESP blocks were performed by three board-certified anesthesiologists and two anesthesia

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residents. The median (range) of bupivacaine 0.5% injected was 0.43 (0.2–0.6) mL kg−1; 2.1
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(1.0–2.8) mg kg−1. Dexmedetomidine (1 µg mL−1) was added as adjuvant to the bupivacaine
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solution for the block in nine out of 42 dogs (21%).
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Dexmedetomidine was administered for premedication in six and 11 dogs in the ESP and
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OP groups, respectively (p > 0.99). Opioids administered perioperatively were methadone,

fentanyl and hydromorphone (Table 2). The ME dose administered as premedication was 0.40
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(0.19–1.01) and 0.39 (0.18–0.95) mg kg−1 for the ESP and OP groups, respectively (p = 0.45).
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Rescue analgesia during surgery was administered to 42 dogs (61.1%) in group OP and 25 (59.5

%) in group ESP (p > 0.99; OR 1.1; 95% CI 0.5 to 2.3). In dogs requiring intraoperative rescue

analgesia, the ME dose was 0.41 (0.20–3.06) and 0.39 (0.18–3.82) mg kg−1 in the ESP and OP

groups, respectively (p = 0.57). In group ESP, rescue analgesia was administered to 70.6% and

52.0% of dogs undergoing hemilaminectomy caudal to L2 and cranial to L1, respectively (p =

0.33; OR 2.2; 95% CI 0.6 to 7.8). No differences in the preemptive (administration for

premedication and general anesthetic maintenance) opioid doses administered to dogs

undergoing hemilaminectomy caudal to L2 or cranial to L1 were found (p = 0.25). In group OP,

rescue analgesia was administered in 59.3% and 62.2 % of the dogs undergoing

hemilaminectomy caudal to L2 and cranial to L1, respectively (p = 0.81; OR 0.88; 95% CI 0.3 to

2.3).

Total intraoperative opioid consumption was significantly lower in group ESP than in

group OP (Table 3). Multiple linear regression revealed that the ESP block was the only

independent variable associated with reduction in the total intraoperative ME consumption (p =

0.02). Age, weight, sex, number of spaces fenestrated, duration of surgery, body temperature and

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perioperative use of dexmedetomidine, steroids, lidocaine or ketamine had no significant effect

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on the opioid consumption in this population of dogs.
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Intraoperative lidocaine as adjuvant analgesic was administered to 10 dogs (23.8%) and
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49 dogs (68%) in groups ESP and OP, respectively (p < 0.0001; Table 3). Intraoperative
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ketamine was administered in nine (21.4%) and 29 (40.3%) dogs in groups ESP and OP,
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respectively (p = 0.04).

The cumulative ME administration in the first 24 and 48 hours was significantly lower in
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group ESP than in group OP (Table 3). In the postoperative period, 18 (42.6%) and 33 (45.8%)
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dogs were administered NSAIDs in groups ESP and OP, respectively (p = 0.84). Postoperative

adjuvant analgesics (tramadol and gabapentin) administration did not differ between groups

(Table 3). Multiple linear regression identified the ESP block as the only independent variable

associated with reduction in the postoperative ME consumption (p = 0.005). Other independent

variables, such as age, weight, sex, number of spaces fenestrated, duration of surgery, body

temperature and perioperative use of dexmedetomidine, steroids, NSAIDs, lidocaine or ketamine

showed no effect on the postoperative opioid consumption. Overall postoperative pain scores

were 0 (0–2) and 0 (0–3) for groups ESP and OP, respectively (p = 0.24).
Complications

Intraoperative pharmacological cardiovascular intervention, incidence of dysphoria upon

recovery and postoperative vomiting and regurgitation are shown in Table 4. In group OP, eight

dogs developed postoperative regurgitation and/or vomiting which was treated with

metoclopramide for 48 (20–80) hours. No dog in group ESP was administered metoclopramide.

High grade second degree atrioventricular block with escape beats were identified during the

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final portion of the surgery in one dog in group OP. The heart rate and rhythm stabilized with

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administration of atropine (cumulative dose 0.08 mg kg−1). Continuous telemetry
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electrocardiography was attached to this dog in the intensive care unit. Cardiopulmonary arrest
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occurred 14 hours after extubation. After two cycles of cardiopulmonary resuscitation, the dog
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regained spontaneous circulation but remained comatose and intubated for 12 hours until the
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owner elected euthanasia.

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Discussion
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Retrospective studies are typically considered less reliable than randomized controlled clinical

trials because they can introduce bias and confounding factors. In addition, retrospective studies

can only determine association between events and not causation. However, important changes

in the medical practice, such as the use of spinal anesthesia for cesarean section, took place from

data obtained from retrospective studies (Riley et al. 1995). Information retrieved from

retrospective studies might more accurately reflect a clinical scenario without the manipulation

introduced by the strict case selection and protocols imposed by controlled studies, which poorly

mirror the reality in clinical practice (Riley 2014). The study presented here retrospectively
evaluated the perioperative analgesic consumption and the incidence of complications in dogs

undergoing hemilaminectomy and receiving a multimodal analgesic treatment, with or without

an ESP block. The study identified the ESP block as the only independent variable associated

with a reduction in the intraoperative and postoperative opioid consumption measured as mg

kg−1 of ME.

Full µ-agonists are cornerstone drugs for the management of surgical pain (Epstein et al.

2015). However, they can produce bradycardia, hypoventilation, ileus, nausea, vomiting,

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immune system impairment, dysphoria, increased hospitalization time and hyperalgesia (Bowdle

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1998; Oderda et al. 2007; Koepke et al. 2018; Colvin et al. 2019). In the report presented here,
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dogs treated preoperatively with an ESP block required lower intraoperative doses of opioids and
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ketamine compared with animals not administered the block, confirming the primary hypothesis
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of the study. Regarding the requirement for intraoperative administration of lidocaine, there were
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no differences in the dose administered to both groups, however dogs in the ESP group were less

likely to be administered lidocaine. Owing to the retrospective nature of this study, the
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intraoperative administration of analgesics may have been biased because the anesthetist
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performing the anesthesia was not blinded to the administration of the ESP block; therefore, this

may have influenced the decision to give higher doses of preemptive analgesia in dogs without

the block.

In our study, the need for intraoperative rescue analgesia was not significantly different

between groups. For the purpose of this retrospective evaluation, rescue analgesia was defined as

any analgesic drug administered intraoperatively any time after the surgery started, and

presumably in response to nociception. However, administration of rescue analgesia may have

been prompted by reasons other than nociception, such as anesthetist personal preference and
arousal from general anesthesia. Therefore, owing to lack of standardized criteria for

administration of analgesics, the requirement for intraoperative rescue analgesia may not reflect

the real need for analgesics in this cohort of dogs undergoing hemilaminectomy surgery.

Moreover, information regarding the tissue being stimulated that prompted the rescue analgesia

was not registered in the record. The authors noticed several dogs in the ESP group showing

nociceptive response during manipulation of the dorsal root ganglion (DRG). Based on a

previous anatomical study, dye solution was not frequently found in proximity to the DRG

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(Ferreira et al. 2019), therefore it is unlikely that these structures would be affected by the local

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anesthetic after an ESP block.
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Interestingly, within the ESP group, dogs administered the block caudal to L1 for lumbar
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hemilaminectomy were 18.6% more likely to require rescue analgesia than dogs with a thoracic
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ESP block for surgery cranial to L1. This difference was not statistically significant, but the
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study was likely underpowered to detect differences for this event. This finding may suggest that

the ESP block performed using a technique described for the thoracic region should not be
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extrapolated to different spinal levels, as the anatomy of the lumbar spine and the location of the
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spinal nerves in relation to the lumbar epaxial muscles may differ from the thoracic spine

(Medina Serra et al. 2020). Nonetheless, a recent case report showed that a bilateral lumbar ESP

block in combination with continuous rate infusion (CRI) of ketamine and dexmedetomidine

provided acceptable intra and postoperative analgesia in a dog undergoing a thoracolumbar

hemilaminectomy (Zannin et al. 2020). The rationale of performing bilateral blocks is based on

the fact that cutaneous nerves can cross midline and innervate a small skin portion of the

contralateral side (Capek et al. 2015). However, the main source of pain and nociception during

hemilaminectomies are the paraspinal muscles and the laminae that are innervated by the
ipsilateral dorsal rami of the spinal nerves (Forsythe & Ghoshal 1984; Evans & de Lahunta

2013). Considering that nociceptive reaction to skin incision may have been blunted by the

preemptive administration of systemic analgesic drugs, it is unknown if the analgesic

consumption would have been affected by use of bilateral blocks in this cohort of dogs.

Postoperative opioid consumption was also higher in group OP. The bias generated by

knowledge that a block had been administered is unlikely to have had a significant impact on the

postoperative analgesic management, as the clinicians managing the postoperative treatment

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were not familiar with the ESP block and were therefore unlikely to rely on it for analgesia. This

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finding is in agreement with studies showing that the use of the ESP block in humans undergoing
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spinal surgery is associated with reduced postoperative opioid consumption (Chin et al. 2019;
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Ueshima et al. 2019).
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In the present study, postoperative pain scores were similar between the two groups.
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Since a nonvalidated pain scale was used, it is possible that the lack of difference may be the

result of the inability of this scale to discriminate subtle changes in pain levels. The discrepancy
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between the pain scores and the opioid consumption may have been influenced by analgesic
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management because opioids may be administered at standard dosing intervals regardless of the

pain score.

Spinal cord perfusion is influenced by systemic blood pressure, hence intraoperative

hypotension might have detrimental consequences for the injured spinal cord (Martirosyan et al.

2011). Dogs without the ESP block were more likely to require pharmacological interventions to

treat cardiovascular complications such as bradycardia or hypotension. The severity and duration

of the cardiovascular complication were not evaluated in this study; however, our results support
the finding that animals with the ESP block were less likely to require pharmacological

interventions to treat hemodynamic imbalances.

The incidence of postoperative complications was similar between groups. The sample

size for this study was calculated based on the primary outcome. Therefore, a larger sample size

may be necessary to detect significant differences in the incidence of postoperative

complications between the two groups.

Postoperative administration of opioids, regardless of the pain score, has been identified

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as a risk factor that increases the incidence of gastrointestinal complications (Bini et al. 2018). In

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the present study, the frequency of postoperative regurgitation and vomiting were not statistically
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different between the two groups. Although the study was probably underpowered to detect
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postoperative complications, the odds ratio showed that dogs in group OP were 1.7 times more
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likely to develop postoperative regurgitation. Furthermore, eight out of 72 dogs (11.1%) in group
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OP required metoclopramide CRI for up to 80 hours to treat persistent postoperative

regurgitation. None of the dogs in group ESP required pharmacological intervention to treat
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gastrointestinal complications.
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Dogs in group ESP started eating voluntarily sooner than those in group OP. This

difference could be attributed to the lower dose of opioids administered to the ESP group

resulting in less nausea, or reflect a more complete postoperative pain control that may have been

undetected with the nonvalidated pain scale used.

There are several limitations in the present study. Being a retrospective study, the

anesthetic and analgesic management were not standardized between groups, possibly affecting

the interpretation of the results. No standardized attempts were made to administer the minimal

possible amount of inhalational anesthetic and analgesic drugs, masking the potential inhalant
and analgesic sparing effects of the ESP block. Analgesic drugs, other than steroids and NSAIDs

administered more than 2 hours before premedication were not compared between the groups

and could have potentially influenced the results observed in the present study. The execution of

the ESP block was performed by different clinicians with variable skills and using different

volumes of local anesthetics which might also have affected the success rate of the block.

Moreover, even if the injectate is observed spreading in the correct fascial plane, it is not

possible to be sure that all the nerves involved in the surgery will be blocked. Dogs were

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administered three full µ-agonists with different potencies. It is difficult to compare the clinical

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effect when the analgesic protocol is not standardized. Consequently, in this study the opioid
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dose was converted to ME and the consumption expressed in mg kg−1 of ME as performed in
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other studies (Adhikary et al. 2019; Floriano et al. 2019). This equipotency method was
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developed for use in humans; therefore, its reliability in dogs is unknown. Pain transmission is
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severely impaired in animals without deep pain perception, which could affect the interpretation

of the analgesic effect of a locoregional block. For this reason, dogs with negative deep pain
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sensation were excluded, reducing the total number of cases analyzed. Finally, we cannot
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exclude that the systemic absorption of bupivacaine may enhance the analgesic effect of the

systemic opioids, although it is unlikely that absorbed bupivacaine will have an effect for 48

hours after surgery.

Conclusion

Preoperative ESP block in dogs undergoing hemilaminectomy was associated with significantly

lower administration of intraoperative and postoperative opioids and intraoperative adjuvant

analgesics. A reduced incidence of intraoperative cardiovascular complications requiring

treatment and a shorter time to voluntary feeding after surgery was also recorded. Postoperative

complications such as dysphoria, regurgitation and vomiting were similar between the groups;

however, a larger sample size may be necessary to detect differences for these variables.

Randomized prospective clinical trials are warranted to investigate if there is a causal

relationship between the ESP block administration and reduced perioperative opioid

consumption in dogs undergoing hemilaminectomy.

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Acknowledgements

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This project was funded by the College of Veterinary Medicine, University of Florida.
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Authors’ responsibilities
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DAP: study design, data collection, analysis of the results, manuscript preparation. MR: analysis
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of the results, manuscript preparation. GAZ: data collection and interpretation. FG-P, LSP, BJG

and ANJ: analysis of the results, manuscript review. PEO: study design, analysis of the results,
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manuscript preparation. All authors approved the final version to be published.

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Conflict of interest statement

The authors declare no conflict of interest.

References

Adhikary SD, Liu WM, Fuller E et al. (2019) The effect of erector spinae plane block on

respiratory and analgesic outcomes in multiple rib fractures: a retrospective cohort study.

Anaesthesia 74, 585–593.

Bini G, Vettorato E, De Gennaro C, Corletto F (2018) A retrospective comparison of two

analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs. Vet

Anaesth Analg 45, 557–565.

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Bowdle TA (1998) Adverse effects of opioid agonists and agonist-antagonists in anaesthesia.

ro
Drug Saf 19, 173–189.
-p
Capek S, Tubbs RS, Spinner RJ (2015) Do cutaneous nerves cross the midline? Clin Anat 28,
re
96–100.
lP

Chin KJ, Dinsmore MJ, Lewis S, Chan V (2019) Opioid-sparing multimodal analgesia with
na

bilateral bi-level erector spinae plane blocks in scoliosis surgery: a case report of two

patients. Eur Spine J 42, 838.

ur

Colvin LA, Bull F, Hales TG (2019) Perioperative opioid analgesia—when is enough too much?
Jo

A review of opioid-induced tolerance and hyperalgesia. The Lancet 393, 1558–1568.

Epstein M, Rodan I, Griffenhagen G et al. (2015) 2015 AAHA/AAFP Pain management

guidelines for dogs and cats. J Am Anim Hosp Assoc 51, 67–84.

Evans HE, de Lahunta A (2013) Spinal nerves. In: Miller’s Anatomy of the Dog (4th edn). Evans

HE, de Lahunta A (eds). Saunders Elsevier, USA. pp. 611–657.

Ferreira TH, St James M, Schroeder CA et al. (2019) Description of an ultrasound-guided erector

spinae plane block and the spread of dye in dog cadavers. Vet Anaesth Analg 46, 516–522.
Floriano D, Sahagian MJ, Chiavaccini L (2019) Impact of epidural bupivacaine on perioperative

opioid requirements, recovery characteristics, and duration of hospitalization in dogs

undergoing cystotomy: a retrospective study of 56 cases. Vet Surg 48, 1330–1337.

Forsythe WB, Ghoshal NG (1984) Innervation of the canine thoracolumbar vertebral column.

Anat Rec 208, 57–63.

Grossman SA, Nesbit S, Loscalzo M.

http://www.hopweb.org/hop/oettbl_vw.cfm?cfid=119072766&cftoken=54570257. Accessed

of
1 Oct 2020.

ro
Koepke EJ, Manning EL, Miller TE et al. (2018) The rising tide of opioid use and abuse: the role
-p
of the anesthesiologist. Perioper Med (Lond) 7, 16.
re
Kot P, Rodriguez P, Granell M et al. (2019) The erector spinae plane block: a narrative review.
lP

Korean J Anesthesiol 72, 209–220.

na

Martirosyan NL, Feuerstein JS, Theodore N et al. (2011) Blood supply and vascular reactivity of

the spinal cord under normal and pathological conditions. J Neurosurg Spine 15, 238–251.
ur

Medina Serra RMS, Palacios Jimenez C, Foster A et al. (2020) Lumbar erector spinae plane
Jo

(ESP) block in the dog: anatomical study and assessment of two ultrasound-guided

techniques in dog cadavers (abstract). Vet Anaesth Analg 47, 285.

Oderda GM, Said Q, Evans RS et al. (2007) Opioid-related adverse drug events in surgical

hospitalizations: impact on costs and length of stay. Ann Pharmacother 41, 400–406.

Portela DA, Castro D, Romano M et al. (2020) Ultrasound-guided erector spinae plane block in

canine cadavers: relevant anatomy and injectate distribution. Vet Anaesth Analg 47, 229–

237.

Riley E (2014) Retrospective studies provide valuable information. Anaesthesia 69, 1052–1053.
Riley ET, Cohen SE, Macario A et al. (1995) Spinal versus epidural anesthesia for cesarean

section: a comparison of time efficiency, costs, charges, and complications. Anesth Analg 80,

709–712.

Ueshima H, Inagaki M, Toyone T, Otake H (2019) Efficacy of the erector spinae plane block for

lumbar spinal surgery: a retrospective study. Asian Spine J 13, 254–257.

Zannin D, Isaka LJ, Pereira RH, Mencalha R (2020) Opioid-free total intravenous anesthesia

with bilateral ultrasound-guided erector spinae plane block for perioperative pain control in a

of
dog undergoing dorsal hemilaminectomy. Vet Anaesth Analg 47, 728–731.

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Appendix A Morphine equivalents (ME)

Opioid Route Relative potency ME

Morphine Parenteral 10 1

Methadone Parenteral 5 2

Fentanyl Parenteral 0.1 100

Hydromorphone Parenteral 1.5 6.6

Adapted from human equipotencies doses of parenteral full µ-agonists, created by Grossman SA,

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Nesbit S, Loscalzo M for The Hopkins Opioid Program.

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© 2003–2020 The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins.
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Table 1 Demographic distribution of dogs undergoing hemilaminectomy and administered either

an erector spinae plane (ESP) block (group ESP) or opioids-based treatment (group OP) as part

of the perioperative analgesic management. Data are presented as median (range) and number

(percentage).

Demographic Group p

ESP OP

Age (years) 6 (1–13) 5 (0.75–15) 0.35

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Weight (kg) 8.4 (3.0–30.6) 9.0 (2.3–50.7) 0.89

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Sex 0.32

Male n (%)
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19 (45.2) 40 (55.5) -
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Female n (%) 23 (54.7) 32 (44.4) -
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Breed size
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Toy n (%) 14 (33.3) 27 (37.5) 0.65

Small n (%) 18 (42.8) 28 (38.8) 0.69

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Medium n (%) 8 (19.0) 12 (16.6) 0.80

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Large n (%) 2 (4.7) 5 (6.0) 0.90

Spinal level

L1-to-cranial n (%) 25 (59.5) 45 (59.5) 0.84

L2-to-caudal n (%) 17 (40.5) 27 (37.5) 0.84

Number of laminae fenestrated 1 (1–4) 1 (1–3) 0.76

Presurgical CT or MRI n (%) 29 (69.1) 43 (59.7) 0.42

Duration anesthesia (minutes) 269 (102–490) 256 (117–505) 0.49

Duration surgery (minutes) 133 (40–254) 138 (60–361) 0.27

Extubation time (minutes) 9 (2–37) 11 (2–53) 0.06

Temperature at extubation (ºC) 37.5 (35.0–39.1) 37.6 (34.4–39.2) 0.59

Toy, small, medium and large breed correspond to body weights < 6 kg, 7–12 kg, 13–25 and >

26 kg, respectively. L1-to-cranial, thoracolumbar and thoracic surgeries; L2-to-caudal, lumbar

surgeries second to seventh lumbar vertebrae; CT, computed tomography; MRI, magnetic

resonance imaging.

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Table 2 Opioid administration during anesthesia and postoperatively in dogs undergoing

hemilaminectomy with perioperative analgesic management including either an erector spinae

plane block (group ESP; 42 dogs) or opioids-based treatment (group OP; 72 dogs). Data are

presented as number (percentage) of dogs.

Opioid Group p

ESP OP

During anesthesia

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Methadone 37 (88.1) 70 (97.2) 0.10

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Fentanyl 8 (19.1) 18 (25.0) 0.49

Hydromorphone 3 (7.1)
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Postoperative
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Methadone 19 (45.2) 25 (34.7) 0.32

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Fentanyl 14 (33.3) 44 (66.7) 0.01*

Hydromorphone 7 (16.7) 3 (4.2) 0.03*

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None 2 (4.8) 0 (0) 0.13

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*Significant difference between groups (p < 0.05).

Table 3 Intraoperative and cumulative postoperative opioid and adjuvant analgesics administration from extubation to 24 (0–24) and

48 (0–48) hours postoperatively and administered either an erector spinae plane block (ESP) or opioids-based treatment (OP) as part

of the perioperative analgesic management. Opioid administration is expressed morphine equivalents (ME) in mg kg–1. Data are

presented as median (range).

f
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pr
Drugs (mg kg–1)

e-
Stage of Group Median difference p
a

Pr
procedure ESP OP (95% CI)
Intraoperative

al
ME

rn
Preemptive 0.42 (0.19–3.09) 0.56 (0.18–5.20) 0.09 (0.01, 0.24) 0.04*
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Total 0.65 (0.20–3.74) 0.79 (0.19–5.60) 0.16 (0.01, 0.34) 0.03*
Adjuvants
Lidocaine 6.9 (0.6–23.6) 8.1 (0.9–18.0) 1.0 (–2.9, 4.2) 0.59
Ketamine 1.6 (0.1–5.0) 2.7 (0.7–13.0) 1.7 (0.1, 3.5) 0.03*
Postoperative
ME
0–24 hours 1.87 (0–6.81) 4.35 (0.37–7.61) 0.97 (0.17, 2.35) 0.01*
0–48 hours 2.33 (0–6.81) 4.35 (0.37–12.63) 1.15 (0.12, 2.65) 0.02*
 Gabapentin
0–24 hours 26.8 (7.7–62.5) 26.3 (5.3–43.8) –0.6 (–4.7, 3.5) 0.72
24–48 hours 56.8 (19.6–153.3) 54.1 (6.7–87.6) –4.0 (11.2, 2.8) 0.24
Tramadol
0–24 hours 5.9 (1.7–25.2) 4.7 (2.7–27.8) –0.2 (–2.6, 1.2) 0.81
24–48 hours 13.5 (1.8–53.0) 14.3 (2.7–45.2) –0.5 (–4.4, 3.5) 0.83

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ME, morphine equivalents. Preemptive is defined as the sum of the ME given in premedication and during surgery independently of

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the surgical stimulation. Total is defined as the ME administered preemptively and as rescue analgesia. aHodges-Lehmann median

pr
e-
difference with 95% confidence interval (CI). * Significantly different between groups (p < 0.05).

Pr
al
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Table 4 Perioperative complications retrieved in the medical records of dogs undergoing hemilaminectomy and administered either an

erector spinae plane block (ESP) or opioids-based treatment (OP) as part of the perioperative analgesic management. Data are

presented as number of dogs (percentage).

Stage of Treatment or Group OR (95% CI) p

procedure complication ESP OP

f
Intraoperative

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Cardiovascular 9 (21.4) 34 (47.2) 3.3 (1.3, 7.6) 0.008*

pr
intervention

e-
Anticholinergic 7 (16.7) 27 (37.5) 3.0 (1.2, 7.5) 0.02*

Pr
Sympathomimetic 0 (0.0) 4 (3.5) - 0.29
Fluid bolus 3 (7.1) 9 (12.5) 1.8 (0.5, 6.6) 0.53

al
rn
Postoperative
8 (19.0) 17 (23.6) 1.3 (0.5, 3.3) 0.64
Dysphoria
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Regurgitation 4 (9.5) 11 (15.3) 1.7 (0.5, 5.1) 0.56
Vomition 0 (0.0) 2 (2.8) - 0.53
Death 0 (0.0) 1 (1.4) - >0.99
OR, odds ratio; CI, confidence interval. * Significant difference between groups (p < 0.05).