Lumbar Erector Spinae Plane Block as a Main Anesthetic Technique versus Spinal Anesthesia Combined with PENG Block for Urgent Intertrochanteric Fracture Surgery in Elderly Patients: Preliminary Results from a Multicenter Pilot Study

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Background and Aim: Neuraxial anesthesia is commonly used for intertrochanteric fracture surgery but may be contraindicated in frail elderly patients, particularly in the presence of anticoagulation or urgent surgical settings. The Lumbar Erector Spinae Plane Block (L-ESPB) has been proposed as a para-neuraxial technique potentially suitable as a main anesthetic strategy. This study aimed to evaluate whether L-ESPB could represent a viable alternative to Spinal Anesthesia (SA) combined with a Pericapsular Nerve Group (PENG) block in patients undergoing urgent intramedullary nailing for intertrochanteric fractures. Methods: This multicenter comparative pilot study included ≥65 years undergoing surgery within 48 hours of hospital admission, between May and November 2025. Fifty patients were analyzed: 24 received L-ESPB as the sole anesthetic technique, and 26 received SA combined with a PENG block. The comparison focused on anesthesiologic plane adequacy, intraoperative hemodynamic stability, and postoperative recovery outcomes. Results: An adequate anesthesiologic plane was achieved in all patients. Sensory and motor block onset was faster and more intense in the PENG + SA group. Intraoperatively, hemodynamic stability was more frequently preserved in the L-ESPB group (58.3% vs 19.2%, p = 0.02), despite similar surgical duration. Intraoperative ketamine rescue was required in a small proportion of patients in the L-ESPB group. Postoperatively, time to mobilization was shorter in the PENG + SA group, whereas pain scores remained low in both groups, with minimal need for rescue analgesia and no relevant anesthesia-related adverse events. Conclusion: L-ESPB provided effective surgical anesthesia and was associated with greater intraoperative hemodynamic stability compared with SA combined with PENG block. These preliminary findings suggest that L-ESPB may represent a feasible alternative in elderly patients with contraindications to neuraxial anesthesia, warranting confirmation in larger prospective studies.

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