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Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.

TLIP Block in Transforaminal Lumbar Interbody Fusion

This case study represents an individual clinician experience with and methodology for using EXPAREL.

Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.

Please see Important Safety Information below and refer to the Full Prescribing Information.

Disclosure: Dr Sharan is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
Alok Sharan, MD, MHCDS
Affiliation
Orthopedic Spine Surgeon, Director, Spine and Orthopedics
NJ Spine and Wellness, Old Bridge, NJ
Surgical Case Performed
Minimally invasive TLIF with TLIP block
Inpatient or Outpatient Procedure
Outpatient
PATIENT CHARACTERISTICS
 
Gender
Male
Age
39 years
Patient History
and Characteristics
Patient previously underwent microdiscectomy for a herniated disk. He presented with a reherniated disk 1 year later. Based on the patient’s labor-intensive occupation, he elected to have a lumbar fusion
PROCEDURAL DETAILS
 
Incision Size
4-cm bilateral Wiltse incision
Dose of EXPAREL and
Total Volume Used
40ml
Intraoperative Anesthesia
Spinal anesthesia; 10 to 15 mg isobaric bupivacaine HCl 0.5%/fentanyl 25 μg
MULTIMODAL ANALGESIA AND ENHANCED RECOVERY AFTER SURGERY PROTOCOL
 
Preoperative Medications Used
PO oxycodone 10 mg
Intraoperative Medications Used
TLIP ultrasound-guided injection at L4 with 20 mL EXPAREL and 20 mL bupivacaine HCl 0.5%
Postoperative Medications Used
PO diazepam 2.5 mg q6h prn for the first 24 hours; PO oxycodone 5 mg or 10 mg/acetaminophen 325 mg q4h prn for moderate or severe breakthrough pain
PO=by mouth; prn=as needed; q4h=every 4 hours; q6h=every 6 hours.

The recommended dose of EXPAREL for infiltration in adults is based on the size of the surgical site, the volume required to cover the area, and individual patient factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg. The recommended dose of EXPAREL for patients aged 6 to <17 years old is 4 mg/kg, up to a maximum of 266 mg. The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal is 133 mg. The recommended dose of EXPAREL in adults for adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) of 0.5% bupivacaine HCl, for a total volume of 20 mL.

EXPAREL can be administered unexpanded (20 mL) or expanded to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL [ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.

Bupivacaine HCl (which is approved for use in patients aged 12 and older) may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should be used with caution, including monitoring for neurological and cardiovascular effects related to local anesthetic systemic toxicity. Other than with bupivacaine, EXPAREL should not be admixed with other drugs prior to administration.

After induction of spinal anesthesia, Dr Sharan performed an ultrasound-guided bilateral TLIP injection at L4, with the patient in the prone position. Dr Sharan used a 40-mL total volume admixture of 20 mL of EXPAREL and 20 mL of bupivacaine HCI 0.5%, which was divided equally for bilateral injection.

Step #1

Using a linear probe, Dr Sharan used a medial-to-lateral scanning technique to identify the L4 spinous process and transverse process (TP) in a transverse view on each side. The Multifidus muscle can be found directly lateral to the spinous process bilaterally and directly posterior to the lamina. The Longissimus muscle can be found lateral to the Multifidus muscle and posterior-lateral to the TP.

step1-img

Step #2

Using a lateral-to-medial needle approach, a 20-gauge, 4-inch echogenic needle was positioned within the fascial plane between the Multifidus (M) and Longissimus (L) muscles directly posterior to the ipsilateral TP. After negative aspiration, a test dose of 0.5 mL was injected to confirm the correct location. Then 15 mL of the EXPAREL admixture was injected at the interface between the Multifidus and Longissimus muscles, and 5 mL was infiltrated above the fascia. The same technique was used bilaterally.

step2-img
injection

Dr Sharan used a 4-inch echogenic needle advanced in plane to ensure adequate visualization on the ultrasound monitor and to provide sufficient needle depth to reach the interface between muscles.

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Important Notice

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

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