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. 2025 Dec;69(12):1341-1358.
doi: 10.4103/ija.ija_1066_25. Epub 2025 Nov 19.

Ultrasound-guided sacral multifidus plane block for perioperative analgesia: A comprehensive systematic review, meta-analysis, and trial sequential analysis

Abhijit S Nair  1 , Tuhin Mistry  2 , Rakesh Garg  3
Affiliations

Ultrasound-guided sacral multifidus plane block for perioperative analgesia: A comprehensive systematic review, meta-analysis, and trial sequential analysis

Abhijit S Nair et al. Indian J Anaesth. 2025 Dec.

Abstract

Background and aims: The sacral multifidus plane block (SMPB) is an emerging regional anaesthesia technique targeting the dorsal rami of sacral spinal nerves, with potential applications in lower limb, pelvic, and perineal surgeries. Evidence from randomised controlled trials (RCTs) has not been systematically synthesised.

Methods: We conducted a systematic review and meta-analysis following the PRISMA 2020 guidelines, and the study was registered prospectively in PROSPERO. PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched (January 2019-May 2025) for RCTs comparing SMPB with other regional techniques or no block. The primary outcome was time to rescue analgesia. Secondary outcomes included 24-h opioid consumption, postoperative pain scores, patient satisfaction, and adverse events. Data were pooled using a random-effects model; trial sequential analysis (TSA) and GRADE assessment were performed.

Results: Twelve RCTs (n = 768; 348 received SMPB) were included. SMPB significantly prolonged time to first rescue analgesia, reduced 24-h opioid consumption, and lowered pain scores at rest and movement during the first postoperative day, particularly during the intermediate (6-12 h) and late (24 h) postoperative periods. Patient satisfaction was generally higher with SMPB, correlating with improved analgesia and reduced opioid use. TSA confirmed the robustness of findings for time to rescue analgesia and opioid consumption, although the required sample size was not reached. No serious block-related complications were reported.

Conclusions: SMPB appears to be a safe, effective regional anaesthesia technique, offering opioid-sparing benefits, prolonged analgesia, and high patient satisfaction. However, current evidence is limited by small sample sizes, methodological heterogeneity, and potential publication bias.

Keywords: Meta-analysis; nerve block; patient satisfaction; postoperative analgesia; regional anaesthesia; sacral multifidus plane block; ultrasonography.

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Conflict of interest statement

Dr. Rakesh Garg, who is one of the co-authors of this manuscript, is an Editor of this journal. He was not involved in any decision-making process, and an independent editor handled this manuscript. The authors declare that they have no other conflicts of interest.

Figures

Figure 1
Figure 1
Cross-sectional schematic illustration of the sacral multifidus plane block (SMPB) at the S2 level (caudocranial view), depicting key anatomical structures and local anaesthetic deposition points. 1 and 2 represent the midline approach at the median sacral crest (MSC) and the paramedian approach at the intermediate sacral crest (ISC), respectively. ST = subcutaneous tissue; GMM = gluteus maximus muscle; LDA = latissimus dorsi aponeurosis originating from the posterior layer of thoracolumbar fascia (PTLF); LTMA = longissimus thoracis muscle aponeurosis; MFM = multifidus muscle; SSL = supraspinous ligament; ILMA = iliocostalis lumborum muscle aponeurosis; PSIL = posterior sacroiliac ligament; LSC = lateral sacral crest
Figure 2
Figure 2
PRISMA 2020 flow diagram. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Figure 3
Figure 3
Risk-of-bias assessment- a: Traffic light plot; b: Summary plot
Figure 4
Figure 4
a: Forest plot showing comparison of time to rescue analgesia between the SMPB group and control group. b: Funnel plot between outcome time to rescue analgesia between the SMPB group and control group, showing asymmetry; c: TSA graph showing comparison of time to rescue analgesia between the SMPB group and control group.. CI = confidence interval; IV = inverse variance; SD = standard deviation; SMPB = sacral multifidus plane block; TSA = trial sequential analysis
Figure 5
Figure 5
a: Forest plot showing comparison of 24-h opioid consumption between the SMPB group and control group. b: TSA graph showing comparison of 24-h opioid consumption between the SMPB group and control group. CI = confidence interval; IV = inverse variance; SD = standard deviation; SMPB = sacral multifidus plane block; TSA = trial sequential analysis
Figure 6
Figure 6
a: Forest plot showing comparison of patients requiring rescue analgesia between the SMPB group and control group. b: TSA graph showing comparison of patients requiring rescue analgesia between the SMPB group and control group. CI = confidence interval; IV = inverse variance; SD = standard deviation; SMPB = sacral multifidus plane block; TSA = trial sequential analysis; M-H = Mantel-Haenszel method
See this image and copyright information in PMC

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