Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Combined Lumbar Plexus-Sciatic Nerve Block for Urgent Lower Limb Surgery: A Good Alternative in Patients With High Anesthetic Risk

The use of peripheral nerve blocks has grown significantly in recent years not only because of the progress and availability of the materials necessary for its realization but also for enhancing patient safety. Anesthesia in the elderly or individuals with high anesthetic risk is always a challenge for the practitioner. Hence, the importance of peripheral nerve blocks in avoiding the side effects associated with general or spinal anesthesia. In this report, we present a case series of five patients with high anesthetic risk (classified American Society of Anesthesiologists (ASA) III or IV) who underwent different lower limb surgeries under a combined lumbar plexus-sciatic nerve block. The goal of this case series was to evaluate the effectiveness of this technique as an anesthetic alternative for these different types of surgical procedures.

A Novel Approach to Improving Post-Operative Pain and Minimizing Opioid Consumption After a Hip Arthroscopy

Background

There have been many different approaches to controlling pain in patients undergoing hip arthroscopy. These include medications, nerve blocks, and intra-articular injections among many others. We introduced a combination of a pre-operative pericapsular nerve group (PENG) block, and intra-operative pericapsular injection of BKK (bupivacaine, ketamine, and ketorolac).

Methods

Patients undergoing primary hip arthroscopy were identified. There were three patient cohorts based on type of anesthesia: general anesthesia only (GA), general anesthesia and a pericapsular Marcaine injection (GA/Marcaine), or GA with pre-operative PENG block and an intraoperative BKK pericapsular injection (GA+PENG/BKK). Data collected included post-operative pain scores in the PACU (Post-Anesthesia Care Unit), time spent in the PACU, inpatient opioid consumption (both PACU and inpatient), and outpatient opioid prescriptions filled.

Results

20 patients received GA, 11 patients received GA/Marcaine, and 20 patients received GA+PENG/BKK. The GA+PENG/BKK group had average PACU pain score of 3.9 out of 10 compared to 7.7 in the GA group (p<.001) and 6.6 in the GA/Marcaine injection group (p=.048). The GA+PENG/BKK group had shorter mean PACU times than either other group (p<.001). The GA+PENG/BKK also consumed less opioids than the GA or GA/Marcaine groups in the PACU (p<.001), and in the total inpatient stay (p=.002, p=.003), as well as outpatient (p=.019, p=.040).

Conclusion

In patients undergoing a hip arthroscopy, performing a pre-operative PENG block and intra-operative BKK pericapsular injection will result in decreased postoperative pain, PACU time, and inpatient and outpatient opioids compared to general anesthesia only and general anesthesia with intracapsular Marcaine.

A Practical Guide to Lower Extremity Nerve Blocks for the Sports Medicine Surgeon

BACKGROUND

Peripheral nerve blocks (PNBs) are vital in the administration of surgical analgesia and have grown in popularity for use in lower extremity arthroscopic procedures because of their capacity to safely and effectively control pain. The number and specificity of PNBs, however, have made choosing the best option for a procedure nebulous for orthopaedic surgeons.

PURPOSE

To present a narrative literature review of the PNBs available for arthroscopic hip and knee procedures that is adapted to an audience of orthopaedic surgeons.

STUDY DESIGN

Narrative literature review.

METHODS

A combination of the names of various lower extremity PNBs AND "hip arthroscopy" OR "knee arthroscopy" was used to search the English medical literature including PubMed, Cochrane Library, ScienceDirect, Embase, and Scopus. Placement technique, specificity of blockade, efficacy, and complications were assessed. Searches were performed through May 2, 2021.

RESULTS

A total of 157 studies were included in this review of lower extremity PNBs. Femoral nerve, lumbar plexus, sciatic nerve, and fascia iliaca compartment blocks were most commonly used in arthroscopic hip surgery, while femoral nerve, 3-in-1, and adductor canal blocks were preferred for arthroscopic knee surgery. Each block demonstrated a significant benefit (P > .05) in ≥1 of the following outcomes: intraoperative morphine, pain scores, nausea, and/or opioid consumption. Combination blocks including the lateral femoral cutaneous nerve block, obturator nerve block, quadratus lumborum block, and L1 and L2 paravertebral block have also been described. Complication rates ranged from 0% to 4.8% in those administered with ultrasound guidance. The most commonly reported complications included muscular weakness, postoperative falls, neuropathy, intravascular and intraneural injections, and hematomas.

CONCLUSION

When administered properly, PNBs were a safe and effective adjuvant method of pain control with a significant potential to limit postoperative narcotic use. While blockade choice varies by surgeon preference and procedure, all PNBs should be administered with ultrasound guidance, and vigilant protocols for the risk of postoperative falls should be exercised in patients who receive them.

Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy.

PURPOSE

To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption.

RESULTS

Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities.

CONCLUSION

In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

Peri-operative pain management in hip arthroscopy: a systematic review of the literature

The purpose of this article was to review current literature on peri-operative pain management in hip arthroscopy. A systematic review of the literature on pain control in hip arthroscopy published January 2008 to December 2018 was performed. Inclusion criteria consisted of English language or articles with English translations, subjects undergoing hip arthroscopy with documented peri-operative pain control protocols in studies reporting Level I to IV evidence. Exclusion criteria were non-English articles, animal studies, prior systematic review or meta-analyses, studies not reporting peri-operative pain control protocols, studies documenting only pediatric (<18 years of age) patients, studies with Level V evidence and studies including less than five subjects. Statistical analysis was performed to assess pain protocols on narcotic consumption in PACU, VAS score on discharge, time to discharge from PACU and incidence of complications. Seventeen studies were included, comprising 1674 patients. Nerve blocks were administered in 50% of patients (n = 838 of 1674), of which 88% (n = 740 of 838) received a pre-operative block while 12% (n = 98 of 838) post-operative block. Sixty-eight complications were recorded: falls (54%, n = 37), peripheral neuritis (41%, n = 28), seizure (1.5%, n = 1), oxygen desaturation and nausea (1.5%, n = 1) and epidural spread resulting in urinary retention (1.5%, n = 1). No significant differences in narcotic consumption, VAS score at discharge, time until discharge or incidence of complication was found based on pain control modality utilized. No statistically significant difference in PACU narcotic utilization, VAS pain scores at discharge, time to discharge or incidence of complications was found between peri-operative pain regimens in hip arthroscopy.