Sensory distribution of the lateral femoral cutaneous nerve block - a randomised, blinded trial

Lateral Femoral Cutaneous Nerve Block for Postoperative Pain Control After Total Hip Arthroplasty Using the Direct Anterior Approach: A Single-blinded Randomized Control Trial

Background

Total hip arthroplasty (THA) employing the direct anterior approach (DAA) is increasingly performed as a less invasive procedure with faster recovery than other approaches. Unlike other approaches, the skin incision is made on the lateral thigh, distal to the inguinal ligament. However, the effectiveness of ultrasound-guided lateral femoral cutaneous nerve (LFCN) block for postoperative analgesia after THA using DAA has not been investigated.We hypothesized that ultrasound-guided LFCN block using DAA would reduce postoperative pain after THA.

Methods

A prospective, randomized, observer-blinded controlled trial was conducted. The 92 patients included were divided into two groups: those who received only femoral nerve block (FNB group) and those who received femoral nerve block and LFCN block with 10mL of 0.25% levobupivacaine (FNB + LFCNB group). Both groups received intravenous patient-controlled analgesia (fentanyl) postoperatively. A numerical rating scale was used to quantify pain at 3 and 48 h postoperatively.

Results

There was no significant difference in pain at rest and during movement between the FNB and FNB + LFCNB groups (at rest: Z = -1.6814, p=0.0927; during on movement: Z = -0.9677, p=0.9487). There was also no significant difference in pain severity at rest and during movement between the FNB and FNB + LFCNB groups postoperatively.

Conclusions

LFCNB did not improve postoperative pain relief in patients undergoing THA with DAA.

Posterior Lumbar Plexus Block Anesthesia for Elderly Patients with Lower Limb Fracture

The incidence rate of lower limb fractures is high and has increased over the recent years, which affects the physical and mental health and the daily activities of patients. Lower limb fractures are often treated surgically. Therefore, an effective anesthesia regimen is crucial for a smooth and stable operation. To investigate the efficacy of posterior lumbar plexus block anesthesia during surgery for elderly patients with lower extremity fractures. In total, patients were divided into study and control groups. Anesthesia was administered by posterior lumbar plexus nerve block in the study group and epidural anesthesia in the control group. Hemodynamic parameters, anesthesia condition, pain level (VAS), and adverse effects were measured in both groups before anesthesia (T0), at anesthesia induction (T1), 30 min into the operation (T2), and at the end of the operation (T3). At T0, there were no significant differences in MAP and HR between the study and control groups. However, MAP and HR in the study group were significantly lower than those in the control group at T1, T2, and T3. The BIS value of the study group at each time point after anesthesia was significantly lower than that of the control group. The onset and induction time of anesthesia in the study group were also significantly shorter than those in the control group. Preoperative VAS scores did not differ between the study and control groups. However, the VAS scores of the study group at each time point were significantly lower than those of the control group. There was no significant difference in the incidence of adverse reactions between the two groups. Our results suggest that anesthesia with posterior lumbar plexus block surgery for lower extremity fractures in elderly patients can maintain hemodynamic stability and reduce block onset time, anesthesia induction time, and pain.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb

OBJECTIVES

To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications.

METHODS

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper.

RESULTS

Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia.

CONCLUSION

Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures.

KEY POINTS

• Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

The aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control.

METHODS

Two hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications.

RESULTS

Groups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery.

CONCLUSION

Combining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.

Ultrasound-guided adductor canal block combined with lateral femoral cutaneous nerve block for post-operative analgesia following total knee arthroplasty: a prospective, double-blind, randomized controlled study

PURPOSE

The purpose of this study was to investigate whether adductor canal block (ACB) combined with lateral femoral cutaneous nerve block (LFCNB) could improve the efficacy of post-operative analgesia in a comparison with a standard peri-articular infiltration analgesia (PIA) after a total knee arthroplasty (TKA).

METHODS

One hundred and sixty patients of scheduled unilateral primary TKA were randomly allocated into two groups for post-operative analgesia. Eighty cases were treated with ACB combined with LFCNB and the other eighty treated with PIA. The primary outcomes were pain visual analogue scale (VAS) and rescue pain killer consumption, and the secondary outcomes were knee active range of motion (ROM), quadriceps strength, patients' ambulation ability, Knee Society Score (KSS), length of hospital stay, and adverse events.

RESULTS

We found that ACB combined with LFCNB was better on decreasing the post-operative pain score within 12 hours at rest and 8 h with activity (p < 0.05) and provided longer duration of analgesia (19.91 ± 5.09 VS 12.06 ± 3.67 h, p < 0.01) and less rescue morphine consumption (13.63 ± 9.84 vs 18.00 ± 11.52 mg, p = 0.011) than the PIA. There was no significant difference between the two groups (p > 0.05) in terms of knee ROM, quadriceps strength, daily mobilization distance, KSS, and complication occurrence.

CONCLUSIONS

ACB combined with LFCNB provides a significantly better pain control, less opioid consumption, and longer duration of analgesia than peri-articular infiltration while preserving muscle function without affecting knee functional recovery nor the length of stay or side effects occurrence.

Lateral femoral cutaneous nerve block with different volumes of Ropivacaine: a randomized trial in healthy volunteers

Background

Nerve block of the lateral femoral cutaneous nerve (LFCN) is a predominantly sensory block. It reduces pain following total hip arthroplasty (THA), but the non-responder rate is high. We hypothesized, that an increased volume of ropivacaine, would result in greater coverage of incisions used for THA.

Methods

We conducted a randomized, blinded trial in 20 healthy volunteers. Participants were randomized to receive bilateral LFCN-blocks with 8 mL ropivacaine 0.75% on the left side and 16 mL ropivacaine 0.75% on the right side, or vice versa. Allocation was blinded to both participants and outcome assessors. Before nerve block performance, incision lines for posterior and lateral THA approaches were depicted with invisible ultraviolet-paint, thereby securing sufficient blinding during outcome assessment. The blocked area was mapped using temperature and mechanical discrimination tests. Quadriceps muscle strength was monitored. Primary outcome was coverage of the posterior incision line assessed by temperature discrimination test.

Results

We found no difference in coverage of the posterior or lateral incision lines when comparing LFCN-blocks with 8 mL versus 16 mL of ropivacaine. The blocked area was significantly larger in the 16 mL group, assessed by both temperature discrimination test (p = 0.012) and mechanical discrimination test (p = 0.034). We observed no difference between groups regarding quadriceps muscle strength (p = 1.0).

Conclusions

A LFCN-block with increased volume of ropivacaine from 8 mL to 16 mL did not result in a greater coverage of posterior or lateral incision lines used for THA, but in a larger blocked sensory area.

Trial registration

Clinicaltrials.gov: NCT03138668. Registered 3rd of May 2017.

Cutaneous anaesthesia of hip surgery incisions with iliohypogastric and subcostal nerve blockade: A randomised trial

BACKGROUND

Cutaneous nerve blockade may improve analgesia after hip surgery. Anaesthesia after the lateral femoral cutaneous (LFC) nerve block is too distal for complete coverage of most hip surgery incisions, which requires additional anaesthesia of the adjacent, proximal area. The transversalis fascia plane (TFP) block potentially anaesthetises the iliohypogastric and subcostal nerves. The primary aim of the present study was to investigate, if the TFP block provides cutaneous anaesthesia adjacent to the LFC nerve block.

METHODS

Active vs placebo TFP blocks were compared in a paired randomised controlled trial (RCT) in 20 volunteers, who all had bilateral LFC nerve blocks. The day preceding the RCT, the area anaesthetised by a novel selective ultrasound guided subcostal nerve block was identified bilaterally in order to assess the contribution of the subcostal nerve to the area anaesthesia by the TFP block.

RESULTS

Anaesthesia of the lateral hip region after TFP block was 80%. The cutaneous anaesthesia after active TFP block was in continuity with the LFC nerve block in 65%. Combined TFP and LFC nerve blockade significantly increased the coverage of hip surgery incisions compared to LFC nerve block alone. The success rate of blocking the subcostal nerve was 50% with the TFP block.

CONCLUSION

The TFP block anaesthetises the skin proximal to the LFC nerve block by anaesthetising the iliohypogastric and subcostal nerves. TFP block as a supplement to LFC nerve block improves the coverage of the proximal surgical incisions used for hip surgery.