A lateral approach to ultrasound-guided sacral plexus block in the supine position

Deep posterior gluteal compartment block for regional anaesthesia of the posterior hip: a proof-of-concept pilot study

Background

Various regional anaesthesia approaches to branches of the anterior lumbar plexus have been proved effective in providing analgesia in hip surgery. However, some patients still experience significant residual posterior hip pain attributed to the posterior nerve supply of the hip. This not only suggests that anterior approaches may not always provide sufficient pain relief, but also that the blocking of major nerves supplying the posterior pericapsular region is needed.

Methods

We present an ultrasound-guided technique to block all major nerves supplying the posterior capsule of the hip joint. The optimal target area was determined by ultrasound imaging, cross-sectional digitised anatomy, and cadaver research, and was found in the deep gluteal compartment. Furthermore, this posterior pericapsular deep-gluteal block was evaluated in two patients.

Results

The spread of dye in the cadaver was observed deep to the gluteus maximus and in between the quadratus femoris and piriformis muscles, and conformed to the presumed location during the ultrasound procedure. It included all major supplying nerves to the posterior hip capsule, that is the superior gluteal nerve, nerve to quadratus femoris and sciatic nerve. In both patients where this posterior pericapsular deep-gluteal block was applied the pain was substantially reduced (numeric rating scale: 4 to 1 and 7 to 1).

Conclusion

We present a successful ultrasound-guided technique targeting the deep gluteal compartment to block all major nerves supplying the hip joint's posterior capsule. This posterior pericapsular deep-gluteal block can be applied as an additional block in hip surgery, with also a possible role in chronic hip pathology.

Applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block in the supine versus lateral position during surgeries for lower limb fracture-a prospective randomized controlled trial

Background

Patients with lower limb fracture often have acute pain and discomfort from changes in position, and such pain affects early postoperative recovery. This study aimed to compare the applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block (LSPB) in the supine versus lateral position during lower limb fracture surgery.

Methods

We included 126 patients who underwent elective internal fixation for lower limb fracture who were divided into the S group and the L group by the random number table method and underwent LSPB guided by ultrasound combined with a nerve stimulator in the supine and lateral positions, respectively. The primary outcome was the dose of sufentanil used in surgery. The secondary outcomes were the maximum VAS (visual analogue scale) pain score at position placing for LSPB, the time of position placing, the time for nerve block,the number of puncture attempts,the haemodynamic indicators, the VAS score at 1, 12, and 24 h following surgery, postoperative satisfactory degree to analgesia and adverse events related to nerve block.

Results

There was no statistically significant difference in dose of sufentanil used between the two groups(P = 0.142). The maximum VAS pain score at position placing(P < 0.01), the time of position placement(P < 0.01), the time for lumbar plexus block and the time of puncture attempts were significantly lower in the S group than in the L group (P < 0.01). However, the time for sacral plexus block was higher in the S group than in the L group (P = 0.029). There was no significant difference in haemodynamic indicators,number of puncture attempts for the sacral plexus, postoperative VAS scores, postoperative satisfactory degree to analgesia or adverse events related to nerve block between the two groups (all P > 0.05).

Conclusions

Our study provides a more comfortable and better accepted anaesthetic regimen for patients undergoing lower limb fracture surgery. LSPB in the supine position is simple to apply and has definite anaesthetic effects. Additionally, it has a high level of postoperative analgesia and therefore should be widely applied.

Trial registration

The trial was registered prior to patient enrolment at the Chinese Clinical Trail Registry (Date:11/03/2021 Number: ChiCTR2100044117).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01710-9.

Ultrasound-guided anterior iliopsoas muscle space block versus posterior lumbar plexus block in hip surgery in the elderly: A randomised controlled trial

BACKGROUND

Ultrasound-guided posterior lumbar plexus block is widely used for hip fracture surgery but it requires a change of position, which may be painful.

OBJECTIVES

Our primary objective was to describe a new technique, the anterior iliopsoas muscle space block, which can be performed in the supine position, and to test the hypothesis that its analgesia for hip surgery was similar to that of the traditional posterior lumbar plexus block.

DESIGN

Randomised, double-blind study.

SETTING

Shanghai 6th People's Hospital, China, from February to August 2019.

PATIENTS

Forty-eight patients scheduled for unilateral hip fracture surgery were included in the study. The exclusion criteria were infection at the puncture site, history of hip surgery, pre-existing neurological deficits of the lower extremity, contraindications for regional anaesthesia, allergy to local anaesthetics, coagulopathy, abuse of medicine or alcohol, or daily consumption of analgesics.

INTERVENTIONS

Patients were randomised to receive a lateral sacral plexus block with either an anterior iliopsoas muscle space block or a posterior lumbar plexus block, using 0.33% ropivacaine (30 ml each).

MAIN OUTCOME MEASURES

The main outcome was verbal numerical scale (VNS) pain intensity 1 h after surgery in the postanesthesia care unit, and the secondary outcome was the dose of intra-operative fentanyl. The differences in VNS scores and fentanyl use between the groups were analysed.

RESULTS

Based on previous work, we considered a difference (confidence interval [CI]) of 1.6 on the VNS to be significant. The median [IQR] pain scores in postanesthesia care unit were similar in the anterior 0 [0 to 3] and posterior groups 1.5 [0 to 3]. The median scores for intra-operative fentanyl use were similar in the anterior 20 [10 to 42.5] μg and posterior groups 15 [0 to 50] μg (P = 0.34). The difference in the median pain score at-rest was NS: anterior group 0.5 [0 to 5], posterior group 0 [0 to 2], median difference -0.5 (95% CI -2 to 0). The median post to preblock difference in VNS was higher in the anterior -0.5 [-2 to 0] than in the posterior group 0 [-1.25 to 0], median difference 0.5 (95% CI 0 to 1). The median block onset time was longer in the anterior 11 [6 to 14.25] min than in the posterior group 6 [4.75 to 8] min (P = 0.002), median difference -5 (95% CI -7 to -1).

CONCLUSION

The anterior iliopsoas muscle space block had the same effect as the posterior lumbar plexus block on peri-operative analgesia for hip surgery, but with a longer onset time. Therefore, anterior iliopsoas muscle space block can be recommended as a routine technique for hip and lower limb procedures.

TRIAL REGISTRATION

http://www.chictr.org.cn identifier: ChiCTR1900021214.

Ultrasound-guided suprainguinal fascia iliaca block combined with a sacral plexus block for lower extremity surgery: A case report

RATIONALE

The anesthetic management of patients with severe pulmonary hypertension is different from that of normal, healthy patients, and regional nerve blocks are commonly used for them. Due to the individual variability of the course, distribution, and branching of the nerves below the inguinal ligament, the supra-inguinal fascia iliaca (SIFI) block has a wider and more stable blocking area. In combination with the sacral plexus block, they can satisfy the needs of surgical anesthesia below the hip.

PATIENT CONCERNS

A 46-year-old man with tuberculosis, chronic obstructive pulmonary disease, pulmonary heart disease, World Health Organization (WHO) class III pulmonary hypertension and right heart dysfunction, and American Society of Anesthesiologists physical status class III needed fixation of an intramedullary nail in the left lower extremity. Additionally, he had broken his left lower limb after a recent fall. Both general anesthesia and epidural anesthesia were not appropriate.

DIAGNOSES

The patient had a clear history of tuberculosis, computerized tomography scan displayed destructive pneumonophthisis. Furthermore, he had chronic obstructive pulmonary disease and pulmonary heart disease.

INTERVENTIONS

An ultrasound-guided SIFI combined with a sacral plexus block was successfully performed for surgical anesthesia and avoided all hemodynamic fluctuations.

OUTCOMES

We successfully performed an ultrasound-guided SIFI combined with a sacral plexus block for surgical anesthesia and avoided all hemodynamic fluctuations.

LESSONS

Ultrasound-guided suprainguinal fascia iliaca block combined with a sacral plexus block can be suitable for anesthesia for patients with severe circulatory compromise.

Combination of ultrasound-guided lumbosacral plexus block with anterior quadratus lumborum block in supine position for hip surgery: a case report

It was widely recognized that the procedure of ultrasound-guided lumbar and sacral plexus block is required to be performed in a lateral decubitus position that patients' hips and knees were bended. It is difficult, however, for patients with hip fractures to change position because of severe pain and confined movements. We here reported a new modified combination of ultrasound-guided lumbosacral plexus block with anterior quadratus lumborum block in supine position that had been successfully applied in one elderly patient who underwent hip surgery.