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Jessen C, Espelund US, Brix LD, Nielsen TD, Lund B, Bendtsen TF. Subpectineal obturator nerve block reduces opioid consumption after hip arthroscopy: a triple-blind, randomized, placebo-controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105638. [PMID: 38925710 DOI: 10.1136/rapm-2024-105638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Hip arthroscopy causes severe pain during the first few hours in the postoperative care unit. This is probably due to the intraoperative stretching of the hip joint capsule. Pain relief requires high doses of opioids which may prolong recovery and may cause opioid-related adverse events.The majority of hip joint capsule nociceptors are located anteriorly. The obturator nerve innervates the anteromedial part of the hip joint capsule. We hypothesized that a subpectineal obturator nerve block using 15 ml bupivacaine 5 mg/mL with added epinephrine 5 μg/mL would reduce the opioid consumption after hip arthroscopy. METHODS 40 ambulatory hip arthroscopy patients were enrolled in this randomized, triple-blind controlled trial. All patients were allocated to a preoperative active or placebo subpectineal obturator nerve block. The primary outcome was opioid consumption for the first 3 hours in the postanesthesia care unit. Secondary outcomes were pain, nausea, and hip adductor strength. RESULTS 34 patients were analyzed for the primary outcome. The mean intravenous morphine equivalent consumption in the subpectineal obturator nerve block group was 11.9 mg vs 19.7 mg in the placebo group (p<0.001). The hip adductor strength was significantly reduced in the active group. No other intergroup differences were observed regarding the secondary outcomes. CONCLUSION We found a significant reduction in the opioid consumption for patients receiving an active subpectineal obturator nerve block. The postoperative intravenous morphine equivalent reduction the first painful 3 hours was reduced by 40% for patients receiving a subpectineal obturator nerve block in this randomized, triple-blind trial. TRIAL REGISTRATION NUMBER EudraCT database 2021-006575-42.
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Affiliation(s)
- Christian Jessen
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Ulrick Skipper Espelund
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Lone Dragnes Brix
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Thomas Dahl Nielsen
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Bent Lund
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
- Department of Orthopedic Surgery, H-Hip, Horsens Regional Hospital, Horsens, Denmark
| | - Thomas Fichtner Bendtsen
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Jessen C, Brix LD, Nielsen TD, Espelund US, Lund B, Bendtsen TF. Efficacy of iliopsoas plane block for patients undergoing hip arthroscopy: a prospective, triple-blind, randomized, placebo-controlled trial. Reg Anesth Pain Med 2023:rapm-2023-104989. [PMID: 38050149 DOI: 10.1136/rapm-2023-104989] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/20/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Intraoperative stretching of the hip joint capsule often generates severe pain during the first 3 hours after hip arthroscopy. The short-lived severe pain mandates high opioid consumption, which may result in adverse events and delay recovery. The femoral nerve nociceptors are located anteriorly in the hip joint capsule. A femoral nerve block reduces pain and opioid demand after hip arthroscopy. It impedes, however, ambulation and home discharge after outpatient surgery. The iliopsoas plane block selectively anesthetizes the femoral sensory nerve branches innervating the hip joint capsule without compromising ambulation. We aimed to assess reduction of opioid consumption after iliopsoas plane block during the short-lived painful postsurgical period of time after hip arthroscopy. METHODS In a randomized, triple-blind trial, 50 patients scheduled for hip arthroscopy in general anesthesia were allocated to active or placebo iliopsoas plane block. The primary outcome was opioid consumption during the first three postoperative hours in the postanesthesia care unit. Secondary outcomes included pain, nausea, and ability to ambulate. RESULTS Forty-nine patients were analyzed for the primary outcome. The mean 3-hour intravenous morphine equivalent consumption in the iliopsoas plane block group was 10.4 mg vs 23.8 mg in the placebo group (p<0.001). No intergroup differences were observed for the secondary outcomes during the postoperative follow-up. CONCLUSION An iliopsoas plane block reduces opioid consumption after hip arthroscopy. The reduction of opioid consumption during the clinically relevant 3-hour postsurgical period of time was larger than 50% for active versus placebo iliopsoas plane block in this randomized, triple-blind trial.
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Affiliation(s)
- Christian Jessen
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Lone Dragnes Brix
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | | | - Ulrick Skipper Espelund
- Department of Anesthesiology and Intensive Care, PeriSCOP, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
| | - Bent Lund
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
- Department of Orthopedic Surgery, H-Hip, Horsens Regional Hospital, Horsens, Denmark
| | - Thomas Fichtner Bendtsen
- Department of Clinical Medicine, Aarhus University Faculty of Health, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Restrepo-Holguin M, Kopp SL, Johnson RL. Motor-sparing peripheral nerve blocks for hip and knee surgery. Curr Opin Anaesthesiol 2023; 36:541-546. [PMID: 37552001 DOI: 10.1097/aco.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW To summarize the recent literature describing and comparing novel motor-sparing peripheral nerve block techniques for hip and knee surgery. This topic is relevant because the number of patients undergoing same day discharge after hip and knee surgery is increasing. Preserving lower extremity muscle function is essential to facilitate early physical therapy for these patients. RECENT FINDINGS Distal peripheral nerve blocks may allow for preserved quadriceps motor strength and comparable analgesia to traditional techniques. However, few studies in hip and knee populations include strength or function as primary outcomes. For hip surgeries, studies have failed to show analgesic differences between regional blocks and periarticular infiltration. Similarly for knee arthroplasty in the absence of periarticular infiltration, recent evidence suggests adding combinations of blocks (ACB plus iPACK or genicular nerve blocks) may balance pain control and early ambulation. SUMMARY The use of motor-sparing peripheral nerve block techniques enables early ambulation, adequate pain control, and avoidance of opioid-related side effects facilitating outpatient/ambulatory lower extremity surgery. Further studies of these techniques for continuous peripheral nerve block catheters are needed to assess if extended blockade continues to provide motor-sparing and opioid-sparing benefits.
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Parameters of Iliopsoas Plane Immediately Caudal to the Indirect Tendon of Rectus Femoris in Axial Plane Measured on Magnetic Resonance Images in an Adult Eastern Asian Population. Healthcare (Basel) 2022; 11:healthcare11010069. [PMID: 36611529 PMCID: PMC9819308 DOI: 10.3390/healthcare11010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The iliopsoas plane (IP) is a fascial plane deep to the iliopsoas complex and is the target of several novel ultrasound-guided analgesic interventions for hip. Currently, limited information is known about its parameters. From the pelvic magnetic resonance (MR) images of an adult Eastern Asian population (n = 49), the IP width, depth, and needle-beam angle in the axial plane immediately caudal to the level of indirect tendon of rectus femoris (RF) were found to be 10.7 ± 1.6 mm, 48.5 ± 15.5 mm, and 84.2 ± 8.2 degrees, respectively. There was a statistically significant difference in the age categories for IP width, and older patients seemed to have wider IP. Our data may provide applications for the technical modification of ultrasound-guided iliopsoas plane block (IPB) in acute hip pain management and the future development of ultrasound-guided single-needle-entry radiofrequency neuroablation in chronic hip pain management.
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Kaur G, Saikia P, Dey S, Kashyap N. Pericapsular nervegroup (PENG) block—a scoping review. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2022. [PMCID: PMC8919174 DOI: 10.1186/s42077-022-00227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The obturator nerve and its accessory branch supplying the hip region, unlike the femoral nerve, are not adequately anaesthetized by conventional regional anaesthetic techniques targeting the hip region. With advancements in ultrasound-guided regional anaesthetic techniques, interests are revived in the field and efforts are being made to block them together. One such successful attempt is the novel peri-capsular nerve group (PENG) block. Consequently, further research on the PENG block began to explore its versatilities. The present study undertakes a scoping review of research on the PENG block in humans for any indication to determine the extent of the research done, the methodologies used, and other practical issues addressed in the research. This will help to identify potential research gaps that should be addressed in the future. PubMed, Google Scholar, Cochrane Library, KoreaMed, Latin American and Caribbean Health Science Literature, and the directory of open access journals were searched with the keyword “PENG block” and “pericapsular nerve group”. Manual search of electronically retrieved papers was also carried out. Among the 67 articles selected in our review, eighteen are case series; twenty-nine are case reports; two are randomized studies; one each of prospective cohort study, review, and cadaveric study; and 15 are editorials. However, only 64 articles were included later due to the retraction of three case reports. Data is insufficient to provide firm recommendations for or against different aspects of the block. The review encourages future work addressing different aspects of the PENG block.
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Casas Reza P, Gestal Vázquez M, López Álvarez S. New ultrasound-guided capsular blocks for hip surgery: A narrative review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:556-566. [PMID: 36220728 DOI: 10.1016/j.redare.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 04/27/2021] [Indexed: 06/16/2023]
Abstract
Surgery on the hip joint is very common. Improving pain management has been and is one of the fundamental pillars to optimize the functional recovery of patients. To do this, we must design a multimodal anesthetic-analgesic plan that covers the entire perioperative period. Peripheral nerve blocks and fascial blocks are an important component of multimodal analgesic strategies. Traditional blocks have moderate efficacy, prolonged motor impairment, and increased risk of falls. As an alternative, capsular blocks ("ileopsoas plane block" or "IPB" and pericapsular nerve group block or "PENG block") have recently been described that aim to avoid motor impairment while maintaining optimal analgesic efficacy. The objective of this review is to describe the new capsular blocks and to analyze whether they allow to improve postoperative analgesia and promote functional recovery with fewer complications, based on the innervation of the hip. To do this, a bibliographic review was carried out in the PubMed, Embase and Cochrane Library databases from January 2018 to June 2020.
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Affiliation(s)
- P Casas Reza
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain.
| | - M Gestal Vázquez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - S López Álvarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
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Pericapsular Nerve Group Block and Iliopsoas Plane Block: A Scoping Review of Quadriceps Weakness after Two Proclaimed Motor-Sparing Hip Blocks. Healthcare (Basel) 2022; 10:healthcare10081565. [PMID: 36011222 PMCID: PMC9408030 DOI: 10.3390/healthcare10081565] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 01/18/2023] Open
Abstract
Iliopsoas plane (IP) is a fascial plane deep to the iliopsoas complex that can serve as a potential space for the injection of local anesthetics to selectively block the articular branches of femoral nerve and accessory obturator nerve to the anterior hip capsule. Two highly similar ultrasound-guided interfascial plane blocks that target the IP, pericapsular nerve group (PENG) block and iliopsoas plane block (IPB), were both designed to achieve motor-sparing sensory block to the anterior hip capsule. However, the most recent evidence shows that PENG block can cause 25% or more of quadriceps weakness, while IPB remains the hip block that can preserve quadriceps strength. In this scoping review of quadriceps weakness after PENG block and IPB, we first performed a focused review on the complicated anatomy surrounding the anterior hip capsule. Then, we systematically searched for all currently available cadaveric and clinical studies utilizing PENG block and IPB, with a focus on quadriceps weakness and its potential mechanism from the perspectives of fascial plane spread along and outside of the IP. We conclude that quadriceps weakness after PENG block, which places its needle tip directly deep to iliopsoas tendon (IT), may be the result of iliopectineal bursal injection. The incidental bursal injection, which can be observed on ultrasound as a medial fascial plane spread, can cause bursal rupture/puncture and an anteromedial extra-IP spread to involve the femoral nerve proper within fascia iliaca compartment (FIC). In comparison, IPB places its needle tip lateral to IT and injects just one-fourth of the volume of PENG block. The current evidence, albeit still limited, supports IPB as the true motor-sparing hip block. To avoid quadriceps weakness after PENG block, a more laterally placed needle tip, away from the undersurface of IT, and a reduction in injection volume should be considered. Future studies should focus on comparing the analgesic effects and quadriceps function impairment between PENG block and IPB.
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Del Buono R, Padua E, Pascarella G, Costa F, Tognù A, Terranova G, Greco F, Fajardo Perez M, Barbara E. Pericapsular nerve group block: an overview. Minerva Anestesiol 2021; 87:458-466. [PMID: 33432791 DOI: 10.23736/s0375-9393.20.14798-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The PENG block is a recently described ultrasound-guided technique for the blockade of the sensory nerve branches to the anterior hip joint capsule. It was described as an analgesic block for the acute pain management after hip fracture, while subsequent studies expanded the original indication. The aim of this narrative review was to summarize the existing knowledge about the PENG block from the anatomical bases and to provide an up-to-date description of the technique, applications and effects. EVIDENCE ACQUISITION We reviewed the following medical literature databases for publications on PENG block: PubMed, Google Scholar, EMBASE, and Web of science until August 31st, 2020. Data regarding anatomy, indications, drugs and technique were also collected, reported and discussed. EVIDENCE SYNTHESIS From our search result we selected 57 relevant publications. Among them, 36 were case reports or case series and 12 publication were letters or correspondence; no RCT was identified. The main indication is the hip-related analgesia. The most commonly injected drug is a 20ml long-acting local anesthetic. There are some cases of femoral and obturator nerve block, but no major complication such as hematoma/bleeding or needle-related organ injury has been reported yet. CONCLUSIONS The PENG block is a promising technique. Randomized controlled trials of high methodological quality are required to further elaborate the role of this block.
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Affiliation(s)
- Romualdo Del Buono
- Unit of Anesthesia, Resuscitation, Intensive Care and Pain Management, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy
| | - Eleonora Padua
- Unit of Anesthesia, Resuscitation, Intensive Care and Pain Management, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy
| | - Giuseppe Pascarella
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University, Rome, Italy -
| | - Fabio Costa
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Andrea Tognù
- Department of Anesthesia and Postoperative Intensive Care, Rizzoli Orthopedic Institute, Bologna, Italy
| | - Gaetano Terranova
- Unit of Anesthesia, Resuscitation, Intensive Care and Pain Management, ASST Gaetano Pini, Milan, Italy
| | - Federico Greco
- Unit of Diagnostics for Corporate Territorial Images, Cittadella della Salute, ASL Lecce, Lecce, Italy
| | - Mario Fajardo Perez
- Department of Anesthesia, Department of Chronic Pain, Hospital Móstoles, Madrid, Spain
| | - Enrico Barbara
- Unit of Anesthesia, Resuscitation, Intensive Care and Pain Management, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy
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Endersby RVW, Moser JJ, Ho ECY, Yu HC, Spencer AO. Motor blockade after iliopsoas plane (IPB) and pericapsular nerve group (PENG) blocks: A little may go a long way. Acta Anaesthesiol Scand 2021; 65:135-136. [PMID: 32939753 DOI: 10.1111/aas.13707] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ryan V. W. Endersby
- Department of Anesthesia, Perioperative and Pain Medicine University of CalgarySouth Health Campus Calgary Alberta Canada
| | - Joanna J. Moser
- Department of Anesthesia, Perioperative and Pain Medicine University of CalgarySouth Health Campus Calgary Alberta Canada
- Department of Anesthesia Red Deer Regional Hospital Red Deer Alberta Canada
| | - Esther C. Y. Ho
- Department of Anesthesia, Perioperative and Pain Medicine University of CalgarySouth Health Campus Calgary Alberta Canada
| | - Hai C. Yu
- Department of Anesthesia, Perioperative and Pain Medicine University of CalgarySouth Health Campus Calgary Alberta Canada
| | - Adam O. Spencer
- Department of Anesthesia, Perioperative and Pain Medicine University of CalgarySouth Health Campus Calgary Alberta Canada
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Roy R, Agarwal G, Patel A. IPB with LFCN can provide ambulatory analgesia for hip surgeries. Reg Anesth Pain Med 2020; 45:840. [DOI: 10.1136/rapm-2020-101300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/04/2022]
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Del Buono R, Pascarella G, Costa F, Barbara E. Ultrasound-guided local infiltration analgesia for hip surgery: myth or reality? Minerva Anestesiol 2019; 85:1242-1243. [PMID: 31124626 DOI: 10.23736/s0375-9393.19.13701-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Romualdo Del Buono
- Unit of Anesthesia, Intensive Care and Pain Management, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy -
| | - Giuseppe Pascarella
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Fabio Costa
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Enrico Barbara
- Unit of Anesthesia, Intensive Care and Pain Management, Humanitas Mater Domini Hospital, Castellanza, Varese, Italy
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Peng PWH, Perlas A, Chin KJ. Reply to Dr Nielsen: Pericapsular Nerve Group (PENG) block for hip fracture. Reg Anesth Pain Med 2019; 44:415-416. [DOI: 10.1136/rapm-2018-100234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/05/2018] [Indexed: 11/04/2022]
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Nielsen ND, Bendtsen TF. Motor-sparing regional analgesia for hip-derived pain. Reg Anesth Pain Med 2019; 44:rapm-2018-100157. [PMID: 30636715 DOI: 10.1136/rapm-2018-100157] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Niels Dalsgaard Nielsen
- Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Thomas F Bendtsen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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