Continuous Psoas Compartment Block for Postoperative Analgesia After Total Hip Arthroplasty: New Landmarks, Technical Guidelines, and Clinical Evaluation

Interventional therapies for management of hip fracture pain peri-operatively: A review article

Background

Hip fracture is a common reason for elderly admission to hospital and majority of patients will require a hip fixation surgery. Pain originating from a hip fracture is usually severe and the need to improve comfort is paramount, especially before the hip fixation surgery because severe pain results in unnecessary stress response such as catecholamines release, tachycardia and hypertension. This worsens outcomes, increases risk of complications such as myocardial ischaemia, strokes, pulmonary embolus or deep vein thrombosis. Multimodal systemic analgesia has been shown to be effective in reducing pain in hip fractures but the associated side effects and contraindications have accelerated the adoption of nerve blocks in the peri-operative management of hip fracture patients. 1 As a result, this has been increasingly recognised as a important component of the hip fracture pathway (as part of a multimodal approach for analgesia) and many hospitals have protocols to perform various interventional therapies (various nerve blocks) for newly admitted patients with hip fracture to alleviate pain immediately and potentially provide intra and post-operative analgesia.

Objective

The aim of this review is to elucidate the various interventional therapies currently available (including pericapsular nerve group (PENG) block which was first described in 2018), their evidence and the pros and cons.

Methods

We reviewed the latest evidence for femoral nerve block (FNB), 3-in-1 block, lumbar plexus block (LPB), fascia iliaca block (FIB), erector spinae plane block (ESPB) and pericapsular nerve group (PENG) block.

Results and conclusion

Each block has its pros and cons, as discussed in this review article. The procedurist should deliberate these considerations before deciding which block is most appropriate.

Effect of erector spinae plane block on postoperative analgesia after pediatric hip surgery: Randomized controlled study

BACKGROUND

ESPB in pediatric patients presented for hip surgery may improve the postoperative analgesia.

AIM

The study aimed to investigate the effect of ultrasound guided ESPB on the postoperative analgesia after pediatric hip surgery.

METHODS

Forty children scheduled for hip surgeries were included in this trial and randomly distributed into; Control group, patients received sham ultrasound-guided ESPB at the level of L3 or Erector spinae plane block group, patients received real ultrasound-guided ESPB at the level of L3 with injection of 0.4 ml/kg of plain bupivacaine 0.25%. The time for the first call of rescue analgesia, intraoperative fentanyl consumption, postoperative morphine consumption, Children's Hospital Eastern Ontario Pain Scale (CHEOPS), and Objective Behavioral Pain score (OPS) scores were recorded.

RESULTS

As compared to the control group, the use of ESPB significantly prolonged the time for first request of rescue analgesia from 170.50 ± 44.066 min to 256.50 ± 66.434 min (P < 0.0001), decreased the intraoperative fentanyl consumption from 1.025±0.379 ug/kg to 0.775±0.343 ug/kg (P = 0.035), decreased the postoperative morphine consumption from 0.105 ± 0.036 mg/kg to 0.065 ± 0.023 mg/kg (P = 0.0002). Also, it significantly decreased postoperative CHEOPS and OPS scores 2, 4, and 6 h after the surgery (P < 0.05) with insignificant difference between the two groups at all other time intervals (P ˃ 0.05).

CONCLUSION

The use of ESPB in pediatric patients undergoing hip surgery prolonged the time for first call of analgesia, decreased the intraoperative and postoperative opioid consumption, and decreased the postoperative pain.

Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis

BACKGROUND

For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.

METHODS

We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.

RESULTS

We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.

CONCLUSIONS

We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.

[Incidence of epidural spread after Chayen's approach to lumbar plexus block: a retrospective study]

BACKGROUND AND OBJECTIVES

The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread.

METHOD

We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for total hip arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and sciatic nerve block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period.

RESULTS

A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%; p <0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded.

CONCLUSIONS

This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

Incidence of epidural spread after Chayen’s approach to lumbar plexus block: a retrospective study

Background and objectives

The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread.

Method

We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for Total Hip Arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and Sciatic Nerve Block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen’s technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period.

Results

A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%;p < 0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded.

Conclusions

This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen’s approach, is characterized by a lower epidural spread than the other approach to the LPB.

Inadvertent epidural anesthesia associated with catheterization following continuous psoas compartment block in a patient with scoliosis: A Case report

RATIONALE

Psoas compartment block (PCB) is typically performed using surface anatomical landmarks and neurostimulation for guidance. However, anatomical anomalies, such as scoliosis, make this technique unreliable, posing a challenge for the anesthesiologist when inducing regional anesthesia.

PATIENT CONCERNS

A 69-year-old woman with lumbar scoliosis scheduled for total hip arthroplasty underwent PCB with catheterization.

DIAGNOSES

Inadvertent epidural anesthesia with catheterization following PCB was diagnosed using a lumbar radiograph.

INTERVENTIONS

Due to hypotension induced by local anesthetic (LA) epidural diffusion, the patient received intravenous hydration and vasopressor. Since bilateral sensory block was noted at the T3 level, with an incomplete motor blockade in both legs, the surgery was performed under epidural anesthesia.

OUTCOMES

The patient remained hemodynamically stable throughout the duration of the surgical procedure. The surgery was uneventful and without further complications.

LESSONS

Patients with lumbar scoliosis are highly at risk of LA epidural diffusion, following PCB using traditional landmark-based approach. Other nerve-localizing technique can minimize the risk of this complication.

Safety margin for needle placement during lumbar plexus block: An anatomical study using magnetic resonance imaging

PURPOSE

We aimed to provide anatomic characteristics of the lumbar plexus and a safety margin for needle placement during lumbar plexus block in adults.

METHODS

Lumbar spine magnetic resonance images from 377 adults were reviewed. We determined the depth of the lumbar plexus from the needle insertion point for the modified traditional and Capdevila's approaches at the L4 and L5 levels. The relationship of age, height, and body weight with lumbar plexus depth, and the presence of the kidney on the transverse plane at the L4 level were assessed.

RESULTS

The lumbar plexus was deeper at the L5 level than at the L4 level for both approaches (mean difference 3.2 mm [95% confidence interval (CI), 2.4 to 4.0] for the modified traditional approach; mean difference 4.4 mm [95% CI, 3.7 to 5.2] for Capdevila's approach). Eighty-six (22.8%) patients had an L4 transverse process shorter than 40 mm, which implies that the needle may not contact the L4 transverse process with the modified traditional approach. The mean (standard deviation) of safety margins for needle insertion, defined as the distance from the posterior aspect of the L4 transverse process to the anterior margin of the psoas muscle, were 45 (8) and 44 (6) mm, respectively for the modified traditional and Capdevila's approach (mean difference, 0.5 mm; 95% CI, -0.1 to 1.1]). The lumbar plexus depth for each approach at the L4 level was predicted using the following equations: Depth (mm) = 87.24 - 0.36 × height (cm) + 0.69 × weight (kg) for the modified traditional approach (r² = 0.37) and Depth (mm) = 86.51 - 0.35 × height (cm) + 0.61 × weight (kg) for Capdevila's approach (r² = 0.33). The kidney was observed at the L4 level in 60 (15.9%) patients, with higher incidence in patients over 70 yr and those shorter than 150 cm.

CONCLUSION

The surface anatomic relations of the lumbar plexus found in this study may be useful for performing successful and safe lumbar plexus block.

Pain Management After Hip Arthroscopy: Systematic Review of Randomized Controlled Trials and Cohort Studies

BACKGROUND

Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications.

PURPOSE

To collect, examine, and provide a comprehensive review of the available evidence from randomized controlled trials and comparative studies on pain control after hip arthroscopy.

STUDY DESIGN

Systematic review.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature for postoperative pain control after hip arthroscopy was performed using electronic databases. Only comparative clinical studies with level 1 to 3 evidence comparing a method of postoperative pain control with other modalities or placebo were included in this review. Case series and studies without a comparative cohort were excluded.

RESULTS

Several methods of pain management have been described for hip arthroscopy. A total of 14 studies met our inclusion criteria: 3 on femoral nerve block, 3 on lumbar plexus block, 3 on fascia iliaca block, 4 on intra-articular injections, 2 on soft tissue surrounding surgical site injection, and 2 on celecoxib (4 studies compared 2 or more methods of analgesia). The heterogeneity of the studies did not allow for pooling of data. Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed. Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with increased risk of cutaneous nerve deficits. Patients receiving lumbar plexus block experienced significantly decreased pain compared with fascia iliaca block. Portal site and periacetabular injections provide superior analgesia compared with intra-articular injections alone. Preoperative oral celecoxib, compared with placebo, resulted in earlier time to discharge and provided significant pain relief up to 24 hours.

CONCLUSION

Perioperative nerve blocks provide effective pain management after hip arthroscopy but must be used with caution to decrease risk of falls. Intra-articular and portal site injections with local anesthetics and preoperative celecoxib can decrease opioid consumption. There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.

Predicting the Depth of the Lumbar Plexus in Pediatric Patients: A Retrospective Magnetic Resonance Imaging Study

BACKGROUND

The lumbar plexus (LP) block is commonly used for analgesia for lower extremities. If the depth of the LP (LPD) can be predicted, the performance time and procedure-related complications could be reduced.

METHODS

Three hundred sixty-one magnetic resonance images of pediatric patients (<18 years of age) were analyzed. Simple linear regression and multiple linear regression analyses were performed to predict the LPD using patient age, weight, height, and the distance between the midline and posterior superior iliac spine (midline-PSIS). The ratio of the distance between the midline and the most lateral aspect of the LP (midline-LP) to midline-PSIS (midline-LP/midline-PSIS ratio) was calculated to suggest a needle insertion point at the L4/L5 intervertebral level. The presence of the kidney at the L4 level and the L4/L5 intervertebral level was determined.

RESULTS

The LPD at the L4/L5 intervertebral levels was predicted using the equation LPD = 0.844 × weight (kg) + 25.8 (mm) in pediatric patients <18 years of age (r = 0.791; 95% confidence interval [CI] of r, 0.753-0.829). The overall midline-LP/midline-PSIS ratio was 0.87 (95% CI, 0.86-0.89), and the ratio was higher in neonates and infants (0.98 [95% CI, 0.95-1.02]) than in the other age groups. The presence of the lower kidney pole at the L4 level was common in pediatric patients (43.7% of neonates and infants and 13.7% of toddlers and preschool-aged children). The lower kidney pole was observed at the L4/L5 level in 6 patients (1.7%).

CONCLUSIONS

When LP block is performed in pediatric patients, the LPD and risk of renal injury should be considered for successful and safe analgesic block.

Update on Selective Regional Analgesia for Hip Surgery Patients

In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.

[Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial]

BACKGROUND

Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject.

METHODS

Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring.

RESULTS

Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores.

CONCLUSIONS

Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Ultrasound-guided lumbar plexus block in children and adolescents using a transverse lumbar paravertebral sonogram: Initial experience

BACKGROUND

The clinical reliability and reproducibility of ultrasound-guided lumbar plexus blocks is not established in pediatric populations. We present the results of a combined nerve stimulation ultrasound-guided lumbar plexus block using the vertebral body, transverse process, and psoas muscle as landmarks on a transverse lumbar paravertebral sonogram with mid-axillary transducer placement, "shamrock method," in children and adolescents.

AIMS

Our primary objective was to determine the rate of achieving sensory changes in the lumbar plexus distribution. Secondary outcomes were performance time, reliability of echo-landmarks, measures of patient comfort, and complications.

METHODS

We reviewed prospectively collected quality assurance data and electronic medical records of 21 patients having major orthopedic surgery with lumbar plexus block catheter for postoperative analgesia.

RESULTS

Twenty-one patients were studied with mean age and weight (SD, range) of 13.6 years (3.8, 6-18) and 49.3 kg (18.6, 19.2-87.6). Surgical procedures included periacetabular osteotomy, pelvic osteotomy, and proximal femoral osteotomy. Mean volume of 0.5 mL/kg (0.05) 0.2% ropivacaine produced thermal sensory changes to femoral and lateral femoral cutaneous nerves in 20/21 (95% CI 0.76 to >0.99) and 19/21 (95% CI 0.70-0.99) patients. Identification of transverse process (TP), vertebral body (VB), and psoas muscle (PM): 21/21 (95% CI 0.86-1.0). Average block performance time was 9:08 minutes (2:09, 2-13). Average opioid consumption (SD) in operating room, postanesthesia care unit, 0-12 and 12-24-hour periods were 0.17 mg/kg (0.08), 0.08 mg/kg (0.06), 0.06 mg/kg (0.06), and 0.06 mg/kg (0.05). Median pain score by severity category in postanesthesia care unit: (0-3) 66.7%, (4-6) 28.5%, (>7) 4.8%; 0-12 hours: (0-3) 76.2%, (4-6) 19.0%, (>7) 4.8%; 12-24 hours: (0-3) 57.2%, (4-6) 42.8%, (>7) 0%. No complications were recorded.

CONCLUSION

Ultrasound guidance using lateral imaging of transverse process, vertebral body, and psoas muscle allows practitioners to reach the nerves of the lumbar plexus and achieve sensory block in pediatric patients with a high success rate.

Comparison of lumbar plexus block using the short axis in-plane method at the plane of the transverse process and at the articular process: a randomized controlled trial

BACKGROUND

Although the safety and effectiveness of the short-axis in-plane method has been confirmed for lumbar plexus block, the operation is difficult and has a high rate of epidural spread at the plane of the articular process. Therefore, we developed a new in-plane technique, called the beach chair method, which displays images from the transverse process. We compared the operative difficulty and incidence of epidural spread of the beach chair method with those of the control method (at the plane of the articular process) in this randomized controlled clinical trial.

METHODS

Sixty patients, aged 18 to 75 years, scheduled for unilateral arthroscopic knee surgery were randomized to receive double-guided lumbar plexus block by the beach chair method (n = 30) or the control method (n = 30) with 30 ml 0.5% ropivacaine hydrochloride; all patients received a sciatic nerve block with 10 ml 1% lidocaine hydrochloride and 10 ml 0.5% ropivacaine hydrochloride.

RESULTS

The incidence of epidural spread after lumbar plexus block was significantly lower in the beach chair group than that in the control group [1 case (3.3%) vs. 9 (30.0%), P = 0.006]. Moreover, the imaging time (34.2 ± 16.7 s vs. 48.9 ± 16.8 s, P = 0.001), needling time (85.0 ± 45.3 s vs. 131.4 ± 88.2 s, P = 0.013) and number of needle punctures (2.7 ± 1.3 vs. 4.5 ± 2.1, P = 0.000) were significantly lower in the beach chair group than those in the control group; the ultrasound visibility score of the beach chair group was better than that of the control group. There were no significant differences in the remaining indicators.

CONCLUSIONS

The beach chair method was easier and was associated with a lower incidence of epidural spread than the control method. Therefore, the beach chair method (at the plane of the transverse process) provides another promising option for lumbar plexus block for the non-obese population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR), Registration number:ChiCTR-INR-15007505, registered on November 06, 2015.

Continuous Posterior Lumbar Plexus Nerve Block Versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Total Hip Arthroplasty: A Three-Arm Randomized Clinical Trial

BACKGROUND

Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI.

METHODS

This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units.

RESULTS

We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication.

CONCLUSIONS

In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lower limb orthopedic surgery in geriatric patients under paravertebral blocks: A prospective feasibility study

BACKGROUND

Aging causes progressive deterioration of all the organ systems. Physiological changes of aging and co-morbidities make regional anesthesia a preferred technique for this age group. Regional anesthesia with risk of hypotension and its consequences is fraught with dangers. Peripheral nerve blocks (PNBs) are much safer and give much superior post-op analgesia. The present study was undertaken to perform major lower limb orthopedic surgeries PNBs in geriatric settings.

METHODS

A feasibility study was undertaken in patients above age of 60 years admitted for lower limb surgeries to undertake these surgeries under para-vertebral blocks for a period of one year from Mar 2011 to Feb 2012.

RESULTS

The responses and results of 203 eligible patients averaging 69.5 years. Mean duration of surgical procedure was 174.6 min and surgical analgesia was 334.5 min. Mean time of analgesic supplementation postoperative 398.3 min. The incidence of adverse effects (hypotension) requiring intervention was 5 out of 203, failure rate 2 out of 203.

CONCLUSION

All major lower limb surgeries can be done under combined lumbar and sacral plexus block with additional supplementation for the skin at the line of incision especially in case the surgery involving hip with intercostal block at 11th ICS. The study strongly recommends it as a technique of choice in geriatric cases rather than reserving it for only moribund cases.

Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study

BACKGROUND

Upon arrival at the emergency department, hip-fracture pain relief is usually carried out via systemic opioids. Continuous nerve blocks are efficient in the postoperative period, but have not been evaluated preoperatively. This study compared the reduction in morphine consumption and related side effects of a continuous femoral block with a single shot block in hip-fracture patients.

METHODS

Hip-fracture patients admitted to the emergency department received a femoral nerve catheter, with a single lidocaine injection. They were then randomized to ropivacaine (group R) or saline continuous infusion (placebo, group P) in a double-blind manner. Morphine consumption and side effects were prospectively collected until the 24th postoperative hour.

RESULTS

Sixty patients were included and 55 analyzed. There were no significant differences between the 2 groups regarding fracture types, delay before surgery (median [Q1-Q3]: 21.3 [14.5-29.4] versus 20.8 [15.7-36.2] hours for groups R and P, respectively; P=0.87) and catheter duration (47.5 [39.8-52.4] versus 42.5 [32.1-50.5] hours, P=0.29). Total morphine consumption was not significantly decreased in group R (5 [0-14] versus 8 [4.5-11] mg, P=0.3) and pain scores were similar (mean±SD; VAS 29±15/100 versus 33±13, P=0.3). We observed a significant reduction in morphine adverse effects (31% versus 69% for groups R and P, respectively; P<0.01), mainly nausea (31% versus 59%, P=0.03). One morphine side effect could be avoided for every 5 patients treated.

CONCLUSION

Preoperative continuous femoral blockades using ropivacaine reduce morphine side effects (mainly nausea) in hip-fracture patients without reducing morphine consumption.

Lumbar plexus block surface landmarks as assessed by computed axial tomography in adult patients with scoliosis: a case series

BACKGROUND AND OBJECTIVES

Lumbar plexus (LP) block is a common and useful regional anesthesia technique. Surface landmarks used to identify the LP in patients with healthy spines have been previously described, with the distance from the spinous process (SP) to the skin overlying the LP being approximately two-thirds the distance from the SP to the posterior superior iliac spine (PSIS) (SP-LP:SP-PSIS ratio). In scoliotic patients, rotation of the central neuraxis may make these surface landmarks unreliable, possibly leading to an increased block failure rate and an increased incidence of complications. The objective of the present study was to describe these surface landmarks of the LP in patients with scoliosis.

METHODS

We selected 47 patients with known thoracolumbar scoliotic disease from our institution's radiology archives. We measured bony landmark geometry, Cobb angle, and the LP location and depth. Additionally, we calculated the SP-LP:SP-PSIS ratio for both the concave and convex sides.

RESULTS

In scoliotic patients (31 females and 16 males), the median (range) Cobb angle was 23 (8-54) degrees. The LP depth was 7.5 (5.7-10.7) cm on the concave side of the scoliotic spine and 7.6 (5.4-10.8) cm on the convex side, while the distance from the SP-LP was 3.4 (1.9-4.7) cm on the concave side and 3.7 (2.4-5.1) cm on the convex side. The SP-LP:SP-PSIS ratio was 0.61 (0.20-0.97) and 0.65 (0.45-0.98) on the concave and convex sides, respectively. None of these distances were significantly different between sides.

CONCLUSIONS

In patients with scoliotic disease of the spine, there is wide variability in the bony surface landmarks. The location of the LP is generally more medial than expected when compared with both modified and traditional landmarks. A review of the imaging studies and the pre-procedural ultrasound assessment of the anatomy should be considered prior to needle puncture.

The analgesic impact of preoperative lumbar plexus blocks for hip arthroscopy. A retrospective review

This study aimed to examine the impact of preoperative lumbar plexus blockade on perioperative analgesia and opioid consumption following hip arthroscopy. The records of patients (n = 236) who underwent hip arthroscopy between July 27, 2004 and November 15, 2009 were reviewed (118 patients with preoperative lumbar plexus block and 118 procedure matched patients without a preoperative block). Baseline patient characteristics were similar between groups. Immediate post-anaesthesia care unit (PACU) pain scores, peak PACU pain scores, perioperative opioid administration, and PACU antiemetic administration favoured preoperative block placement. Postoperative modified Harris Hip scores and postoperative day one pain scores were similar between groups. Total hospital time following the surgical procedure was longer in the block group. While preoperative lumbar plexus blockade may be helpful for analgesia following hip arthroscopy, more research needs to be done to determine the ideal analgesic regimen for these patients.

Lateral Cutaneous Femoral Nerve Blockade—Limited Skin Incision Coverage in Hip Arthroplasty

This paper seeks to assess the potential use of blocking the lateral cutaneous femoral nerve (LCN) for patients undergoing hip surgery. In this study, ultrasound guidance was used to specifically block the LCN using a small volume of local anaesthetic in 20 healthy volunteer anaesthetists. An orthopaedic surgeon then drew lines on the volunteers reflecting three common cutaneous incision lines (anterolateral, lateral, and posterior approach) for hip arthroplasty using an ultraviolet reflecting pen invisible in normal lighting. The relationship between the anaesthesia produced by this block and the marked incision lines was then assessed. More than half (32 of 60) of the drawn incision lines fell completely outside of the anaesthesia produced by the LCN block. Of the remaining incision lines drawn, most were less than half covered by LCN blockade with only three lines more than 50% covered and none more than 75% covered. The skin anaesthesia produced by LCN blockade was usually anterior and inferior to the surgical lines marked. This significant lack of overlap between common hip arthroplasty incision lines and the anaesthesia produced by blockade of the lateral cutaneous femoral nerve draws into question the utility of this block for hip surgery.

Lumbar plexus block for management of hip surgeries

Background:

Lumbar plexus block (LPB) is one of the anesthetic options in the elderly patients undergoing hip surgeries. LPB could be safe because it targets somatic nerve in psoas region. Effectiveness of LPB is attributed to the sufficient analgesia provided intraoperatively as well as postoperatively. Adequate muscle relaxation and immobility during surgery refers to its acceptability.

Objectives:

In this study, LPB was used as the anesthetic method to manage the elderly patients subjected to hip surgery.

Patients and Methods:

A total of 50 patients aged 51 to 100 years were enrolled in this study. LPB was accomplished after a mild sedation and with a modified method using patient's fingertip width (FTW) as the distance unit to determine needle entry point under electrical nerve stimulation assistance. After targeted injection, procedure time, establishment time, block duration, surgery time, hemodynamic variables, and surgeon satisfaction score were documented and analyzed. Propofol in trivial doses was infused intraoperatively to provide clinical sedation.

Results:

Mean patient's age was 73 ± 12 years with ASA II/III. Procedure time was 5.65 ± 1.24 minutes, establishment time was 130 ± 36 seconds, block duration was 13.1 ± 8 hours, surgery time was 149.7 ± 32.2 minutes, and surgeon satisfaction score was 9.8 ± 0.1. There was no complication and no failure. Hemodynamic stability was pleasantly achieved.

Conclusions:

By preserving hemodynamic stability, LPB in conjunction with a light sedation could be considered as a reliable prudent satisfying anesthetic option in management of hip fractures in the elderly patients with three beneficial characteristics of safety, effectiveness, and acceptability.

Is L2 paravertebral block comparable to lumbar plexus block for postoperative analgesia after total hip arthroplasty?

BACKGROUND

Continuous lumbar plexus block (LPB) is a well-accepted technique for regional analgesia after THA. However, many patients experience considerable quadriceps motor weakness with this technique, thus impairing their ability to achieve their physical therapy goals.

QUESTIONS/PURPOSES

We asked whether L2 paravertebral block (PVB) provides better postoperative analgesia (defined as decreased postoperative opioid consumption and lower pain scores), better preservation of motor function, and decreased length of hospital stay (LOS) compared to LPB in patients undergoing THA.

METHODS

Sixty patients undergoing minimally invasive THA under standardized spinal anesthesia were enrolled in this randomized controlled study. After exclusions, 53 patients were randomized into the L2 PVB (n = 27) and LPB (n = 26) groups. Patient-controlled analgesia was available for 24 hours. Motor and pain assessments were performed in the recovery room and at the end of 24 hours. LOS was also noted.

RESULTS

Postoperative opioid consumption during the first 24 hours was less in the LPB group (mean ± SD: 24 ± 15 mg morphine) than in the L2 PVB group (32 ± 15 mg morphine; p = 0.005); however, postoperative pain scores were not different between groups. Postoperative motor and rehabilitation outcomes and LOS were also similar.

CONCLUSIONS

Our study demonstrates that use of a LPB results in slightly less morphine consumption but comparable pain scores when compared with continuous L2 PVB. No difference was noted in terms of motor preservation or LOS. Although the difference in morphine consumption was only slightly in favor of the LPB group, the advantage of L2 PVBs noted by previous authors as preservation of motor function, was not seen. At our institute where LPBs have been performed for years, there seems to be no real advantage in switching to L2 PVBs. However, L2 PVB could be a reasonable alternative for operators who are wary of LPBs due to their high potential for complications and/or requiring advanced skills for its placement. But, since L2 PVBs are relatively new, not much is known about their complication profile. We recommend a thorough understanding of both techniques before attempting to place them.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Surgeon delivered psoas compartment block in total hip arthroplasty

Total hip arthroplasty is associated with significant postoperative pain. A psoas compartment block is superior to other regional techniques in analgesia post THA. However, traditional methods of delivery are associated with serious complications. We present a technique of a surgeon delivered lumbar plexus block through injection at the portion of the iliopsoas seen intraoperatively. We randomised fifty-three consecutive patients into two groups. The group that received the block had an increased period prior to requesting supplementary analgesia and lower overall pain scores. There were no adverse effects. We have demonstrated the analgesic efficacy of Psoas Compartment Block performed during surgical access for total hip arthroplasty. This technique should be considered in the analgesic regimen for total hip arthroplasty.

The role of continuous peripheral nerve blocks

A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.

Effect of continuous psoas compartment block and intravenous patient controlled analgesia on postoperative pain control after total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) generates severe postoperative pain in 60% of patients and moderate pain in 30% of patients. Because inadequate postoperative pain control can hinder early physiotherapy and rehabilitation, it is the most influential factor dictating a good outcome. The purpose of this study was to evaluate the effectiveness of continuous psoas compartment block (PCB) in comparison to intravenous patient-controlled analgesia (IVPCA) in TKA patients.

METHODS

40 TKA patients were randomly divided into 2 groups. Group IVPCA (n = 20) received intravenous patient controlled analgesia (IVPCA) for 48 hours. Group PCB (n = 20) received continuous PCB for 48 hours at the fourth intertransverse process of the lumbar using the C-arm. Pain scores, side effects, satisfaction, the length of hospital stay, rescue antiemetics, and analgesics were recorded.

RESULTS

Pain scores (VNRS 0-100) were higher in Group IVPCA than in Group PCB. Nausea and sedation occurred more frequently in Group IVPCA than in Group PCB. There were no differences between the groups in the length of the hospital stay, satisfaction scores, and the use of rescue antiemetics and analgesics.

CONCLUSIONS

Continuous PCB seemed to be an appropriate and reliable technique for TKA patients, because it provided better analgesia and fewer side effects such as nausea and sedation when compared to IVPCA.

Peripheral catheter techniques

With ultrasound, continuous peripheral nerve blocks (CPNBs) are one of the most recent developments in regional anesthesia in children. CPNBs are now used more widely in children because more suitable materials have been marketed, allowing complete, and prolonged postoperative pain control. Their use after orthopedic procedures in children and treatment for complex regional pain syndrome in adolescents has demonstrated the benefits. Perineural catheters have also shown their superiority over other techniques of continuous regional anesthesia in terms of side effects. The efficiency and the safety of these techniques may facilitate early ambulation with improved pain management, treatment at home with disposable pumps, and improved rehabilitation of children. Studies on large cohorts of patients published to date have failed to highlight any severe complications in their use compared with other adult studies. Accidents owing to systemic toxicity are very unlikely if the recommended maximum dose is not exceeded. The safety of continuous regional anesthesia techniques in children relies on the use of low-concentration l-enantiomer solutions (ropivacaine or levobupivacaine) accompanied by low plasma concentrations of local anesthetics, limiting the risk of systemic toxicity of these molecules. CPNB can ensure strong and lasting analgesia in hospital or at home.

Psoas compartment block for operative reduction of hip fracture in a patient with increased intracranial pressure due to inoperable brain tumor

General and neuraxial anesthesia in patients with increased intracranial pressure (ICP) who present for non-neurosurgical surgery may cause life-threatening changes in ICP, with possible fatal outcome. Peripheral nerve blocks may be a safe alternative technique for limb surgery. The successful use of psoas compartment block for operative reduction of a hip fracture in a patient with increased ICP due to an inoperable brain tumor is presented.