Transmuscular Quadratus Lumborum and Lateral Femoral Cutaneous Nerve Block in Total Hip Arthroplasty

Analgesic Quality Improvement in Paravertebral Blocks for Pediatric Nuss Procedure: An Exploratory Report on the Effects of Perineural Combined Glucocorticoids

Purpose

Pectus excavatum repair using the Nuss procedure is associated with significant postoperative opioid consumption even in the presence of a continuous thoracic paravertebral block.

Patients and Methods

A CQI project was initiated by adding combined glucocorticoids as perineural adjuvants to continuous thoracic paravertebral block. An electronic health record review of patients undergoing Nuss procedures by a single surgeon at a major academic children's hospital from June 2013 to December 2021 was performed with no patients excluded. The patients received pre-incision continuous bilateral T4 paravertebral blocks preoperatively either with plain ropivacaine (standard group, N = 34) or with a combination of dexamethasone sodium phosphate (DXP) and methylprednisolone acetate (MPA) in addition to ropivacaine (experimental group, N = 10). The primary outcome studied was postoperative opioid consumption measured by oral morphine milligram equivalents (MME).

Results

A total of 44 patients were included in the final analysis. The experimental group had 72% lower postoperative opioid usage than the standard group during the hospitalization (p < 0.001) with comparable pain scores and hospital length of stay and no increase in wound dehiscence or other complications.

Conclusion

The addition of dexamethasone sodium phosphate and methylprednisolone acetate to continuous paravertebral blocks significantly decreased postoperative opioid consumption while maintaining comfort pain scores.

Use of Peripheral Nerve Blocks for Total hip Arthroplasty

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent literature regarding regional anesthesia (RA) techniques and outcomes for total hip arthroplasty (THA) in the face of changing surgical techniques and perioperative considerations.

RECENT FINDINGS

Based on large meta-analyses, peripheral nerve blocks are indicated for THA. Each block has its own risks and benefits and data for outcomes for particular techniques are limited. New surgical techniques, improved use of multimodal analgesia, and improved ultrasound guided regional anesthetics lead to better pain control for patients undergoing THA with less associated risks. Block selection continues to be influenced by provider comfort, surgical approach, patient anatomy, and postoperative goals. Head-to-head studies of particular nerve blocks are warranted.

Lumbar Erector Spinae Plane Block for Total Hip Arthroplasty Comparing 24-Hour Opioid Requirements: A Randomized Controlled Study

Design

Prospective, randomized, controlled trial. Patients. Sixty-three adult patients with an American Society of Anesthesiologists Status I–III who are undergoing elective primary total hip arthroplasty. Interventions. Patients were randomized to the control group (no block) or the ESPB group (preoperative ultrasound-guided lumbar ESPB). Intraoperatively, all patients received spinal anesthesia with moderate sedation. Postoperatively, patients received a standardized multimodal analgesia protocol. Measurements. The primary outcome was cumulative opioid consumption at 24 hours postoperatively. Secondary outcomes included cumulative opioid consumption at 8 hours and through 48 hours postoperatively and pain scores at 24 and 48 hours post surgery. Main Results. Thirty-one patients were randomized to the control group (spinal alone) and 32 patients to the ESPB group. The median opioid requirement in the first 8 hours after surgery was higher in the control group (28 mg of oral morphine equivalents (OME) versus 5 mg of OME in the ESPB group) (p = 0.013). There was no statistically significant difference in opioid consumption between the groups at 24 hours (p = 0.153) or 48 hours (p = 0.357) postoperatively. There was no statistically significant difference in pain scores between the two groups through 24 hours (p = 0.143) or 48 hours (p = 0.617) after surgery.

Conclusion

Lumbar ESPB reduces opioid utilization during the first 8 hours postoperatively after total hip arthroplasty but not thereafter. Evaluating the use of either adding a local anesthetic adjunct to the ESPB or using longer-acting local anesthetic warrants further investigation.

Peripheral Nerve Block for Pain Management after Total Hip Arthroplasty: A Retrospective Study with Propensity Score Matching

This study aimed to evaluate the effect of a peripheral nerve block (PNB) on immediate postoperative analgesia and the early functional outcomes for patients who underwent total hip arthroplasty (THA). From January 2016 to August 2021, 353 patients who underwent THA were divided into two groups: the patient-controlled analgesia (PCA) group (n = 217) who received only intravenous (IV) analgesia, and others who received IV PCA and PNB (PCA + PNB group) (n = 136). After propensity score matching for age and sex, 136 patients from each group were included in the study. Primary outcomes were the visual analogue scale (VAS) at rest, activity status at postoperative 6, 24, 48 h. Secondary outcomes were functional scores by the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and rescue medications used. The postoperative VAS at 6, 24, 48 h at rest and 6 h at activity were significantly lower in the PCA + PNB group (p = 0.000, 0.001, 0.000, 0.004 in order). There was no significant difference for postoperative 3-month HHS (p = 0.218), except for 3-month WOMAC index (p = 0.001). There were no significant differences for VAS between the PNB methods except femoral nerve block (FNB) and fascia iliaca compartment block (FICB) at postoperative activity 48 h (p = 0.028). There was no significant difference in the total count and amount of rescue medication (p = 0.091, 0.069) and difference in the quadriceps weakness was not noted. Therefore, PNB is beneficial for patients who undergo THA as it provides sufficient postoperative analgesia, especially during immediate postoperative resting pain without quadriceps weakness.

Perineural Methylprednisolone Depot Formulation Decreases Opioid Consumption After Total Knee Arthroplasty

Purpose

Opioid consumption after total knee arthroplasty (TKA) remains a challenge with single injection nerve blocks even with common local anesthetic adjuvants dexamethasone (DEX). This study aimed to investigate the effects of adding methylprednisolone acetate (MPA) to adductor canal blocks (ACB) and interspace between the popliteal artery and capsule of the posterior knee (iPACK) blocks on postoperative opioid consumption.

Methods

A retrospective analysis was conducted on 100 consecutive TKA patients equally assigned into two groups, with one group receiving DEX through ACB and iPACK block and the other group receiving DEX and methylprednisolone acetate (DEX/MPA) through the same nerve blocks. The primary outcome was cumulative opioid consumption (oral milligram morphine equivalent, OME) during hospitalization for up to three days. Secondary outcomes included daily opioid consumption, highest rest and active pain scores, prosthetic knee joint active range of motion (AROM), laboratory studies including fasting serum glucose (FSG) and white blood cell count (WBC) on each postoperative day (POD), and length of hospital stay.

Results

Cumulative opioid consumption was significantly lower in the DEX/MPA group vs DEX group (median difference (95% CI) = -45.3 (-80.5 to -10), P = 0.011). The highest rest and active pain scores were both significantly lower in the DEX/MPA group than in DEX group on POD 2 (least square mean difference (95% CI) = -1.3 (-2.3 to -0.4), P = 0.005 and -0.9 (-1.8 to -0.1), P = 0.031, respectively). Except on POD 1, FSG values were significantly lower in the DEX/MPA group (median difference (95% CI) = -22.5 (-36 to -8.9), P = 0.001). AROM, WBC, and length of stay were comparable between both groups.

Conclusion

Compared to perineural DEX alone, the addition of MPA further decreases postoperative opioid consumption without clinically significant changes on FSG and WBC.

Level of Evidence

III.

Comparative efficacy analysis of ultrasound-guided quadratus lumborum block and lumbar plexus block in hip arthroscopy: a pilot prospective randomized controlled trial

Controlled trials assessing quadratus lumborum block (QLB) for post-operative analgesia in hip surgery are scarce. This study aimed to compare ultrasound-guided QLB and lumbar plexus block (LPB) for clinical efficacy in hip arthroscopy. Patients undergoing hip arthroscopy in Beijing Jishuitan Hospital in January-June 2019 were randomized to the lumbar plexus (L) and quadratus lumborum (Q) groups (n = 25/group). After either ultrasound-guided block for 30 min, both groups were prepared for surgery after muscle strength measurement in the affected limbs. Opioid doses for patient-controlled analgesia (PCA), visual analog scale (VAS) scores in the resting and active states, upon leaving the post-anesthesia care unit (PACU), and at 2-48 h post-surgery were recorded, and post-operative complications were also recorded. Muscle strength in the affected limbs was significantly higher in the Q group compared with the L group (4.0 versus 2.0, P < 0.001). VAS scores were similar in both groups post-surgery (P > 0.05). One patient had epidural spread in the L group, with no other complications. Compared with ultrasound-guided LPB, ultrasound-guided QLB provides similar and good post-operative analgesia after hip arthroscopy, with less impact on muscle strength and fewer complications. These results should be confirmed in larger trials.

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

Nerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA.

METHODS

In this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB + sham AQLB (SFIB group), or an ultrasound-guided AQLB + sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24 hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications.

RESULTS

There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .774), the time to first rescue analgesia (P = .890), the time to hospital discharge (P = .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2 hours (P = .008) and 6 hours (P = .009) after surgery.

CONCLUSION

Under the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6 hours after surgery.

Ultrasound-Guided Anterior Quadratus Lumborum Block Reduces Postoperative Opioid Consumption and Related Side Effects in Patients Undergoing Total Hip Replacement Arthroplasty: A Propensity Score-Matched Cohort Study

Quadratus lumborum block (QLB) has been shown to be effective for pain relief after hip surgery. This study evaluated the efficacy of ultrasound-guided anterior QLB in pain control after total replacement hip arthroplasty (TRHA). A total of 115 patients receiving anterior QLB were propensity score-matched with 115 patients who did not receive the block. The primary outcome was opioid consumption at 24, 24-48, and 48 postoperative hours. Secondary outcomes included pain scores at the post-anesthesia care unit (PACU), 8, 16, 24, 32, 40, and 48 h length of hospital stay, time to first ambulation, and the incidence of opioid-related side effects. Postoperative opioid consumption 48 h after surgery was significantly lower in the QLB group. Resting, mean, worst, and the difference of resting pain scores compared with preoperative values were significantly lower in the QLB group during the 48 postoperative hours. The length of hospital stay was shorter in the QLB group. The incidence of postoperative nausea and vomiting was significantly lower in the QLB group during the 48 postoperative hours, except at the PACU. This study suggests that anterior QLB provides effective postoperative analgesia for patients undergoing THRA performed using the posterolateral approach.

Erector Spinae Plane Block for Perioperative Pain Control and Short-term Outcomes in Lumbar Laminoplasty: A Randomized Clinical Trial

BACKGROUND

Spine surgery causes severe pain and can be associated with significant opioid utilization; however, the evidence for opioid-sparing analgesic techniques such as erector spinae plane (ESP) block from controlled studies is limited. We aimed to investigate the analgesic effects of ESP block in lumbar laminoplasty.

METHODS

In this prospective, double-blind, controlled single-center trial, 62 consecutive elective lumbar laminoplasty patients were randomized into either a control group (Group G, N=32) or a treatment group (Group E, N=30). Group G received general anesthesia and multimodal analgesia, similar to group E, while Group E received additional bilateral ESP block after induction of general anesthesia. The primary outcome was postoperative pain scores for the first 48 h after surgery, and the secondary outcomes analyzed included intraoperative anesthetic usage, perioperative analgesic consumption, return of bowel function and satisfaction for acute pain management indicated by overall benefit of analgesia score (OBAS).

RESULTS

Significant differences in pain scores over time were found between the two groups (P=0.010), with Group E patients having significantly lower pain scores than Group G during the first six hours (P=0.000). The opioid consumption in Group G was significantly higher than in Group E both intraoperatively (P=0.000) and postoperatively (P=0.0005). Group E patients had lower intraoperative sevoflurane requirement, improved satisfaction with pain management, and earlier return of bowel function than Group G patients.

CONCLUSION

ESP block is effective in reducing postoperative pain scores and lowering opioid utilization (both intraoperatively and postoperatively), resulting in improved patient satisfaction for pain management in lumbar laminoplasty.