Postoperative Pain Treatment With Transmuscular Quadratus Lumborum Block and Fascia Iliaca Compartment Block in Patients Undergoing Total Hip Arthroplasty

A Randomized Controlled Trial

Qin Xia; Wenping Ding; Chao Lin; Jiayi Xia; Yahui Xu; Mengxing Jia

Disclosures

BMC Anesthesiol. 2021;21(188) 

In This Article

Discussion

Our results showed that compared with single-shot T-QLB alone, the combination of T-QLB and FICB could reduce sufentanil consumption by 36% at 24 h postoperatively, significantly decrease the pain score, increase the early postoperative range of motion and improve the early quality of recovery without increasing complications.

Accumulating published data[13–15] were dedicated to exploring more effective multimodal analgesia with opioid-sparing. However, hip innervation is complex, with contributions from many nerve components.[17] Birnbaum[25] et al. reported that the nerves involved in THA incision pain mainly included the subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, femoral nerve, lateral femoral cutaneous nerve, obturator nerve, and sciatic nerve. Additionally, the latest studies[15,26] indicated that the femoral nerve, dominating the hip joint, branches at a higher position, and the location of the lateral femoral cutaneous nerve under the inguinal ligament have significant anatomical variability. It is difficult for single-shot PNB to meet the analgesic requirements of patients.

Previous studies[14–16] have shown that T-QLB and FICB can relieve postoperative pain after THA. T-QLB provides pain relief over the incision area for patients undergoing THA, mainly through blockade of the T10-L3 nerve territories and dermatomal tissue.[20] Kadam[27] et al. found that single-shot T-QLB can reduce pain scores and the demand for analgesic drugs 24 h postoperatively. Supra-inguinal FICB is accessed via a minimal risk approach to block the femoral nerve, lateral femoral cutaneous nerve, and obturator nerve, with rapid onset and definite analgesic effect, which procedure the anesthetization of the anterior, lateral, and medial areas of the thigh.[16] Wennberg[28] et al. reported that FICB effectively provided high-quality pain relief after THA.

It seems that both QLB and FICB cover similar parts of the fields. Cadaveric studies and clinical studies have shown that QLB leads to consistent blockade of branches of the lateral femoral cutaneous, ilioinguinal, iliohypogastric, and superior cluneal nerves and inconsistent anesthetization of the obturator, femoral nerve, and lumbar sympathetic trunk.[19,20] FICB can produce a consistent sensory block of the femoral, obturator, and lateral femoral cutaneous nerves.[16] The combination of QLB and FICB, which is the high-and-low combination, can optimize nerve block effects from block range and degree. In our study, the patients in group QF had better pain relief, lower opioid requirements, and higher quality of recovery than patients in group Q. Additionally, the safety of T-QLB and FICB was higher than that of traditional techniques (such as lumbar plexus block). As the fascial plane block target is a fascial plane rather than a specific nerve (nerve root), this approach decreases the risk of nerve injury.[29] The injection site of the needle tip is more superficial, which reduces the risk of unrecognized blood vessel bleeding.[30] Furthermore, FICB is considered easy to learn and perform, and it can relieve patients' pain when changing positions and ensure patients' comfort during the whole process.

Our results suggest that T-QLB combined with FICB can provide effective analgesia for up to 18 h. The prolongation of analgesia time seems to exceed the expectation of 0.375% ropivacaine in peripheral nerve blockade.[31] Multiple reasons account for these results. First, in our study, both QLB and FICB involved tissue (fascial) plane injections. The absorption rate of local anesthetics depends on local tissue perfusion.[30] Murouchi[32] et al. reported that the peak concentration of ropivacaine after QLB was lower than that of TAPB at a comparable time, and the duration of analgesia was significantly longer. Second, the procedure performed on individuals in group QF further reduced the sensitivity of nerves to surgical stimulation, prevented central and peripheral sensitization, and reduced or eliminated pain caused by nociceptive stimulation.[33] Last, patients' oral paracetamol 1 g regularly at 6 h intervals after operation also prolonged the time to the first opioid requirement.

The ability of the NRS to reflect the effect of pain control is limited due to the application of multimodal analgesia. In our study, we observed that there was no significant difference in NRS between the two groups at 18 h after surgery. Taking postoperative sufentanil consumption into account, we believe that the combination of QLB and FICB provides a more effective analgesic effect in control group Q, which mainly maintains a low pain score by increasing sufentanil consumption. Additionally, we applied the Qor-15 scale (scores from 0–10 for each term, where 0 = no existence, 10 = always existed. The higher the Qor-15 scale score, the better the recovery quality of patients) to evaluate recovery quality after surgery and anesthesia, including physiological comfort, physical independence, psychological support, emotion, and pain.[23] Our study shows a significant difference in the Qor-15 scale score and ROM between the two groups at 24 h and 48 h, consistent with a significant reduction in sufentanil consumption. Therefore, it further confirmed that the blockade combination contributes to relieving postoperative pain, reducing postoperative anxiety, improving patient satisfaction and comfort, and optimizing early postoperative recovery quality.

All blocks were performed before anesthesia induction. Hydroseparation of the target interfascial plane with saline is beneficial to the local anesthetic's correct deposition and improves the block's success rate. Moreover, a professional investigator evaluated the analgesic effect 30 min after performing the nerve block to avoid potential block failure. In our study, three patients in group Q were excluded due to an ineffective block, which reduced the occurrence of selective bias.

It would be better for elderly patients with comorbidities to use an anesthetic with higher safety and longer half-life, such as ropivacaine.[31] In this study, 150 mg of ropivacaine was safe and effective for elderly patients. However, previous studies[14,34] reported that complications such as hypotension and urinary retention were observed after performing QLB, which did not occur in our study. Future studies should focus on the minimal effective volume for proximal spreading and the dose–response relationship. Additionally, ropivacaine has the function of sensory-motor integration, and it can block the sensory nerve while retaining motor nerve function, which has significant advantages for the early recovery of postoperative patients.[31]

We acknowledge that our study has some limitations. First, we did not use objective indicators to quantify the nerve block effect on muscle strength. However, the postoperative evaluation of motor function is difficult. The motor function may be affected by severe postoperative pain, iatrogenic nerve injury, and transient nerve palsy[35] Therefore, it can be considered that the decrease in motor function postoperatively is not entirely caused by nerve block. Second, we evaluated the sensory block of the obturator, femoral, and lateral femoral cutaneous nerves in our study. However, we did not test the subcostal, ilioinguinal, and iliohypogastric nerve distributions as a part of the sensory assessment. Third, we did not investigate the time to first ambulation, length of hospital stay, patient satisfaction, or all-important outcome parameters for evaluating the efficacy of ERAS. Finally, we performed two different PNBs under general anesthesia for surgery usually performed under spinal anesthesia, which limited the applicability of the practice and the external generalizability of our results. Our findings are preliminary, and future research should investigate the effects of the combination of T-QLB and FICB under spinal anesthesia or local anesthetic infiltration techniques.

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