Combination of 2 Nerve Blocks Better Than 1 in Reducing Postoperative Pain After Hip Replacement

Tinker Ready

August 25, 2021

A combination of two nerve blocks reduced immediate postsurgery opioid use in total hip arthroplasty (THA) patients by about 35% compared with use of a transmuscular quadratus lumborum block (T-QLB) alone, according to a small study published in BMC Anesthesiology.

The study, which included 50 subjects, concluded that those treated with both T-QLB and a fascia iliaca compartment block (FICB) "had better pain relief, lower opioid requirements, and higher quality of recovery" than those who did not.

The research is aimed at finding the best way to control surgical pain with fewer opioids by using regional or local anesthesia such as nerve blocks.

Peripheral nerve blocks are "an essential part of perioperative multimodal analgesia, providing site-specific, rapid-onset analgesia and attracting increasing attention," according to the authors, who are based at Xuzhou Medical University in Jiangsu Province, China.

Researchers are testing different combinations of blocks and analgesia to find the best approach. In addition to lower opioid use, practitioners (and patients) want to see patients come out of surgery in shape to soon head home or start rehab.

The study notes that various approaches have been adopted, "such as intravenous analgesia, epidural analgesia, local anesthetic infiltration techniques, and peripheral nerve block (PNB), that aim to minimize THA perioperative pain in elderly patients. Nevertheless, there is no consensus on the optimal analgesic scheme for total hip arthroplasty."

The subjects were randomized, and block procedures were performed before anesthesia induction. The blocks were checked after 30 minutes with a pin prick and then general anesthesia was delivered. Postoperative multimodal analgesia included oral nonsteroidal anti-inflammatory drugs, patient-controlled intravenous analgesia, and rescue analgesia. The primary outcome was cumulative sufentanil use over 24 hours.

The use of T-QLB  is relatively new, said Gavin Hamilton, a researcher at the Department of Anaesthesiology and Pain Medicine at the University of Ottawa in Canada, who was not a part the study. The research was well done, he said. But Hamilton noted that he was more interested in the secondary outcomes — patient pain scores — than the primary outcome: the reduction in sufentanil use.

In particular, Hamilton pointed to the Quality of Recovery-15 (QoR-15) score, which is based on patient-reported outcome measures. Higher scores indicate better outcomes. Preoperative scores did not differ between the groups. Postoperative, the QoR-15 scores of patients in the treatment group were higher at 24 hours and 48 hours, according to the study (both P < .001)

"There have been a lot of new blocks that have been developed recently that have improved patient care drastically," Hamilton said, pointing out that, in the age of ultrasound, surgeons are able to target specific nerves more accurately.

But Hamilton also said he would like to see researchers collect more postoperative data on patient outcomes to identify which subgroups are having the most success with nerve blocks. "Our patients really want to get home as quickly as possible," he said.

Bradley Lee, MD, who specializes in regional anesthesiology at the Hospital for Special Surgery in New York City, and who was not involved in the study, said in an email to Medscape Medical News that various combinations of peripheral nerve blocks have been found to be effective in THA. But he is concerned about their impact on mobility.

"There are different types of 'peripheral nerve blocks' that numb the area of surgery and help reduce pain," he explained. "Some of these peripheral nerve blocks also cause temporary muscle weakness, though, and can sometimes limit ability to walk immediately after. Therefore, the ideal type of peripheral nerve block that reduces pain but doesn't limit ability to walk still needs to be identified."

Limitations of the findings cited by the researchers were lack of measurements on the time to first ambulation, length of hospital stay, and patient satisfaction. In addition, they wrote, "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."

BMC Anesthesiol. Published online July 10, 2021. Full text

Tinker Ready is a health and science writer based in Cambridge, Massachusetts.

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