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Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy
Journal of Clinical Anesthesia (2007) 19, 591–595
Original contribution
Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy Abdulkadir Atim MD (Staff Anesthesiologist)a,⁎, Atilla Ergin MD (Assistant Professor)b , Ercan Kurt MD (Professor)b , Yusuf Özdemiroglu MD (Staff Orthopedist)a , Erdal Guzeldemir MD (Professor)b a
Department of Anesthesiology, Beytepe Military Hospital, Ankara 06835, Turkey Department of Anesthesiology, Gulhane Military Medical Academy, Ankara, Turkey
b
Received 26 November 2006; revised 7 June 2007; accepted 13 June 2007
Keywords: Arthroscopy; Sciatic psoas compartment block; Sciatic femoral 3-in-1 block; Tourniquet pain
Abstract Study Objectives: To compare the clinical effectiveness of two peripheral nerve block techniques combined with sciatic nerve block: sciatic psoas compartment (SPC) and sciatic femoral 3-in-1 (SF 3in-1) block. Design: Prospective, randomized study. Setting: Military medical academy hospital. Patients: Thirty-six ASA physical status I patients, aged 20 to 33 years, undergoing elective knee arthroscopy. Interventions: Patients having SPC block (n = 19) or SF 3-in-1 block (n = 17) received 40 mL of a mixture of solution containing 15 mL of 0.5% bupivacaine, 15 mL of 2.0% prilocaine, and 10 mL of 0.9% sodium chloride. In both groups, the sciatic nerve was blocked with 20 mL of the same solution. An intravenous bolus injection of fentanyl 0.1 mg was used if patients complained of pain. Measurements and Main Results: None of the patients in the SPC group experienced pain owing to the applied tourniquet during the operation, whereas 7 patients from the SF 3-in-1 group (41.2 %) reported tourniquet pain. All SF 3-in-1 group patients but only 5 patients (26.3 %) in the SPC group required fentanyl during the operation. In addition, 7 patients in the SF 3-in-1 group required second doses of fentanyl. Patient satisfaction was significantly higher in the SPC group than in the SF 3-in-1 block group (P b 0.0001). Conclusions: Both SPC and SF 3-in-1 provided sufficient anesthetic efficacy for knee arthroscopy. However, SPC may be preferable to SF 3-in-1 block owing to better patient satisfaction and less requirement for opioid analgesics. © 2007 Elsevier Inc. All rights reserved.
1. Introduction
⁎ Corresponding author. Tel.: +90 312 4648236; fax: +90 312 4646922. E-mail address: [email protected] (A. Atim). 0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2007.06.014
Knee arthroscopy is one of the most commonly performed orthopedic procedures for the diagnosis and treatment of knee diseases [1]. Different types of anesthetic techniques including local, regional, and general anesthesia have been
592 used successfully for this surgical procedure [2-6]. More recently, peripheral nerve block techniques such as femoral, lateral femoral cutaneous, and obturator block with or without sciatic nerve block have also been used [7-11]. Peripheral nerve block techniques include femoral and psoas compartment approaches. The femoral approach combines inguinal paravascular (3-in-1) and sciatic nerve block. Femoral block is the most commonly used peripheral regional technique [12,13]. It is performed easily, but it may not always produce an effective block of the lateral femoral cutaneous and obturator nerves. Therefore, general anesthesia may be needed in about 12% to 15% of patients because of block failure [14,15]. Psoas compartment block, first described about 30 years ago, is a posterior approach for the block of nerves originating from the lumbar plexus [16]. In contrast to the femoral approach, the psoas compartment block produces a block of the entire lumbar plexus including the lateral femoral cutaneous and obturator nerves. Peripheral nerve block has potential advantages in knee arthroscopy such as earlier hospital discharge, less postoperative pain, nausea, emesis, and urinary retention, compared with general anesthesia [17-19]. On the other hand, insufficient anesthesia with the peripheral nerve block may cause limb pain because of the inflated tourniquet during the arthroscopic procedures. It is expected that the femoral approach may cause more pain due to the ineffective block when compared with psoas compartment block. However, there is little information in the literature that compares the approaches in this regard. The aim of this study was to compare the efficiency and advantages of the psoas compartment and femoral approaches.
2. Materials and methods The study protocol was approved by the local ethics committee at Gulhane Military Medical Faculty Hospital, and written, informed consent was obtained from all patients. A total of 42 patients undergoing elective knee arthroscopic surgery were enrolled in the study. All of the patients were ASA physical status I and between the ages of 20 and 33 years (Table 1). Exclusion criteria included epilepsy, peripheral neuropathy, hemorrhagic diathesis, or use of general anesthesia due to the block failure. Patients were randomized by a computer-generated table of random numbers to receive either sciatic psoas compartment (SPC; n = 21) block or combined sciatic femoral 3-in-1 (SF 3in-1; n = 21) block. The surgeon was blinded as to the type of peripheral nerve block used in each study patient. After an 18-gauge intravenous (IV) cannula was inserted into the forearm, patients were premedicated with two mg of midazolam 45 minutes before the surgical procedure. Monitoring included heart rate, arterial blood pressure, and pulse oximetry (Millenia Vital Signs Monitoring System,
A. Atim et al. Table 1 Patient characteristics in the combined SPC and SF 3-in-1 block groups Variable
SPC group SF 3-in-1 group
Age (y) Gender (male/female) Weight (kg) Patients with ASA physical status I, n (%) Knee arthroscopy type (meniscectomy/ACLR), n (%) Patients whose surgery was continued with general anesthesia (meniscectomy/ACLR) Duration of surgery (min)
25.0 ± 5.6 21/0 71.8 ± 4.4 21 (100%)
24.4 ± 4.3 21/0 72.7 ± 5.6 21 (100%)
15 (71%)/6 18 (86%)/3 (29%) (14%) 0/2 2/2
51.7 ± 41.2 36.3 ± 10.1
Data are given as means ± SD. Operation time started with the surgical incision. ACLR = anterior cruciate ligament repair; SPC = sciatic psoas compartment; SF = sciatic femoral.
serial no. 3500, Invivo Corp, Temecula, CA). A standard thigh tourniquet inflated up to 200 mmHg pressure was used during the surgical procedure. Femoral nerve or psoas compartment blocks were performed using the approach described by Winnie et al [16]. Briefly, the femoral nerve block was performed about 1.5 cm lateral to the femoral artery just below the inguinal ligament. The needle in the psoas compartment block was inserted at the intersection of the intercristal line that was drawn in the horizontal plane at the upper margin of the iliac crests and a line drawn parallel to the spine through the posterior superior iliac spine. Immediately after the femoral nerve or psoas compartment block, the sciatic nerve was blocked using the classical posterior approach as described by Labat [20]. Patients were placed in the lateral decubitus position with the knee flexed at a 90° angle. A first line was drawn from the midpoint of the greater trochanter to the posterior superior iliac spine, and a second line was drawn to the sacral hiatus. The puncture was performed at the intersection of a third line, emerging perpendicularly from the first line at its midpoint and the second line. Patients undergoing psoas compartment block or femoral 3-in-1 block received 40 mL of a mixture of solution containing 15 mL of 0.5% bupivacaine, 15 mL of 2.0% prilocaine, and 10 mL of 0.9% sodium chloride. Twenty milliliters of the same solution was used for the sciatic nerve block. A nerve stimulator (Stimuplex, Melsungen, Germany) with a 10-cm, 21-gauge needle was used to locate the nerve. Stimulation frequency was 2 Hz and pulse width was 0.1 ms. Initial intensity of the stimulating current was 1 mA and gradually decreased to 0.3 mA. After completion of the anesthetic injection, motor block of the anesthetized site was evaluated by asking the patient to move the ankle and to elevate the leg with the hip passively fixed; sensory block was evaluated using the pinprick test with a 22-gauge needle and an ice test. Hemodynamic
Sciatic psoas vs sciatic femoral 3-in-1 block Table 2
593
Major outcomes of sciatic femoral (SF) 3-in-1 and sciatic psoas compartment (SPC) groups during knee surgery
SF 3-in-1 SPC Significance (P value)
Continued with regional anesthesia, n (%)
Tourniquet pain, n (%)
17 (81%) 19 (90.5%) 0.66
7 (41.2%) 0 (0%) 0.002
Opioid analgesic requirement during surgery 1st injection, n (%)
2nd injection, n (%)
Injection time (min)
17 (100%) 5 (26.3%) 0.0001
8 (47.1%) 0 (0%) 0.0008
23.4 ± 15.1 81.0 ± 63.5 0.02
n indicates number of patients.
variables were also recorded at the same time. The loss of pinprick sensation and ice test on the knee region were measured at two-minute intervals. Inability of leg elevation and ankle movement as measured with the original Bromage scale at 5-minute intervals was used to determine the time to surgical block. Once the ice and pinprick tests indicated sensory block on the knee region, surgery was started. Contralateral sensory and motor blocks were also evaluated. Visual analog scale (VAS) scores were recorded preoperatively every 10 minutes during the surgery, at each hour after the surgery for a period of 6 hours, then on the 12th, 18th, 24th, 36th, and 48th hour thereafter. The VAS was scored from 0 to 10. Fentanyl 0.1 mg IV bolus injection was used if patients experienced pain due to the surgical procedure or the inflated tourniquet. Supplemental analgesia was given when VAS scores were equal to or greater than 3. The number and time of fentanyl injections were recorded during the surgical procedure. Diclofenac sodium 75 mg IV bolus injection was used for the management of postoperative pain. Patient satisfaction was assessed by asking whether they would accept the same anesthesia technique if required again for future operations. Patients were also asked to give a score between 1 (dissatisfaction) and 10 (complete satisfaction) by considering the pain that they had experienced during the surgery.
by considering α = 0.05, δ = 50%, σ = 20%, and n = 21 patients in each group for the consumption of fentanyl during the surgery.
3. Results A total of 42 ASA physical status I men, aged 20 to 33 years, participated in the study. Patients' ages and weight were similar between the groups (Table 1). The type of knee arthroscopy performed was anterior cruciate ligament reconstruction (9 patients) and menisectomy (33 patients). The distribution of surgical indication for knee arthroscopy was not significantly different between the groups (Table 1). The surgery required general anesthesia in two SPC group patients and 4 SF 3-in-1 group patients owing to insufficient peripheral block (Table 2). Those patients who received general anesthesia were then excluded from the study. Operation times during the regional anesthesia were not significantly different between the groups (P = 0.74; Table 1). The major outcomes are summarized in Table 2. None of the SPC group patients experienced pain owing to the
2.1. Statistical analysis Continuous variables are shown as means ± SD, and ordinal data are presented as medians (ranges). The MannWhitney U test was used for comparison of hemodynamic parameters and the time of pain from the inflated tourniquet. Number of fentanyl injections, patient's satisfaction, and degree of inflated tourniquet pain were compared between groups with Fisher's exact test. Visual analog scale scores were compared with repeated measures analysis of variance between the groups at different periods (GraphPad Prism Software version 4.0, GraphPad Prism Software, Inc, San Diego, CA). A P value of less than 0.05 was considered statistically significant. A power calculation was performed, as described by Dupont and Plummer [21]. A difference of 50% between the scores compared was assessed to be of clinical importance. Power calculation was estimated as 0.94
Fig. 1 Box plot graph of patient satisfaction in the sciatic psoas compartment (SPC) and sciatic femoral (SF) 3-in-1 block groups. A score of 1 = dissatisfaction and 10 = complete satisfaction, considering the pain experienced by the patient during surgery.
594
Fig. 2 Visual analog scale (VAS) scores of the patients during the operative period. The VAS was scored from 0 to 10 (⁎P b 0.0001).
applied tourniquet during the operation, whereas 7 patients (41.2 %) from the SF 3-in-1 group reported tourniquet pain. Patient satisfaction was significantly higher in the SPC group than in the SF 3-in-1 block group (P b 0.0001; Fig. 1). All SF 3-in-1 block group patients and 5 SPC group patients required opioid analgesia during the surgery (Table 2). Mean times for the first administration of fentanyl were 23.4 and 81 minutes in the SF 3-in-1 block and SPC groups, respectively (P = 0.02). Seven patients in the SF 3-in1 block group required second doses of fentanyl, whereas none of the patients from the SPC group needed additional fentanyl administration. Visual analog scale scores of the groups are shown in Fig. 2; they were significantly higher in the SF 3-in-1 block group than in the SPC group for the first 30 and 60 minutes of the operation (P b 0.0001 and P = 0.04, respectively). The difference in VAS score was not significant in other measurements (Fig. 2). There was no significant difference in hemodynamic parameters between the groups. Heart rate, oxygen saturation, and blood pressure values (data not shown) did not significantly change during or after the operation in either group. Neither group reported nausea or vomiting. No complication was observed owing to application of the peripheral block. No sensory or motor block was observed in the contralateral extremity.
4. Discussion In the present study, we compared the combined SPC block and SF 3-in-1 block in patients undergoing knee arthroscopy. Studies have shown that, with psoas compartment block, spread of local anesthetic agent from the injection site allows rapid distribution, whereas with the
A. Atim et al. femoral 3-in-1 block, anesthesia may be insufficient owing to the low distribution of the local anesthetic agent into the obturator and lateral femoral cutaneous nerves [9,22]. Our findings support these data, and they show that more efficient anesthesia may be achieved with the SPC block than with the SF 3-in-1 block. In our study, the pinprick and cold tests of the surgical region were used to assess the success of the sensorial block. The quality of anesthesia was higher in the SPC block than in the SF 3-in-1 block. Similarly, VAS scores were significantly higher during surgery in the SF 3-in-1 block group than in the SPC block group. However, fentanyl was used to provide a sufficient level of analgesia in patients experiencing pain. This difference in VAS scores also reflected patient satisfaction in the two groups. Similar results have been reported by Ganidagli et al [7] and Tokat et al [9]. The additional analgesic requirement was significantly higher in the SF 3-in-1 block group than in the SPC block group in our study. Insufficient block of the obturator and lateral femoral cutaneous nerves in the SF 3-in-1 block may be one of the reasons for this difference. On the other hand, cutaneous distribution of the obturator nerve varies among patients and can be absent or incomplete in some patients [23]. Therefore, implication of the obturator nerve in pain manifestation after peripheral block with SF 3-in-1 and SPC seems less important than was thought previously. Contrary to our results, one group of investigators showed that analgesia after 60 minutes of surgery and postoperative analgesia do not differ in femoral 3-in-1 block or psoas compartment block [10]. Application of a tourniquet is a widely used procedure in extremity surgery to avoid bleeding in the operative field [24,25]. The tourniquet is usually located at the proximal thigh during operations of the knee. Innervation of the thigh depends on the femoral nerve itself, the lateral femoral cutaneous, and the posterior femoral cutaneous nerves [26]. Regional anesthetic techniques such as sciatic, femoral, or psoas compartment block may cause insufficient anesthesia of varying degrees; therefore, an inflated tourniquet may cause severe pain in some patients who are receiving inadequate anesthesia. Contralateral extension of the psoas compartment block is between 4% and 40% [26,27]. The reason for the absence of sensory or motor block in our study at the contralateral extremity was most probably due to examination of the knee area only in our study. In the present study, more patients from the SF 3-in-1 block group experienced tourniquet pain, and they required more opioid analgesia than did those who received the combined SPC block. Pain caused by the applied tourniquet has also been reported in combined SF 3-in-1 block [11]. The block of the femoral lateral cutaneous nerve and the obturator nerve in SPC block may explain the significantly increased tourniquet tolerance compared with the SF 3-in-1 block that was seen in our study. Hemodynamic parameters did not significantly differ between groups. In previous reports, decreased heart rate was
Sciatic psoas vs sciatic femoral 3-in-1 block observed in patients who underwent psoas compartment block [7]. This change was explained by a possible central neuraxial spread of the psoas compartment block due to the injection of large volumes of local anesthetic agent [7,28,29]. Auroy et al [30] reported about a 1% incidence of psoas compartment block complications due to epidural or intrathecal spread of local anesthetic. Another complication of the psoas compartment block may be direct nerve injury due to the needle [31]. However, we observed no signs or symptoms of epidural involvement in our patients, a finding that may explain the lack of difference in hemodynamic changes between the groups. Radiography may be a useful tool to determine catheter tip location [32], but its use has been encouraged only in cases in which systemic or intrathecal spread is suspected. In the current study, radiography or any other technique used for the visualization of epidural spread was not applied because we harbored no suspicions of such spread. During the operation, the time for first use of fentanyl was shorter in the SF 3-in-1 block than in the SPC group. In addition, a second opioid analgesic was needed in about half of the patients from the SF 3-in-1 block group. This finding also reflects patient satisfaction, as patients in the SPC group were more comfortable than those from the SF 3-in-1 block group. In conclusion, the SPC block provided better anesthesia during knee arthroscopy, and patients with this block required less analgesic during the operation than did the patients who received the SF 3-in-1 block.
References [1] di Benedetto P, Bertini L, Casati A, et al. A new posterior approach to the sciatic nerve block: a prospective, randomized comparison with the classic posterior approach. Anesth Analg 2001;93:1040-4. [2] Casati A, Magistris L, Fanelli G, et al. Small-dose clonidine prolongs postoperative analgesia after sciatic-femoral nerve block with 0.75% ropivacaine for foot surgery. Anesth Analg 2000;91:388-92. [3] Cuvillon P, Ripart J, Jeannes P, et al. Comparison of the parasacral approach and the posterior approach, with single- and double-injection techniques, to block the sciatic nerve. Anesthesiology 2003;98: 1436-41. [4] Hadzic A, Vloka JD. A comparison of the posterior versus lateral approaches to the block of the sciatic nerve in the popliteal fossa. Anesthesiology 1998;88:1480-6. [5] Hall MJ, Lawrence L. Ambulatory surgery in the United States, 1996. Adv Data 1998:1-16. [6] Zetlaoui PJ, Bouaziz H. Lateral approach to the sciatic nerve in the popliteal fossa. Anesth Analg 1998;87:79-82. [7] Ganidagli S, Cengiz M, Baysal Z, et al. The comparison of two lower extremity block techniques combined with sciatic block: 3-in-1 femoral block vs. psoas compartment block. Int J Clin Pract 2005;59:771-6. [8] Dilger JA. Lower extremity nerve blocks. Anesthesiol Clin North Am 2000;18:319-40. [9] Tokat O, Turker YG, Uckunkaya N, et al. A clinical comparison of psoas compartment and inguinal paravascular blocks combined with sciatic nerve block. J Int Med Res 2002;30:161-7.
595 [10] Kaloul I, Guay J, Cote C, et al. The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth 2004;51:45-51. [11] Elmas C, Elmas Y, Gautschi P, et al. Combined sciatic 3-in-1 block. Application in lower limb orthopedic surgery. Anaesthesist 1992;41: 639-43. [12] Jochum D, O'Neill T, Jabbour H, et al. Evaluation of femoral nerve blockade following inguinal paravascular block of Winnie: are there still lessons to be learnt? Anaesthesia 2005;60:974-7. [13] Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block”. Anesth Analg 1973;52:989-96. [14] Patel NJ, Flashburg MH, Paskin S, et al. A regional anesthetic technique compared to general anesthesia for outpatient knee arthroscopy. Anesth Analg 1986;65:185-7. [15] Cappelleri G, Casati A, Fanelli G, et al. Unilateral spinal anesthesia or combined sciatic-femoral nerve block for day-case knee arthroscopy. A prospective, randomized comparison. Minerva Anesthesiol 2000;66:131-6. [16] Winnie AP, Ramamurthy S, Durrani Z. Plexus blocks for lower extremity surgery. Anesthesiol Rev 1974;1:11-6. [17] Fanelli G, Casati A, Aldegheri G, et al. Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery. Acta Anaesthesiol Scand 1998;42:80-4. [18] Jankowski CJ, Hebl JR, Stuart MJ, et al. A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy. Anesth Analg 2003;97:1003-9. [19] Brown DL, Wedel DJ. Spinal, epidural, and caudal anesthesia. In: Miller RD, editor. Anesthesia, 3rd ed. New York: Churchill Livingstone; 1990. p. 1377-406. [20] Labat G. Regional anesthesia. Its technique and clinical applications. Philadelphia: W.B. Saunders; 1923. [21] Dupont WD, Plummer WD. PS power and sample size program available for free on the Internet. Control Clin Trials 1997;18:274. [22] Dalens B, Tanguy A, Vanneuville G. Lumbar plexus blocks and lumbar plexus nerve blocks. Anesth Analg 1989;69:852-4. [23] Bouaziz H, Vial F, Jochum D, et al. An evaluation of the cutaneous distribution after obturator nerve block. Anesth Analg 2002;94: 445-9. [24] Kam PC, Kavanagh R, Yoong FF. The arterial tourniquet: pathophysiological consequences and anaesthetic implications. Anaesthesia 2001;56:534-45. [25] Gielen MJ, Stienstra R. Tourniquet hypertension and its prevention: a review. Reg Anesth 1991;16:191-4. [26] Enneking FK, Chan V, Greger J, Hadzic A, Lang SA, Horlocker TT. Lower-extremity peripheral nerve blockade: essentials of our current understanding. Reg Anesth Pain Med 2005;30:4-35. [27] Mannion S, O'Callaghan S, Walsh M, Murphy DB, Shorten GD. In with the new, out with the old? Comparison of two approaches for psoas compartment block. Anesth Analg 2005;101:259-64. [28] Parkinson SK, Mueller JB, Little WL, et al. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 1989;68: 243-8. [29] Stevens RD, Van Gessel E, Flory N, et al. Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology 2000;93:115-21. [30] Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002;97:1274-80. [31] Al Nasser B, Palacios JL. Femoral nerve injury complicating continuous psoas compartment block. Reg Anesth Pain Med 2004; 29:361-3. [32] De Biasi P, Lupescu R, Burgun G, Lascurain P, Gaertner E. Continuous lumbar plexus block: use of radiography to determine catheter tip location. Reg Anesth Pain Med 2003;28:135-9.
Original contribution
Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy Abdulkadir Atim MD (Staff Anesthesiologist)a,⁎, Atilla Ergin MD (Assistant Professor)b , Ercan Kurt MD (Professor)b , Yusuf Özdemiroglu MD (Staff Orthopedist)a , Erdal Guzeldemir MD (Professor)b a
Department of Anesthesiology, Beytepe Military Hospital, Ankara 06835, Turkey Department of Anesthesiology, Gulhane Military Medical Academy, Ankara, Turkey
b
Received 26 November 2006; revised 7 June 2007; accepted 13 June 2007
Keywords: Arthroscopy; Sciatic psoas compartment block; Sciatic femoral 3-in-1 block; Tourniquet pain
Abstract Study Objectives: To compare the clinical effectiveness of two peripheral nerve block techniques combined with sciatic nerve block: sciatic psoas compartment (SPC) and sciatic femoral 3-in-1 (SF 3in-1) block. Design: Prospective, randomized study. Setting: Military medical academy hospital. Patients: Thirty-six ASA physical status I patients, aged 20 to 33 years, undergoing elective knee arthroscopy. Interventions: Patients having SPC block (n = 19) or SF 3-in-1 block (n = 17) received 40 mL of a mixture of solution containing 15 mL of 0.5% bupivacaine, 15 mL of 2.0% prilocaine, and 10 mL of 0.9% sodium chloride. In both groups, the sciatic nerve was blocked with 20 mL of the same solution. An intravenous bolus injection of fentanyl 0.1 mg was used if patients complained of pain. Measurements and Main Results: None of the patients in the SPC group experienced pain owing to the applied tourniquet during the operation, whereas 7 patients from the SF 3-in-1 group (41.2 %) reported tourniquet pain. All SF 3-in-1 group patients but only 5 patients (26.3 %) in the SPC group required fentanyl during the operation. In addition, 7 patients in the SF 3-in-1 group required second doses of fentanyl. Patient satisfaction was significantly higher in the SPC group than in the SF 3-in-1 block group (P b 0.0001). Conclusions: Both SPC and SF 3-in-1 provided sufficient anesthetic efficacy for knee arthroscopy. However, SPC may be preferable to SF 3-in-1 block owing to better patient satisfaction and less requirement for opioid analgesics. © 2007 Elsevier Inc. All rights reserved.
1. Introduction
⁎ Corresponding author. Tel.: +90 312 4648236; fax: +90 312 4646922. E-mail address: [email protected] (A. Atim). 0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2007.06.014
Knee arthroscopy is one of the most commonly performed orthopedic procedures for the diagnosis and treatment of knee diseases [1]. Different types of anesthetic techniques including local, regional, and general anesthesia have been
592 used successfully for this surgical procedure [2-6]. More recently, peripheral nerve block techniques such as femoral, lateral femoral cutaneous, and obturator block with or without sciatic nerve block have also been used [7-11]. Peripheral nerve block techniques include femoral and psoas compartment approaches. The femoral approach combines inguinal paravascular (3-in-1) and sciatic nerve block. Femoral block is the most commonly used peripheral regional technique [12,13]. It is performed easily, but it may not always produce an effective block of the lateral femoral cutaneous and obturator nerves. Therefore, general anesthesia may be needed in about 12% to 15% of patients because of block failure [14,15]. Psoas compartment block, first described about 30 years ago, is a posterior approach for the block of nerves originating from the lumbar plexus [16]. In contrast to the femoral approach, the psoas compartment block produces a block of the entire lumbar plexus including the lateral femoral cutaneous and obturator nerves. Peripheral nerve block has potential advantages in knee arthroscopy such as earlier hospital discharge, less postoperative pain, nausea, emesis, and urinary retention, compared with general anesthesia [17-19]. On the other hand, insufficient anesthesia with the peripheral nerve block may cause limb pain because of the inflated tourniquet during the arthroscopic procedures. It is expected that the femoral approach may cause more pain due to the ineffective block when compared with psoas compartment block. However, there is little information in the literature that compares the approaches in this regard. The aim of this study was to compare the efficiency and advantages of the psoas compartment and femoral approaches.
2. Materials and methods The study protocol was approved by the local ethics committee at Gulhane Military Medical Faculty Hospital, and written, informed consent was obtained from all patients. A total of 42 patients undergoing elective knee arthroscopic surgery were enrolled in the study. All of the patients were ASA physical status I and between the ages of 20 and 33 years (Table 1). Exclusion criteria included epilepsy, peripheral neuropathy, hemorrhagic diathesis, or use of general anesthesia due to the block failure. Patients were randomized by a computer-generated table of random numbers to receive either sciatic psoas compartment (SPC; n = 21) block or combined sciatic femoral 3-in-1 (SF 3in-1; n = 21) block. The surgeon was blinded as to the type of peripheral nerve block used in each study patient. After an 18-gauge intravenous (IV) cannula was inserted into the forearm, patients were premedicated with two mg of midazolam 45 minutes before the surgical procedure. Monitoring included heart rate, arterial blood pressure, and pulse oximetry (Millenia Vital Signs Monitoring System,
A. Atim et al. Table 1 Patient characteristics in the combined SPC and SF 3-in-1 block groups Variable
SPC group SF 3-in-1 group
Age (y) Gender (male/female) Weight (kg) Patients with ASA physical status I, n (%) Knee arthroscopy type (meniscectomy/ACLR), n (%) Patients whose surgery was continued with general anesthesia (meniscectomy/ACLR) Duration of surgery (min)
25.0 ± 5.6 21/0 71.8 ± 4.4 21 (100%)
24.4 ± 4.3 21/0 72.7 ± 5.6 21 (100%)
15 (71%)/6 18 (86%)/3 (29%) (14%) 0/2 2/2
51.7 ± 41.2 36.3 ± 10.1
Data are given as means ± SD. Operation time started with the surgical incision. ACLR = anterior cruciate ligament repair; SPC = sciatic psoas compartment; SF = sciatic femoral.
serial no. 3500, Invivo Corp, Temecula, CA). A standard thigh tourniquet inflated up to 200 mmHg pressure was used during the surgical procedure. Femoral nerve or psoas compartment blocks were performed using the approach described by Winnie et al [16]. Briefly, the femoral nerve block was performed about 1.5 cm lateral to the femoral artery just below the inguinal ligament. The needle in the psoas compartment block was inserted at the intersection of the intercristal line that was drawn in the horizontal plane at the upper margin of the iliac crests and a line drawn parallel to the spine through the posterior superior iliac spine. Immediately after the femoral nerve or psoas compartment block, the sciatic nerve was blocked using the classical posterior approach as described by Labat [20]. Patients were placed in the lateral decubitus position with the knee flexed at a 90° angle. A first line was drawn from the midpoint of the greater trochanter to the posterior superior iliac spine, and a second line was drawn to the sacral hiatus. The puncture was performed at the intersection of a third line, emerging perpendicularly from the first line at its midpoint and the second line. Patients undergoing psoas compartment block or femoral 3-in-1 block received 40 mL of a mixture of solution containing 15 mL of 0.5% bupivacaine, 15 mL of 2.0% prilocaine, and 10 mL of 0.9% sodium chloride. Twenty milliliters of the same solution was used for the sciatic nerve block. A nerve stimulator (Stimuplex, Melsungen, Germany) with a 10-cm, 21-gauge needle was used to locate the nerve. Stimulation frequency was 2 Hz and pulse width was 0.1 ms. Initial intensity of the stimulating current was 1 mA and gradually decreased to 0.3 mA. After completion of the anesthetic injection, motor block of the anesthetized site was evaluated by asking the patient to move the ankle and to elevate the leg with the hip passively fixed; sensory block was evaluated using the pinprick test with a 22-gauge needle and an ice test. Hemodynamic
Sciatic psoas vs sciatic femoral 3-in-1 block Table 2
593
Major outcomes of sciatic femoral (SF) 3-in-1 and sciatic psoas compartment (SPC) groups during knee surgery
SF 3-in-1 SPC Significance (P value)
Continued with regional anesthesia, n (%)
Tourniquet pain, n (%)
17 (81%) 19 (90.5%) 0.66
7 (41.2%) 0 (0%) 0.002
Opioid analgesic requirement during surgery 1st injection, n (%)
2nd injection, n (%)
Injection time (min)
17 (100%) 5 (26.3%) 0.0001
8 (47.1%) 0 (0%) 0.0008
23.4 ± 15.1 81.0 ± 63.5 0.02
n indicates number of patients.
variables were also recorded at the same time. The loss of pinprick sensation and ice test on the knee region were measured at two-minute intervals. Inability of leg elevation and ankle movement as measured with the original Bromage scale at 5-minute intervals was used to determine the time to surgical block. Once the ice and pinprick tests indicated sensory block on the knee region, surgery was started. Contralateral sensory and motor blocks were also evaluated. Visual analog scale (VAS) scores were recorded preoperatively every 10 minutes during the surgery, at each hour after the surgery for a period of 6 hours, then on the 12th, 18th, 24th, 36th, and 48th hour thereafter. The VAS was scored from 0 to 10. Fentanyl 0.1 mg IV bolus injection was used if patients experienced pain due to the surgical procedure or the inflated tourniquet. Supplemental analgesia was given when VAS scores were equal to or greater than 3. The number and time of fentanyl injections were recorded during the surgical procedure. Diclofenac sodium 75 mg IV bolus injection was used for the management of postoperative pain. Patient satisfaction was assessed by asking whether they would accept the same anesthesia technique if required again for future operations. Patients were also asked to give a score between 1 (dissatisfaction) and 10 (complete satisfaction) by considering the pain that they had experienced during the surgery.
by considering α = 0.05, δ = 50%, σ = 20%, and n = 21 patients in each group for the consumption of fentanyl during the surgery.
3. Results A total of 42 ASA physical status I men, aged 20 to 33 years, participated in the study. Patients' ages and weight were similar between the groups (Table 1). The type of knee arthroscopy performed was anterior cruciate ligament reconstruction (9 patients) and menisectomy (33 patients). The distribution of surgical indication for knee arthroscopy was not significantly different between the groups (Table 1). The surgery required general anesthesia in two SPC group patients and 4 SF 3-in-1 group patients owing to insufficient peripheral block (Table 2). Those patients who received general anesthesia were then excluded from the study. Operation times during the regional anesthesia were not significantly different between the groups (P = 0.74; Table 1). The major outcomes are summarized in Table 2. None of the SPC group patients experienced pain owing to the
2.1. Statistical analysis Continuous variables are shown as means ± SD, and ordinal data are presented as medians (ranges). The MannWhitney U test was used for comparison of hemodynamic parameters and the time of pain from the inflated tourniquet. Number of fentanyl injections, patient's satisfaction, and degree of inflated tourniquet pain were compared between groups with Fisher's exact test. Visual analog scale scores were compared with repeated measures analysis of variance between the groups at different periods (GraphPad Prism Software version 4.0, GraphPad Prism Software, Inc, San Diego, CA). A P value of less than 0.05 was considered statistically significant. A power calculation was performed, as described by Dupont and Plummer [21]. A difference of 50% between the scores compared was assessed to be of clinical importance. Power calculation was estimated as 0.94
Fig. 1 Box plot graph of patient satisfaction in the sciatic psoas compartment (SPC) and sciatic femoral (SF) 3-in-1 block groups. A score of 1 = dissatisfaction and 10 = complete satisfaction, considering the pain experienced by the patient during surgery.
594
Fig. 2 Visual analog scale (VAS) scores of the patients during the operative period. The VAS was scored from 0 to 10 (⁎P b 0.0001).
applied tourniquet during the operation, whereas 7 patients (41.2 %) from the SF 3-in-1 group reported tourniquet pain. Patient satisfaction was significantly higher in the SPC group than in the SF 3-in-1 block group (P b 0.0001; Fig. 1). All SF 3-in-1 block group patients and 5 SPC group patients required opioid analgesia during the surgery (Table 2). Mean times for the first administration of fentanyl were 23.4 and 81 minutes in the SF 3-in-1 block and SPC groups, respectively (P = 0.02). Seven patients in the SF 3-in1 block group required second doses of fentanyl, whereas none of the patients from the SPC group needed additional fentanyl administration. Visual analog scale scores of the groups are shown in Fig. 2; they were significantly higher in the SF 3-in-1 block group than in the SPC group for the first 30 and 60 minutes of the operation (P b 0.0001 and P = 0.04, respectively). The difference in VAS score was not significant in other measurements (Fig. 2). There was no significant difference in hemodynamic parameters between the groups. Heart rate, oxygen saturation, and blood pressure values (data not shown) did not significantly change during or after the operation in either group. Neither group reported nausea or vomiting. No complication was observed owing to application of the peripheral block. No sensory or motor block was observed in the contralateral extremity.
4. Discussion In the present study, we compared the combined SPC block and SF 3-in-1 block in patients undergoing knee arthroscopy. Studies have shown that, with psoas compartment block, spread of local anesthetic agent from the injection site allows rapid distribution, whereas with the
A. Atim et al. femoral 3-in-1 block, anesthesia may be insufficient owing to the low distribution of the local anesthetic agent into the obturator and lateral femoral cutaneous nerves [9,22]. Our findings support these data, and they show that more efficient anesthesia may be achieved with the SPC block than with the SF 3-in-1 block. In our study, the pinprick and cold tests of the surgical region were used to assess the success of the sensorial block. The quality of anesthesia was higher in the SPC block than in the SF 3-in-1 block. Similarly, VAS scores were significantly higher during surgery in the SF 3-in-1 block group than in the SPC block group. However, fentanyl was used to provide a sufficient level of analgesia in patients experiencing pain. This difference in VAS scores also reflected patient satisfaction in the two groups. Similar results have been reported by Ganidagli et al [7] and Tokat et al [9]. The additional analgesic requirement was significantly higher in the SF 3-in-1 block group than in the SPC block group in our study. Insufficient block of the obturator and lateral femoral cutaneous nerves in the SF 3-in-1 block may be one of the reasons for this difference. On the other hand, cutaneous distribution of the obturator nerve varies among patients and can be absent or incomplete in some patients [23]. Therefore, implication of the obturator nerve in pain manifestation after peripheral block with SF 3-in-1 and SPC seems less important than was thought previously. Contrary to our results, one group of investigators showed that analgesia after 60 minutes of surgery and postoperative analgesia do not differ in femoral 3-in-1 block or psoas compartment block [10]. Application of a tourniquet is a widely used procedure in extremity surgery to avoid bleeding in the operative field [24,25]. The tourniquet is usually located at the proximal thigh during operations of the knee. Innervation of the thigh depends on the femoral nerve itself, the lateral femoral cutaneous, and the posterior femoral cutaneous nerves [26]. Regional anesthetic techniques such as sciatic, femoral, or psoas compartment block may cause insufficient anesthesia of varying degrees; therefore, an inflated tourniquet may cause severe pain in some patients who are receiving inadequate anesthesia. Contralateral extension of the psoas compartment block is between 4% and 40% [26,27]. The reason for the absence of sensory or motor block in our study at the contralateral extremity was most probably due to examination of the knee area only in our study. In the present study, more patients from the SF 3-in-1 block group experienced tourniquet pain, and they required more opioid analgesia than did those who received the combined SPC block. Pain caused by the applied tourniquet has also been reported in combined SF 3-in-1 block [11]. The block of the femoral lateral cutaneous nerve and the obturator nerve in SPC block may explain the significantly increased tourniquet tolerance compared with the SF 3-in-1 block that was seen in our study. Hemodynamic parameters did not significantly differ between groups. In previous reports, decreased heart rate was
Sciatic psoas vs sciatic femoral 3-in-1 block observed in patients who underwent psoas compartment block [7]. This change was explained by a possible central neuraxial spread of the psoas compartment block due to the injection of large volumes of local anesthetic agent [7,28,29]. Auroy et al [30] reported about a 1% incidence of psoas compartment block complications due to epidural or intrathecal spread of local anesthetic. Another complication of the psoas compartment block may be direct nerve injury due to the needle [31]. However, we observed no signs or symptoms of epidural involvement in our patients, a finding that may explain the lack of difference in hemodynamic changes between the groups. Radiography may be a useful tool to determine catheter tip location [32], but its use has been encouraged only in cases in which systemic or intrathecal spread is suspected. In the current study, radiography or any other technique used for the visualization of epidural spread was not applied because we harbored no suspicions of such spread. During the operation, the time for first use of fentanyl was shorter in the SF 3-in-1 block than in the SPC group. In addition, a second opioid analgesic was needed in about half of the patients from the SF 3-in-1 block group. This finding also reflects patient satisfaction, as patients in the SPC group were more comfortable than those from the SF 3-in-1 block group. In conclusion, the SPC block provided better anesthesia during knee arthroscopy, and patients with this block required less analgesic during the operation than did the patients who received the SF 3-in-1 block.
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