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Continuous quadratus lumborum block analgesia for total hip arthroplasty revision
Journal of Clinical Anesthesia (2016) 35, 235–237
Correspondence Continuous quadratus lumborum block analgesia for total hip arthroplasty revision☆
1. Introduction We read with interest the article by Ueshima et al [1] describing the effective use of quadratus lumborum (QL) block for total hip arthroplasty (THA) as part of a multimodal analgesic regimen. The importance of regional anesthesia as the cornerstone of the multimodal technique was highlighted as the most effective treatment method in these cases of primary THA. We describe how this same analgesic technique can be used effectively even for a patient with chronic pain and opioid dependence for perioperative pain management for revision THA. A 57-year-old man was booked for a second revision of his left THA. He had a medical history significant for chronic hip and lower back pain (secondary to osteoarthritis), narcotic dependency, mixed anxiety-depressive disorder, asthma, hypertension, obstructive sleep apnea, and a current smoker of 40/d. His list of medications included escitalopram, topical fentanyl 125 μg/h, morphine 40 mg q4 hourly, nortriptyline 150 mg, zopiclone 15 mg, oxycodone-acetaminophen, and naproxen, gabapentin 600 mg, bronchodilator, and antihypertensive medications. He admitted to severe baseline pain (most days between 8/ 10 and 9/10 pain score at rest and 10/10 on activity). He was unable to mobilize without a rollator and assistance of 2 because of osteoarthritis and hip pain. Preoperatively, he received his usual morning medications and continued on his fentanyl patch perioperatively. He was consented for placement of continuous QL catheter for postoperative analgesia. After intravenous (IV) access was secured, IV fluids were commenced and full monitoring was connected. The patient was given oxygen via Hudson mask at 4 L/min. He was given 2 mg midazolam and 100 μg fentanyl titrated to effect for sedation. He was then positioned in the right lateral decubitus position.
☆ Disclosures: No acknowledgments, financial support, or conflicts of interest declared.
0952-8180/© 2016 Elsevier Inc. All rights reserved.
A prescan using a low-frequency 8-MHz ultrasound transducer and M-Turbo machine (SonoSite, Bothell, WA) was conducted to locate the L3 transverse process, QL muscle, erector spinae muscles, and the psoas muscle. After sterilizing the skin on his back with chlorhexidine, a sterile technique was used to pass an 18G Tuohy needle in-plane in a medial-tolateral direction (Fig. 1). A transmuscular “QL-3” approach was used to obtain the end point of anterior drift of the bright anterior QL fascia using 5% dextrose for hydrodissection (Fig. 2). After this, 30 mL of 0.5% ropivacaine was injected through the Tuohy needle after negative aspiration. An Arrow FlexTip catheter (Teleflex, Morrisville, NC) was fed easily through the Tuohy needle and was passed to allow 5 cm of catheter within the space created by the local anesthetic injectate (Fig. 3). The catheter infusion was connected to a pump that administered ropivacaine 0.2% at 10 mL/h with a 4-mL bolus and 30-minute lockout. This was continued for 48 hours postoperatively. Twenty minutes after the QL-3 block was placed, loss of cold sensation was observed over T12-L2 dermatomes (Fig. 4). He underwent a general anesthetic for his revision hip surgery and was given sufentanil 25 μg and ketamine 40 mg for analgesia intraoperatively. The patient was given regular multimodal analgesia (gabapentin, paracetamol, and naproxen), as well as his fentanyl patch. Breakthrough pain was treated with oxycodone 20 mg q4 hourly. In the recovery unit, his pain score was 3 at rest and 5 on moving the hip. He received hydromorphone 0.6 mg intravenously. On the ward, his pain scores were between 0 and 4 at rest and 3 and 6 on moving with physiotherapy. Subjectively, the patient felt that his pain was very well controlled with less opioid medication than he required preoperatively (he received 2 doses of oxycodone on both day 1 and day 2) and needed no additional IV opioid rescue. He had used the bolus function on the QL pump a total of 5 times over the 48-hour period. Physiotherapy assessment noted no observable weakness of hip flexion or knee extension as a result of the block when tested before and after using quadriceps dynamometry. In addition, the patient was able to demonstrate 5/5 power on straight leg raise against resistance. He had an uneventful recovery, and no serious adverse incidents occurred during his stay.
236
D.F. Johnston, R.V. Sondekoppam
Fig. 1
Medial-to-lateral advancement of Tuohy needle.
2. Discussion The QL block has been described as an analgesic technique for abdominal surgery [2,3]. Local anesthetic injected at the anterior edge of the QL muscle results in T5-L1 dermatome anesthesia because of spread to the paravertebral space [4,5]. Furthermore, abdominal plane blocks have been used to provide anesthesia for hip hemiarthroplasty [1,6]. The anatomical basis for this technique has been demonstrated by the existence of an anatomical space between the anterior thoracolumbar fascia (QL fascia) and the posterior endoabdominal fascia. The same interfascial space will contain access to the L1 and L2 nerves as they exit the intervertebral foramina before formation of the lumbar plexus within the belly of the psoas muscle. Local anesthetic of sufficient volume injected in this space in a lateral-to-medial direction can therefore block the iliohypogastric, ilioinguinal, genitofemoral, as well as the L2 components of the lateral femoral cutaneous, femoral, and obturator nerves.
Fig. 2
Fig. 3
Continuous quadratus lumborum catheter position.
A large-volume QL block below the L3 transverse process level can therefore be used for hip surgery because of the splitting of the fascial layers between the psoas major muscle anteriorly and the transverse process with paravertebral contents posteriorly, allowing the injectate to extend medially. Theoretical advantages of using continuous QL block when compared with a lumbar plexus block for hip surgery could include less periprocedural pain because it is a more superficial block and less quadriceps weakness due to incomplete femoral nerve involvement. Further work in QL blocks for hip surgery is required to ascertain this.
3. Conclusion We describe the effective use of continuous QL block analgesia for the perioperative pain management of an opioiddependent patient undergoing revision hip arthroplasty surgery.
Needle trajectory of transmuscular quadratus lumborum block at L3 level.
Correspondence
237 Rakesh Vijayashankar Sondekoppam MD, FRCPC Department of Anesthesia and Pain Medicine University of Alberta Health Sciences Edmonton, Alberta, Canada E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2016.08.002
References
Fig. 4 Loss of pinprick sensation over operative site 20 minutes after block placement.
David F. Johnston MB, BCh, BAO, FRCA, EDRA, PGEd Department of Anaesthesia and Perioperative Medicine Royal Victoria Hospital, Grosvenor Rd, Belfast Northern Ireland, United Kingdom E-mail address: [email protected]
[1] Ueshima H, Yoshiyama S, Otake H. The ultrasound-guided continuous transmuscular quadratus lumborum block is an effective analgesia for total hip arthroplasty. J Clin Anesth 2016;31:35. [2] Blanco R. TAP block under ultrasound guidance: the description of a ‘non-pops-technique’. Reg Anesth Pain Med 2007;32(Suppl 1):130. [3] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesth Clin Pharm 2013;29:550-2. [4] Carney J, Finnerty O, Rauf J, Begin D, Laffey J, McDonnell J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011;66:1023-30. [5] Børglum J, Christensen A, Hoegberg L. Bilateral-dual transversus abdominis plane (BD-tap) block or thoracic paravertebral block (TPVB)? Distribution patterns, dermatomal anaesthesia and LA pharmacokinetics. Reg Anesth Pain Med 2012;37:E137-9 [Suppl]. [6] Stuart-Smith K. Hemiarthroplasty performed under transversus abdominis plane block in a patient with severe cardiorespiratory disease. Anaesthesia 2013;68:417-20.
Correspondence Continuous quadratus lumborum block analgesia for total hip arthroplasty revision☆
1. Introduction We read with interest the article by Ueshima et al [1] describing the effective use of quadratus lumborum (QL) block for total hip arthroplasty (THA) as part of a multimodal analgesic regimen. The importance of regional anesthesia as the cornerstone of the multimodal technique was highlighted as the most effective treatment method in these cases of primary THA. We describe how this same analgesic technique can be used effectively even for a patient with chronic pain and opioid dependence for perioperative pain management for revision THA. A 57-year-old man was booked for a second revision of his left THA. He had a medical history significant for chronic hip and lower back pain (secondary to osteoarthritis), narcotic dependency, mixed anxiety-depressive disorder, asthma, hypertension, obstructive sleep apnea, and a current smoker of 40/d. His list of medications included escitalopram, topical fentanyl 125 μg/h, morphine 40 mg q4 hourly, nortriptyline 150 mg, zopiclone 15 mg, oxycodone-acetaminophen, and naproxen, gabapentin 600 mg, bronchodilator, and antihypertensive medications. He admitted to severe baseline pain (most days between 8/ 10 and 9/10 pain score at rest and 10/10 on activity). He was unable to mobilize without a rollator and assistance of 2 because of osteoarthritis and hip pain. Preoperatively, he received his usual morning medications and continued on his fentanyl patch perioperatively. He was consented for placement of continuous QL catheter for postoperative analgesia. After intravenous (IV) access was secured, IV fluids were commenced and full monitoring was connected. The patient was given oxygen via Hudson mask at 4 L/min. He was given 2 mg midazolam and 100 μg fentanyl titrated to effect for sedation. He was then positioned in the right lateral decubitus position.
☆ Disclosures: No acknowledgments, financial support, or conflicts of interest declared.
0952-8180/© 2016 Elsevier Inc. All rights reserved.
A prescan using a low-frequency 8-MHz ultrasound transducer and M-Turbo machine (SonoSite, Bothell, WA) was conducted to locate the L3 transverse process, QL muscle, erector spinae muscles, and the psoas muscle. After sterilizing the skin on his back with chlorhexidine, a sterile technique was used to pass an 18G Tuohy needle in-plane in a medial-tolateral direction (Fig. 1). A transmuscular “QL-3” approach was used to obtain the end point of anterior drift of the bright anterior QL fascia using 5% dextrose for hydrodissection (Fig. 2). After this, 30 mL of 0.5% ropivacaine was injected through the Tuohy needle after negative aspiration. An Arrow FlexTip catheter (Teleflex, Morrisville, NC) was fed easily through the Tuohy needle and was passed to allow 5 cm of catheter within the space created by the local anesthetic injectate (Fig. 3). The catheter infusion was connected to a pump that administered ropivacaine 0.2% at 10 mL/h with a 4-mL bolus and 30-minute lockout. This was continued for 48 hours postoperatively. Twenty minutes after the QL-3 block was placed, loss of cold sensation was observed over T12-L2 dermatomes (Fig. 4). He underwent a general anesthetic for his revision hip surgery and was given sufentanil 25 μg and ketamine 40 mg for analgesia intraoperatively. The patient was given regular multimodal analgesia (gabapentin, paracetamol, and naproxen), as well as his fentanyl patch. Breakthrough pain was treated with oxycodone 20 mg q4 hourly. In the recovery unit, his pain score was 3 at rest and 5 on moving the hip. He received hydromorphone 0.6 mg intravenously. On the ward, his pain scores were between 0 and 4 at rest and 3 and 6 on moving with physiotherapy. Subjectively, the patient felt that his pain was very well controlled with less opioid medication than he required preoperatively (he received 2 doses of oxycodone on both day 1 and day 2) and needed no additional IV opioid rescue. He had used the bolus function on the QL pump a total of 5 times over the 48-hour period. Physiotherapy assessment noted no observable weakness of hip flexion or knee extension as a result of the block when tested before and after using quadriceps dynamometry. In addition, the patient was able to demonstrate 5/5 power on straight leg raise against resistance. He had an uneventful recovery, and no serious adverse incidents occurred during his stay.
236
D.F. Johnston, R.V. Sondekoppam
Fig. 1
Medial-to-lateral advancement of Tuohy needle.
2. Discussion The QL block has been described as an analgesic technique for abdominal surgery [2,3]. Local anesthetic injected at the anterior edge of the QL muscle results in T5-L1 dermatome anesthesia because of spread to the paravertebral space [4,5]. Furthermore, abdominal plane blocks have been used to provide anesthesia for hip hemiarthroplasty [1,6]. The anatomical basis for this technique has been demonstrated by the existence of an anatomical space between the anterior thoracolumbar fascia (QL fascia) and the posterior endoabdominal fascia. The same interfascial space will contain access to the L1 and L2 nerves as they exit the intervertebral foramina before formation of the lumbar plexus within the belly of the psoas muscle. Local anesthetic of sufficient volume injected in this space in a lateral-to-medial direction can therefore block the iliohypogastric, ilioinguinal, genitofemoral, as well as the L2 components of the lateral femoral cutaneous, femoral, and obturator nerves.
Fig. 2
Fig. 3
Continuous quadratus lumborum catheter position.
A large-volume QL block below the L3 transverse process level can therefore be used for hip surgery because of the splitting of the fascial layers between the psoas major muscle anteriorly and the transverse process with paravertebral contents posteriorly, allowing the injectate to extend medially. Theoretical advantages of using continuous QL block when compared with a lumbar plexus block for hip surgery could include less periprocedural pain because it is a more superficial block and less quadriceps weakness due to incomplete femoral nerve involvement. Further work in QL blocks for hip surgery is required to ascertain this.
3. Conclusion We describe the effective use of continuous QL block analgesia for the perioperative pain management of an opioiddependent patient undergoing revision hip arthroplasty surgery.
Needle trajectory of transmuscular quadratus lumborum block at L3 level.
Correspondence
237 Rakesh Vijayashankar Sondekoppam MD, FRCPC Department of Anesthesia and Pain Medicine University of Alberta Health Sciences Edmonton, Alberta, Canada E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2016.08.002
References
Fig. 4 Loss of pinprick sensation over operative site 20 minutes after block placement.
David F. Johnston MB, BCh, BAO, FRCA, EDRA, PGEd Department of Anaesthesia and Perioperative Medicine Royal Victoria Hospital, Grosvenor Rd, Belfast Northern Ireland, United Kingdom E-mail address: [email protected]
[1] Ueshima H, Yoshiyama S, Otake H. The ultrasound-guided continuous transmuscular quadratus lumborum block is an effective analgesia for total hip arthroplasty. J Clin Anesth 2016;31:35. [2] Blanco R. TAP block under ultrasound guidance: the description of a ‘non-pops-technique’. Reg Anesth Pain Med 2007;32(Suppl 1):130. [3] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesth Clin Pharm 2013;29:550-2. [4] Carney J, Finnerty O, Rauf J, Begin D, Laffey J, McDonnell J, et al. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011;66:1023-30. [5] Børglum J, Christensen A, Hoegberg L. Bilateral-dual transversus abdominis plane (BD-tap) block or thoracic paravertebral block (TPVB)? Distribution patterns, dermatomal anaesthesia and LA pharmacokinetics. Reg Anesth Pain Med 2012;37:E137-9 [Suppl]. [6] Stuart-Smith K. Hemiarthroplasty performed under transversus abdominis plane block in a patient with severe cardiorespiratory disease. Anaesthesia 2013;68:417-20.