|Year : 2007 | Volume
| Issue : 2 | Page : 127
Lumbar plexus block for post-operative analgesia following hip surgery: A comparison of "3 in 1" and psoas compartment block
Uma Srivastava1, Aditya Kumar1, Surekha Saxena1, Anjum Naz2, Vineeta Goyal3, Roli Mehrotra4
1 D.A., M.D., Assoc. Prof., Department of Anaesthesia, S.N. Medical College, Agra-282002, India
2 M.D., EX-Resident, Department of Anaesthesia, S.N. Medical College, Agra-282002, India
3 M.D., Lecturer, Department of Anaesthesia, S.N. Medical College, Agra-282002, India
4 M.B.B.S. Resident, Department of Anaesthesia, S.N. Medical College, Agra-282002, India
|Date of Acceptance||20-Feb-2007|
|Date of Web Publication||20-Mar-2010|
15, Master Plan Road, New Lajpat Kunj. Agra
Source of Support: None, Conflict of Interest: None
We used a single shot lumbar plexus block by posterior approach (Psoas compartment block- PCB) or anterior approach ('3in1' block) for postoperative analgesia in the patients of hip fractures operated under spinal anaesthesia. The blocks were given at the end of operation with 0.25% of bupivacaine and pain was assessed using Verbal Rating scale at 1,6,12 and 24 hours postoperatively both during rest and physiotherapy. We also noted time for first analgesic, need of supplemental analgesics and quality of analgesia during 24 hours. The mean time for first demand of analgesia was 12.4 ±7.9 and 10.7±6.4 hrs in groups PCB and '3 in 1' respectively (p>0.05). Requirement of supplemental analgesics was considerably reduced and more than 80% patients in both groups needed only single injection of diclofenac in 24 hrs. It was concluded that both approaches of lumbar plexus block were effective in providing post operative analgesia after hip surgery.
Keywords: Lumbar plexus block, Psoas compartment block, "3 in1" block, Postoperative analgesia, Hip surgery
|How to cite this article:|
Srivastava U, Kumar A, Saxena S, Naz A, Goyal V, Mehrotra R. Lumbar plexus block for post-operative analgesia following hip surgery: A comparison of "3 in 1" and psoas compartment block. Indian J Anaesth 2007;51:127
|How to cite this URL:|
Srivastava U, Kumar A, Saxena S, Naz A, Goyal V, Mehrotra R. Lumbar plexus block for post-operative analgesia following hip surgery: A comparison of "3 in 1" and psoas compartment block. Indian J Anaesth [serial online] 2007 [cited 2019 Sep 18];51:127. Available from: http://www.ijaweb.org/text.asp?2007/51/2/127/61127
| Introduction|| |
Major lower limb surgery is often painful and requires aggressive management. Poorly treated pain can have negative impact on recovery especially owing to disruption in physiotherapy resulting in stiffness of joints and slow progress in mobility. Postoperative pain relief can be achieved by a variety of techniques including parenteral NSAIDS, epidural analgesia  and patient controlled IV analgesia with opioids , Peripheral nerve blocks are suitable substitutes for analgesia after lower limb surgery. The inguinal perivascular technique of lumber plexus block commonly known as "3 in 1" block has been shown to provide effective analgesia following hip  and knee surgery  . Few investigators have questioned its efficacy due to incomplete block of obturator nerve , which although mainly a motor nerve, gives some sensory branches to hip joint. The failure to achieve block of this nerve may cause incomplete analgesia after hip surgery. An alternative technique for lumbar plexus analgesia is psoas compartment block (PCB) which has been reported to be more effective in producing complete block  hence providing better analgesia after hip operations  . The present study was done to compare the efficacy of '3 in 1' block and psoas compartment block in relieving the post operative pain and facilitating physiotherapy in the patients operated for unilateral fracture hip under spinal anaesthesia.
| Material and methods|| |
After institutional approval and informed consent 44 patients of ASA grade I-III requiring trauma related elective surgery of hip were selected for this study. Diabetic patients or those with significant cardiovascular disease were excluded. The patients received 5 mg oral diazepam two hours before operation. Spinal anaesthesia was given with
2.5 - 3.0 ml heavy 0.5% bupivacaine at L2 - L3, or L3L4 interspace. Intravenous midazolam was used for intraoperative sedation in increments of 0.5 mg, if needed. Routine monitoring included heart rate, noninvasive blood pressure, ECG and peripheral oxygen saturation.
The patients were randomized to receive either '3 in 1' block (Group 3 in 1) or Psoas compartment block (Group PCB) at the end of the surgery. The '3 in 1' block was given using the technique described by Winnie et al (1973).  With patient in the supine position femoral artery was palpated below the inguinal ligament. A 3.5 cm, short bevel 23 gauge needle was advanced lateral to the artery in the cephalad direction till the paraesthesia was elicited or a 'double pop' was felt after piercing fascia iliaca and pectineal fascia, and 35-40 ml of 0.25% bupivacaine was injected after negative aspiration for blood. Distal pressure was applied with the thumb at the site of injection, to the femoral sheath for ten minutes, to facilitate proximal spread. Psoas compartment block was achieved by the technique described by Demise J Wedel in Millers Anaesthesia.  With the patient in lateral position, with the neck, back, hip flexed and the operative leg uppermost, a line was drawn to connect the iliac crests (intercristal line) identifying the 4th lumbar spine. A skin weal was raised 3 cm caudad and 5 cm lateral to the L4 spine on the side to be blocked. An 18 gauge Tuohy needle was then advanced perpendicular to the skin until it contacted the 5th lumbar transverse process. The needle was slightly withdrawn and redirected cephalad to walk off the transverse process. At this point, a 20 ml syringe filled with air was attached; the needle was slowly advanced until a loss of resistance was detected. This was psoas compartment and its depth was 5-7 cm from the skin. When the needle was in the psoas compartment, 20 ml of air was injected to distend the compartment and then 30-40 ml of 0.25% bupivacaine was injected slowly in increments of 5 ml after negative aspiration for blood.
In the postoperative period, on the first demand of analgesia, i.m. injection of diclofenac was given. If pain persisted, injection tramadol (100 mg) was given IV. The patients were assessed at 1, 6, 12 and 24 hours after operation regarding the pain at operative site using four point verbal rating scale (none, mild, moderate or severe) both at rest and during movement. The time of first analgesic, total doses of analgesics and any side effects were also recorded. The patients were also asked to rate their satisfaction of postoperative analgesia (excellent, good, or poor). To find the required study size, we conducted power analysis and calculated that atleast 20 patients per group should find a significant difference with 80% power. The data were summarized as mean± SD or median for both groups and were analyzed using two sample t test and Chi square test as required. A p value < 0.05 considered significant.
| Results|| |
Baseline patient characteristics were similar regarding age, sex, type and duration of operation [Table 1]. Verbal rating scale (VRS) for pain over 24 hrs at rest and mobilization are depicted in [Figure 1] and [Figure 2]. There was no difference in VRS in the two groups at all times of observation (p>0.05). Most of the patients experienced either no pain or only mild pain at 1, 6 and 12 hours after operation. At 24 hrs, 27% and 18% patients in groups PCB and "3 in 1" had moderate pain respectively, while none had severe pain [ Figure 1]. During first 12 hours after operation none of the patients in PCB group needed analgesics in first 12 hrs while three patients needed single injection of diclofenac in group "3 in 1" [Table 2]. Four patients did not require any analgesic in 24 hrs in PCB group [Table 2]. The median and mean times for the first demand of analgesia was thirteen and twelve hours, and 12.4+7.9 and 10.7+6.4 hours in PCB and '3 in 1' groups respectively (p>0.05). The 24 hours analgesic consumption was less& time for first analgesic was slightly longer in PCB group but the difference was not statistically significant [Table 2]. Physiotherapy, which included "quadriceps drill" and passive movement at knee were possible without causing pain in most of the patients. More than 90% of patients in both groups graded their analgesia as excellent or good.
| Discussion|| |
Peripheral nerve blocks improve analgesia and reduce the analgesic requirement after many orthopaedic surgeries. The results of the present study indicated that single shot lumbar plexus block, by both the techniques, was effective in providing prolonged postoperative analgesia and reducing the pain scores and requirement of supplemental analgesics during first 24 hrs. The duration of analgesia (time to first analgesic demand) was more or less similar in both the groups. Therefore we presumed that the block of all the major nerves of lumbar plexus supplying lower extremity including obturator nerve was achieved after 3 in 1 block also, contrary to previous reports. , The physiotherapy that included 'quadriceps drill' and passive movement at knee to prevent stiffness of joints could be initiated early because of absence of pain in both the groups.
Very few studies have examined the analgesic efficacy of single shot "3 in 1" or psoas compartment block following hip surgery. ,, Fournier et al (1998)  reported prolongation of post operative analgesia for 4-6 hrs following "3 in 1" block while Stevenes et al (2000) & Hevia-Sanchez (2002)  demonstrated effective analgesia for 10-12 hrs after PCB with subsequent reduction in consumption of rescue morphine. To further prolong the analgesia latter recommend continuous infusion through catheter. Although the use of continuous "3 in 1"& PCB is recommended by many authors, ,, it is a subject of debate  mainly due to chances of local anaesthetic toxicity, need for specialized equipment, technical expertise and need of postoperative monitoring.
Few previously published studies have compared the "3 in 1" and psoas compartment block for hip or knee surgery. , Kaloul et al (2004)  re ported equianalgesic effects of these blocks by continuous catheter technique after knee replacement surgery. Biboulet et al (2004)  compared the efficacy of single shot "3 in 1" and psoas compartment with that of I.V. PCA with morphine after total hip arthroplasty under general anaesthesia. They concluded that the blocks were effective only for first four hours postoperatively and thereafter no difference existed between the three groups regarding pain scores and morphine use.
Contrary to previous studies , we demonstrated longer duration of analgesia, even longer than the expected duration of bupivacaine. We postulated the long duration of analgesia in the present study to be due to summative effects of pre-emptive analgesic effect of spinal anaesthesia, prevention of spasm of quadriceps muscle due to plexus block and the analgesic action of I.M. diclofenac, which was given to majority of the patients.
The standard method of postoperative analgesia in our orthopaedic wards is prescription of parenteral diclofenac or tramadol at 'as and when required' basis and majority of the patients require 2-3 doses of I.M. analgesics. Although the analgesia was said to be 'satisfactory', physiotherapy could never be done on first postoperative day due to pain on movement. After both the above blocks physiotherapy was started on the day of operation.
In conclusion, single short lumbar plexus block by either of the techniques prolonged the duration of post operative analgesia and also facilitated early physiotherapy following hip surgery operated under spinal anaesthesia. There was no clinically significant difference between the '3 in 1' and psoas compartment block with respect to time of first analgesic, supplemental analgesics and intensity of pain at operative site at rest and during physiotherapy. [Figure 1] [Figure 2]
| References|| |
|1.||Singelyn F.J, Deyaert M, Pendeville E, Gouverneur NM. Effects of IV. Patient controlled analgesia with morphine, continuous epidural analgesia and continuous three in one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88-92. |
|2.||Spetzler B, Anderson L. Patient controlled analgesia in the total joint arthroplasty patients. Clin Orthop 1987; 215: 122-25. |
|3.||Singelyn FJ, Vanderelst PE, Gouverneur JA. Extended femoral nerve sheath block after total hip arthroplasty; continuous versus patient controlled techniques. Anesth Analg 2001; 92: 455-59. |
|4.||Ng. HP, Cheong KF, Lim A, Lim J, puhaindran ME. intraoperative single-shot "3 in 1" femoral nerve block with ropivacaine 0.25% ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr. analgesia after unilateral total knee replacement. Can J Anaesth 2001; 48: 1102-08. |
|5.||Lang S, Yip R, Chang P. The femoral 3 in 1 block revisited, J Clin Anaesth 1993; 5: 292-96. |
|6.||Tokat O, Turker YG, Uckunkaya N, Yilmazar A. A clinical comparisonof psoas compartment and inguinal Para vascular blocks combined with sciatic nerve block. J Int Med Res 2002; 30: 161-67. |
|7.||Capdevila X Macaire P, Dadure C, Choqnet O et al. Continuous psoas compartment block for post operative analgesia after total hip arthroplasty: New landmarks technical guidelines and clinical evaluation. Anesth Analg 2002; 94: 1606-16. |
|8.||Winnie A, Ramamurthy S, Durrani Z. The inguinal paravascular technique of lumbar plexus anaesthesia; the "3 in 1 block" Anesth Analg 1973; 52: 989-96. |
|9.||Wedel DL. Nerve blocks in Anaesthesia Ed. Ronald D Miller 5th ed. (vol-I) Churchill livingstone 2000: 1531. |
|10.||Fournier R, Van-Genel E, Gaggero G et al. Postoperative analgesia with "3 in 1" femoral nerve block after prosthetic hip surgery. Can J Anaesth 1998; 45: 34-38. |
|11.||Stevens RD, Van Gessel EV, Flory N et al. lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology 2002; 93: 115-21. |
|12.||Hevia-Sanchez V, Bermejo- Alvarez MA, Hevia - Mendoz A, Fervienza F et al posterior block of lumbar plexus for postoperative4 analgesia after hip arthroplasty. Rev. Esp. Anesthesiology Reanim. 2002; 49: 507-11. |
|13.||Pandin P.C. Vanderteen A, Hollander A. Lumbar plexus posterior approach A, Catheter placement description using electric nerve stimulation - Anesthesia& analgesia 2002, 95, 1428-31. |
|14.||Chudinov A, Berkenstadt H, Salai M Cahana A, Penel A; continuous psoas compartment block for anaesthesia and perioperative analgesia in patients with hip fractures, Reg. Anesth. Pain Med 1999; 24: 563-68. |
|15.||Kaloul I, Guay J, Cote C, Fallaha M. 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 Anaeth 2004; 51: 45-51. |
|16.||Biboulet P, Moran D, Aubas P. Bringuier-Brancheren, Capdevilax postoperative analgesia after total hip arthroplasty; comparison of I.V. Patient controlled analgesia with morphine and single injection of femoral nerve or psoas compartment block. A prospective randomized double blind study. Reg. Anesth. Pain Med 2004; 29: 102-09. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]