Lumbar erector spinae plane block for total hip arthroplasty analgesia. Case report

ABSTRACT

BACKGROUND AND OBJECTIVES:

Total hip replacement surgeries may result in intense postoperative pain. There are many analgesia techniques available in clinical practice and lumbar erector spine plane (LESP) block may be an option of an effective technique with milder adverse effects and easier execution.

CASE REPORT:

Female patient, 23-year-old, allergic to morphine and tramadol, underwent a total left hip arthroplasty under mild sedation, no opioid spinal anesthesia and ultrasound guided LESP. After the surgery the patient’s pain was under control, and methadone rescue analgesia was not used.

CONCLUSION:

LESP block is easy to perform and may be effective for postoperative analgesia in hip surgeries, with fewer adverse effects than other techniques.

Keywords:
Analgesia; Anesthesia conduction; Arthroplasty replacement hip

RESUMO

JUSTIFICATIVA E OBJETIVOS:

Artroplastia total de quadril pode evoluir com dor pós-operatória intensa. Há várias técnicas disponíveis na prática clínica para analgesia. O bloqueio do plano eretor da espinha lombar (LESP block) pode ser uma opção efetiva, de fácil execução e efeitos adversos mais leves.

RELATO DO CASO:

Paciente do sexo feminino, 23 anos, alérgica a morfina e tramadol, submetida à artroplastia total de quadril sob sedação leve, anestesia subaracnóidea sem opioides e LESP block guiado por ultrassonografia. Evoluiu com controle de dor efetivo, sem uso de metadona de resgate.

CONCLUSÃO:

LESP block é fácil de ser executado, pode ser efetivo para analgesia pós-operatória de cirurgias de quadril e apresenta menos efeitos adversos que outras técnicas.

Descritores:
Analgesia; Anestesia regional; Artroplastia de quadril

INTRODUCTION

Hip arthroplasty is a very common surgery and has high postoperative pain potential. There are different ways to execute postoperative analgesia and each of them has advantages and disadvantages¹. As the patients submitted to this procedure are usually older and with multiple comorbidities, analgesia options with better profile of adverse effects should be preferred. Peripheral nerve block with long-acting local anesthetics is very suitable in this situation, in comparison with systemic or neuraxial opioids.

Erector spinae plane block (ESP block) was first described for the treatment of neuropathic chest pain, in which local anesthetic is injected between the spinal erector muscle and the transverse process at T5 level. The analgesic effect is based on its spread to the anterior paravertebral space, thoracic nerve root and its branches, and even epidural space^2-4. If this anatomical mechanism also exists for the lumbar region, a lumbar ESP (LESP) block local anesthetic may spread to lumbar paravertebral space and lumbar nerve roots, reaching the nerves responsible for the innervation of the hip joint lumbar plexus nerves - femoral, obturator and lateral femoral cutaneous nerves - providing analgesia for hip surgery. LESP block can be a block easier to perform than other options for hip surgery analgesia, such as posterior lumbar plexus. Some case reports, case series and small clinical trials already demonstrated this^5-9.

This case report describes the first postoperative day evolution of a total hip replacement undergone with an associated LESP block as postoperative analgesia option in a patient allergic to morphine and tramadol.

CASE REPORT

Female patient, 23-year-old with systemic lupus erythematosus and systemic arterial hypertension, under usage of prednisone (5mg/day), weighting 63kg, allergic to morphine and tramadol, who underwent an anterior total left hip arthroplasty. The patient was monitored with electrocardiogram, non-invasive blood pressure and pulse oximeter. A spinal anesthesia was performed, in sitting position, with a 27G needle, puncture level L3-L4, with 20mg of 0.5% isobaric bupivacaine, without spinal opioid, under mild intravenous sedation with midazolam (2mg) and fentanyl (50µg). Sedation during the procedure was maintained with propofol of 1% TCI mode, adjusted between 1.2 and 1.6µg/mL. Because the patient had history of allergy to morphine and tramadol, her postoperative (PO) analgesia would be very limited in terms of systemic agents. So, at the end of the procedure, an ultrasound guided LESP block was performed with the patient positioned in right lateral decubitus, identification of L4 left transverse process with longitudinal positioned curvilinear probe (5-2 MHz), followed by in-plane insertion of 100mm 20G needle, from cephalad to caudal direction, and injection of 30mL of 0.5% ropivacaine after negative aspiration at the plane between L4 transverse process and erector spine muscle (Figure 1).

Figure 1
Lumbar ultrasound anatomy

GD = Latissimus Dorsi muscle; ES = erector spinae muscles, L3, L4 and L5: 3rd, 4th and 5th lumbar vertebrae transverse process, respectively; S1 = sacrum; LA = local anesthetic.

Postoperative analgesic prescription was: IV dipyrone 2g QID, PO ibuprofen 600mg BID, IV methadone 3mg PRN in case of pain, maximum of four times a day. Patient had no pain for the first nine hours after the blockade. Numerical verbal scale (NVS) for most intense pain was referred as 6/10 at that moment, although the patient asked for no rescue analgesics. After 24 hours of blockade, the patient had no pain at rest and had mild pain (NVS=3/10) when making movements. No methadone request.

DISCUSSION

Since 1960 total hip arthroplasty has become one of the most frequent surgeries in the world, improving quality of life of patients with osteoarthritis, rheumatoid arthritis and proximal femur fractures. However, it is a surgery with high postoperative pain potential. Patients undergoing this type of surgery are usually older, with multiple comorbidities^{(10, 11)}, more sensitive to adverse effects of systemic analgesic drugs and, because pain may lead to decreased mobility, the risk of thromboembolic complications is increased. In this scenario, analgesic alternatives with good efficacy and milder adverse effects are a benefit.

There are many options for postoperative analgesia for total hip arthroplasty, such as spinal morphine; femoral, obturator and lateral femoral cutaneous nerve block; lumbar plexus block; continuous epidural block; and fascia iliaca block. Intrathecal morphine has some adverse effects: pruritus, urinary retention, nausea and vomiting. The fascia iliaca block may be accompanied by partial failure. Blockade of femoral, obturator, and lateral femoral cutaneous nerves requires 3 injections and a larger volume of local anesthetic. The epidural technique allows the use of epidural catheter with or without a patient-controlled analgesia (PCA), but it may lead to hypotension in fragile patients, and may be limited by concomitant use of anticoagulant medications. Lumbar plexus block is a deep block, with greater risk of complications such as retroperitoneal hematoma, deep bleeding, of greater technical difficulty, and erratic local anesthetic spread^1,10-13.

The LESP block emerged based on the same principle as the thoracic ESP block. Some case reports, case series and small clinical trials already demonstrated its application in hip surgery^5-9.

Although some studies demonstrated a clinical effect of LESP block, and some of them showed the possible mechanism of action of the anterior spread reaching the anterior rami of lumbar nerve roots through imaging exams, this data must be reinforced by cadaveric anatomical studies and larger clinical trials.

LESP block has potential advantages: facility to perform, low risk of nerve damage and safety in patients with coagulopathies or on anticoagulants. In 2019 study¹⁴ evaluated retrospectively 308 patients submitted to LESP block. Only one patient experienced motor weakness. A total of 4 patients had suspicious minor neurological findings related to local anesthesia toxicity. No major neurological or minor/major cardiological findings were observed. No complications such as nerve damage or organ damage were observed. A complete epidural block below the T12 level was determined in a patient with a history of spinal surgery after unilateral LESP block. Priapism following LESP block, lower extremity motor weakness following lower thoracic ESP block, and total motor block after lumbar procedures have also been reported.

A study reinforced the efficacy of LESP block as the main anesthetic technique used for hemioarthroplasty or intramedullary nailing-long surgeries in high-risk patients who suffered of hip fracture. All patients had their surgeries completed with no need of local anesthesia infiltration, spinal or general anesthesia⁵.

It’s necessary to highlight the limitations of this study. This is a case report, a single patient description of the outcome, with no comparative patient or group. Conclusions cannot be made based on a single case description. Although strong opioids were not used for postoperative pain management in this case, the patient received analgesic agents in postoperative pain. It’s not possible to conclude that the performed block had any analgesic effect, however, it is of common knowledge that this type of surgery may be accompanied by moderate to severe pain when no long-acting regional block or neuraxial opioid is used. That fact corroborates the published studies in this subject: it raises the hypothesis that LESP block may offer effective postoperative analgesia for hip surgeries. However, larger anatomic studies are needed in order to reach an explanation on how LESP block may work, as well as randomized clinical trials, in order to assess its clinical effect.

CONCLUSION

In this case report, after 24 hours of blockade, the patient had no pain at rest and had mild pain during movements, without methadone request. Considering that LESP block is easy to perform and may be effective for postoperative analgesia in hip surgeries, with fewer adverse effects than other techniques, it’s feasible to use it in specific cases.

• Sponsoring sources: none.

ACKNOWLEDGMENTS

The authors would like to think the Orthopedics team for accepting this option for postoperative analgesia in such a specific case.

REFERENCES

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Publication Dates

• Publication in this collection
  26 Apr 2021
• Date of issue
  Jan-Mar 2021

History

• Received
  28 Dec 2020
• Accepted
  08 Feb 2021