With increased opioid use in the United States, more patients are presenting for elective surgery with a history of opioid tolerance. This can pose significant challenges in the treatment of postoperative pain, making regional anesthesia techniques an invaluable therapeutic tool whenever feasible. As ultrasound-guided nerve blocks become increasingly favored over older, surface landmark-based methods, new and more reliable approaches to regional analgesia have become achievable through knowledge of ultrasound anatomy. Furthermore, the present day has seen metrics reflecting patient satisfaction being more frequently used as comparators between hospitals and providers, adding urgency to the need for safe and effective interventions for controlling postoperative pain. In 2010, there were 310,800 total hip arthroplasties (THAs) performed in the United States.1 These patients often present with chronic pain and a history of substantial opioid use, and postoperative analgesia in this population may prove particularly difficult. Following the CARE Guidelines,2 and after attaining written consent from the patient, we present a case illustrating the novel and successful application of a variant of the transversus abdominis regional anesthetic technique, the continuous quadratus lumborum block (QLB), in achieving excellent postoperative analgesia after THA in a patient with chronic pain and opioid use.
Patient A is a 69-year-old man with a history of hypertension, gout, gastroesophageal reflux disease, chronic low back pain, and right hip pain. He had baseline 4 of 5 motor strength in the right hip, and he ambulated with crutches. He presented to our facility for primary right THA through a posterior approach. His home pain medication regimen consisted of ibuprofen and oral oxycodone with a typical daily intake between 5 and 20 mg as needed. Given his history of chronic pain and opioid use, we felt that the patient would benefit from either a lumbar epidural or a peripheral nerve catheter for postoperative pain. The patient gave consent for nerve catheter placement and strongly echoed our view that it was a priority for him to be able to ambulate early in the postoperative course. Rather than opting for a lumbar epidural, lumbar plexus catheter, or femoral nerve block technique, which can all result in significant motor weakness, we elected to place a quadratus lumborum catheter. A single injection of local anesthetic through this approach was recently shown to improve pain after femoral neck fracture and hip hemiarthroplasty.3
Preoperatively, the patient received an oral multimodal analgesic regimen of 1 g acetaminophen, 200 mg celecoxib, 600 mg gabapentin, and 10 mg dexamethasone IV. After obtaining consent, we placed the patient in a left lateral decubitus position and prepared the site with chlorhexidine solution and a sterile drape. The skin correlating to the Triangle of Petit, a muscular landmark of the lateral lumbar back region bounded by the latissimus dorsi, external oblique, and iliac crest, was infiltrated superficially with 1% lidocaine. A SonoSite© S-Nerve (SonoSite Inc., Bothell, WA) ultrasound machine was used to scan the site through a SonoSite© linear transducer HFL38x (13–6 MHz; SonoSite Inc.). After visualizing the internal oblique muscles and its anterior relationship to the border of quadratus lumborum muscle, an Arrow© 17 Ga. × 3 ½ Tuohy needle (Teleflex, Research Triangle Park, NC) was directed under ultrasound guidance to our target (Figure 1). The posterior border of the quadratus lumborum was infiltrated with saline to create space for the catheter, and an echogenic Arrow 19G Flex-Tip plus catheter was threaded to a depth of 18 cm at the level of the skin and then secured with a transparent dressing and tape. The patient received 15 mL of 0.5% lidocaine through the catheter. After 10 minutes, he achieved a unilateral sensory level on the right of T10 to L2 based on decreased temperature sensation to ice. In the surgical suite, the patient underwent induction of general anesthesia and placement of an endotracheal tube with 200 μg fentanyl IV, 200 mg propofol IV, and 120 mg succinylcholine IV. General anesthesia was maintained with 1.9% sevoflurane, and after return of twitches, 7 mg cisatracurium IV was administered. Surgical time was 152 minutes, during which he received 0.2 mg hydromorphone IV. The patient received another 1 mg hydromorphone IV in the recovery unit, where a continuous infusion of 0.2% ropivacaine at 7 mL/h was initiated through the catheter.
Once on the ward, 0.2% ropivacaine solution continued to be infused at a rate of 7 mL/h through the quadratus lumborum catheter. In our institution, most patients who undergo THA are placed on either oral oxycodone or oral hydromorphone for postoperative pain control with the option of receiving IV hydromorphone for breakthrough pain. Because our patient was previously on oral oxycodone at home, we chose this opioid over oral hydromorphone. On postoperative day (POD) 0, the patient used 5 mg oxycodone. On POD 1, he required 25 mg oxycodone, and on POD 2, he required 20 mg oxycodone. In addition, the patient continued to take 600 mg gabapentin orally at bedtime and 650 mg oral acetaminophen every 6 hours during his hospital stay. He never requested or received IV opioid for breakthrough pain while the nerve catheter was infused and rated his pain as a 1 to 3 based on visual analog scale at rest on POD 1 and 2. The patient was able to ambulate with a walker on POD 1 and reported pain of 0 to 2/10 during physical therapy. The catheter infusion was stopped on POD 2 in anticipation of discharge from the hospital. The patient did not evidence any motor weakness while ropivacaine was being infused. He reported a high degree of satisfaction with his pain control, as evidenced by his verbal report of happiness and satisfaction to the anesthesia acute pain service on both POD 1 and 2. The patient was discharged to a short-term rehabilitation facility uneventfully, continuing the aforementioned oral regimen.
To the best of our knowledge, we are the first to describe a continuous QLB for postoperative analgesia in primary THA. Also referred to as a posterior transversus abdominis plane (TAP) block, the QLB is achieved through deposition of local anesthetic on either the anterolateral or the posterior border of the quadratus lumborum muscle. Blanco and McDonnell4 described the anterolateral QLB approach in 2007 and the posterior border QLB approach in 2012. By using magnetic resonance imaging dye studies, they observed paravertebral spread with either approach to QLB.4 However, they noted that the spread of dye to the paravertebral space was more predictable when the posterior border of the quadratus lumborum muscle was targeted.4 Carney et al.5 found that after a landmark-guided TAP block through the Triangle of Petit, the injection solution tracked along the anterior and lateral border of the quadratus lumborum and that this correlated to contrast enhancement from T10 to T11 and as low as L2 in the paravertebral space in subjects. The ultrasound-guided posterior approach we took to the TAP block correlated anatomically with a needle entrance through the lumbar Triangle of Petit, and by threading our catheter at the posterior border of the quadratus lumborum muscle, we could achieve paravertebral local anesthetic spread from T10 to L2. We presumed that this would result in analgesia over the area of surgical incision, through anesthetization of the cutaneous branches of the 12th thoracic nerve, iliohypogastric nerve, and lateral femoral cutaneous nerve.
Our postprocedure examination confirmed a sensory level of T10 to L2, corresponding well with the actual site of incision. Furthermore, our patient did not exhibit lower extremity weakness above his baseline, which allowed him to complete his physical therapy while reducing fall risk. The obturator nerve, which is formed from the nerve roots of L2 to L4 and provides sensory innervation to the hip, could also have been at least partially anesthetized in our patient secondary to local anesthetic paravertebral spread at L2. In addition, because the femoral and sciatic nerves were spared, the patient did not demonstrate weakness after the QLB was placed.
A recent high-quality systematic review by Højer Karlsen et al.6 concluded that there is still not a “best proven intervention” for THA analgesia. Regional anesthesia techniques traditionally used for THA include a lumbar epidural, femoral nerve block, fascia iliaca block, obturator nerve block, or lumbar plexus block.6 Despite providing partial analgesia, the aforementioned blocks can result in lower extremity motor weakness and thus may impede physical therapy or increase the risk of falls.7,8 Because of the risk of inadvertent epidural spread of a lumbar plexus block, some have recommended that this technique not be used in THA.9,10 Ardon et al.11 recently reported the use of T12, L1, and L2 single-shot paravertebral blockade for analgesia after THA with an anterior approach. In their study, there was no reported motor weakness by the evening of POD 0 with the majority of their patients ambulating on POD 1.11 This study was limited by the fact that it is noncomparative and retrospective. However, their technique shows promise as an alternative for postoperative analgesia in this population. In an era of ultrasound-guided techniques, the dilemma with the lumbar paravertebral block is its landmark-based approach, blind with respect to the internal anatomy; and a literature search did not reveal a description of an ultrasound-guided technique.
There have been 2 case reports describing an ultrasound-guided continuous QLB for postoperative analgesia in abdominal surgery.12,13 Recently, Parras and Blanco3 performed a randomized trial comparing single-shot QLB with femoral nerve block for postoperative analgesia in patients with femoral neck fracture undergoing hip hemiarthroplasty. They found that patients had significantly less pain and required less opioids when they received the QLB compared with the femoral nerve block.3 A 2009 randomized controlled trial found that patients receiving a continuous femoral nerve block for THA had an average requirement of 8 mg hydromorphone IV in the first 48 hours, which equates to approximately 160 mg of oral morphine equivalents.14,15 In that same study, those receiving a continuous lumbar plexus block for THA required an average of 5.7 mg IV hydromorphone in the first 48 hours, which equates to approximately 114 mg oral morphine equivalents.14,15 Our patient required 50 mg oral oxycodone, which is 75 mg of oral morphine equivalents, in the first 48 hours that the QLB infused, much less than is required for other nerve blocks for the same surgery.
Although further studies are needed to evaluate the benefit and safety of this technique, there have been no reported complications of the QLB. Unlike the lumbar plexus block, which is usually performed blindly, the quadratus lumborum muscle can be visualized easily under ultrasound, because it is usually only 3 to 4 cm deep (Figure 2). As indicated by the letter “P” in Figure 2, the peritoneum is located underneath the transversus abdominis muscle, and with careful attention, accidental visceral puncture is easily avoided. By placing this block under direct needle visualization, threading an echogenic catheter, and visualizing the spread of local anesthetic, one can also avoid inadvertent peritoneal placement of the catheter. Furthermore, with the quadratus lumborum approach used in our case, the needle remains at a safe distance from the epidural space and retroperitoneal structures.
Our patient had a history of chronic pain and significant opioid use, presenting us with the challenge of adequately managing his pain while achieving a goal of early ambulation with minimal interruption of motor function. Placement of a quadratus lumborum catheter enabled us to achieve excellent pain control without requirement for IV opioid as an adjunct. He did not experience motor weakness above baseline and had a high level of satisfaction with his pain management in recovery. The use of a quadratus lumborum catheter for postoperative analgesia after THA is a promising technique that merits further study, potentially offering several advantages over other regional techniques that have been used for this indication.
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