Advertisement

Editorial Commentary: Quadratus Lumborum Analgesia for Hip Arthroscopy: The New Kid on the (Nerve) Block

      Abstract

      Quadratus lumborum (QL) nerve block is a new technique aimed to improve perioperative analgesia for patients undergoing hip arthroscopy. The QL block targets nerve roots from the lumbar plexus supplying the hip and is an alternative to the fascia iliaca compartment block, which has been shown to have variable effects on pain control while increasing motor weakness and postoperative fall risk. Although a recent Level I study showed decreased opioid consumption without increased motor weakness after QL block compared to sham block, another Level I study reported contrasting results with QL block demonstrating no improvement in pain control or opioid consumption compared to a multimodal pain regime after hip arthroscopy. These differing conclusions from high-level studies indicate further research is needed for QL block and that investigation of other potential nerve block options for hip arthroscopy patients, such as the PENG block, is warranted.
      As the incidence of hip arthroscopy procedures in the United States approaches its peak,
      • Cevallos N.
      • Soriano K.K.J.
      • Flores S.E.
      • Wong S.E.
      • Lansdown D.A.
      • Zhang A.L.
      Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
      high-level research has led to best practice guidelines for surgical indications and technical considerations. However, protocols for perioperative analgesia remain inconsistent between institutions. Some surgeons prefer spinal analgesia but most will use a combination of general anesthesia with local analgesia. Local anesthetic may be administrated in multiple locations including intra-articularly, in the pericapsular space or in the form of a peripheral nerve block proximal to the hip joint.
      Fascia iliaca compartment block (FICB) is one of the most commonly studied peripheral nerve blocks for hip arthroscopy because this compartment houses the femoral, lateral femoral cutaneous, and obturator nerves.
      • Groot L.
      • Dijksman L.M.
      • Simons M.P.
      • Zwartsenburg M.M.
      • Rebel J.R.
      Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients.
      • Garner M.
      • Alshameeri Z.
      • Sardesai A.
      • Khanduja V.
      Arthroscopy. A Prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery.
      • Behrends M.
      • Yap E.N.
      • Zhang A.L.
      • et al.
      Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial.
      • Purcell R.L.
      • Brooks D.I.
      • Steelman T.J.
      • et al.
      Fascia iliaca blockade with the addition of liposomal bupivacaine versus plain bupivacaine for perioperative pain management during hip arthroscopy: a double-blinded prospective randomized control trial.
      Although FICB has been readily used for hip arthroscopy, Level I evidence studies have demonstrated limited efficacy as Garner et al.
      • Garner M.
      • Alshameeri Z.
      • Sardesai A.
      • Khanduja V.
      Arthroscopy. A Prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery.
      reported local anesthetic injection in the joint and along the portal tracks to be superior to FICB for pain control after surgery with significantly decreased patient pain scores and opioid requirement. Our institution performed a Level I, double-blinded randomized controlled trial comparing FICB with sham block and found no difference in opioid requirements or pain scores within 24 hours of surgery.
      • Behrends M.
      • Yap E.N.
      • Zhang A.L.
      • et al.
      Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial.
      Quadriceps strength was significantly decreased in the blocked group, and patients were 4 times more likely to suffer a postoperative fall after receiving FICB. As a result of these studies, our institution no longer performs FICB for hip arthroscopy surgery.
      A new alternative nerve block for the hip involves anesthetic injection of the quadratus lumborum that can yield analgesia spread from the T6 to L4 thoracolumbar nerve roots.
      • Ueshima H.
      • Otake H.
      • Lin J.A.
      Ultrasound-guided quadratus lumborum block: An updated review of anatomy and techniques.
      The anterior or transmuscular approach to the quadratus lumborum (QL) block is placed between the psoas and QL and may be most likely to cover the lumbar plexus and provide analgesia to the hip joint.
      • Carline L.
      • McLeod G.A.
      • Lamb C.
      A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks.
      In their study, "Preoperative Quadratus Lumborum Block Reduces Opioid Requirements in the Immediate Postoperative Period Following Hip Arthroscopy: A Randomized, Blinded Clinical Trial,” Wilson, George, Matos, Wilson, Johnson, and Woolf
      • Wilson S.H.
      • George R.M.
      • Matos J.R.
      • Wilson D.A.
      • Johnson W.J.
      • Woolf S K.
      Preoperative quadratus lumborum block reduces opioid requirements in the immediate postoperative period following hip arthroscopy: A randomized, blinded clinical trial.
      performed a randomized controlled trial comparing QL block to sham block in 46 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. The authors found decreased postoperative opioid consumption in the postanesthesia care unit (PACU) (28% less in the block group) but no differences in motor function between groups. Decreasing postoperative opioid consumption is a promising result for QL blocks but there are other recent studies that present differing conclusions. Haskins et al.
      • Haskins S.C.
      • Tseng A.
      • Zhong H.
      • et al.
      Anterior quadratus lumborum block does not provide superior pain control after hip arthroscopy: A double-blinded randomized controlled trial.
      performed a randomized controlled trial in 96 patients comparing QL block versus no block for hip arthroscopy in the setting of a standard multimodal postoperative analgesia program (IV acetaminophen and ketorolac). They found that QL block was not superior to multimodal analgesia alone for 24-hour post-operative pain scores or opioid consumption.
      • Haskins S.C.
      • Tseng A.
      • Zhong H.
      • et al.
      Anterior quadratus lumborum block does not provide superior pain control after hip arthroscopy: A double-blinded randomized controlled trial.
      As these are two Level I studies presenting contrary conclusions, the jury may still be out on QL blocks.
      At our institution, we performed a retrospective cohort study in 2018 with 68 hip arthroscopy patients to compare results in those who received pre-operative QL blocks to those who did not receive any blocks.
      • Kinjo S.
      • Kolodzie K.
      • Dong K.
      • Zhang A.L.
      The effects of transmuscular quadratus lumborum blocks on postoperative pain in arthroscopic hip surgery: A cohort analysis.
      We found no differences in perioperative opioid consumption, pain scores or PACU length of stay between the two cohorts. As a result of our experience, we do not routinely perform QL blocks for hip arthroscopy patients. Our current multimodal analgesia program includes routine local anesthetic injection into the intra-articular and peri-capsular space at the end of each case as well as IV ketorolac in the PACU. This regimen works well for the vast majority of our patients. However, for those who require more profound analgesia after hip arthroscopy, we are now studying another novel peripheral block called the pericapsular nerve group (PENG) block.
      • Giron-Arango L.
      • Peng P.W.H.
      • Chin K.J.
      • Brull R.
      • Perlas A.
      Pericapsular nerve group (PENG) block for hip fracture.
      The PENG block aims to anesthetize articular branches supplied by femoral, obturator, and accessory obturator nerves by blocking the myofascial plane of the psoas tendon and superior pubic ramus. This block may provide sufficient analgesia to the hip joint without affecting the motor function of the femoral nerve. We have seen firsthand excellent analgesia results without motor weakness in a case series of patients undergoing the PENG block for hip arthroscopy. This study was recently submitted for publication, but because there are currently no high-level studies assessing the PENG block, our institution aims to further analyze this promising new technique.
      In conclusion, differing results from high-level studies on the effectiveness of QL block for hip arthroscopy indicates that further research is needed and that there is need to investigate other potential peripheral nerve block options, such as the PENG block. Perhaps in the near future, we will be able to provide better evidence on which of these new kids on the (nerve) block is here to stay.

      Supplementary Data

      References

        • Cevallos N.
        • Soriano K.K.J.
        • Flores S.E.
        • Wong S.E.
        • Lansdown D.A.
        • Zhang A.L.
        Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
        Arthroscopy. 2021; 37: 3445-3454
        • Groot L.
        • Dijksman L.M.
        • Simons M.P.
        • Zwartsenburg M.M.
        • Rebel J.R.
        Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients.
        West J Emerg Med. 2015; 16: 1188-1193
        • Garner M.
        • Alshameeri Z.
        • Sardesai A.
        • Khanduja V.
        Arthroscopy. A Prospective randomized controlled trial comparing the efficacy of fascia iliaca compartment block versus local anesthetic infiltration after hip arthroscopic surgery.
        Arthroscopy. 2017; 33: 125-132
        • Behrends M.
        • Yap E.N.
        • Zhang A.L.
        • et al.
        Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial.
        Anesthesiology. 2018; 129: 536-543
        • Purcell R.L.
        • Brooks D.I.
        • Steelman T.J.
        • et al.
        Fascia iliaca blockade with the addition of liposomal bupivacaine versus plain bupivacaine for perioperative pain management during hip arthroscopy: a double-blinded prospective randomized control trial.
        Arthroscopy. 2019; 35: 2608-2616
        • Ueshima H.
        • Otake H.
        • Lin J.A.
        Ultrasound-guided quadratus lumborum block: An updated review of anatomy and techniques.
        Biomed Res Int. 2017; 2017: 2752876
        • Carline L.
        • McLeod G.A.
        • Lamb C.
        A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks.
        Br J Anaesth. 2016; 117: 387-394
        • Wilson S.H.
        • George R.M.
        • Matos J.R.
        • Wilson D.A.
        • Johnson W.J.
        • Woolf S K.
        Preoperative quadratus lumborum block reduces opioid requirements in the immediate postoperative period following hip arthroscopy: A randomized, blinded clinical trial.
        Arthroscopy. 2022; 38: 808-815
        • Haskins S.C.
        • Tseng A.
        • Zhong H.
        • et al.
        Anterior quadratus lumborum block does not provide superior pain control after hip arthroscopy: A double-blinded randomized controlled trial.
        Anesthesiology. 2021; 135: 433-441
        • Kinjo S.
        • Kolodzie K.
        • Dong K.
        • Zhang A.L.
        The effects of transmuscular quadratus lumborum blocks on postoperative pain in arthroscopic hip surgery: A cohort analysis.
        J Anesth. 2019; 33: 516-522
        • Giron-Arango L.
        • Peng P.W.H.
        • Chin K.J.
        • Brull R.
        • Perlas A.
        Pericapsular nerve group (PENG) block for hip fracture.
        Reg Anesth Pain Med. 2018; 43: 859-863