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Table of Contents  
Year : 2018  |  Volume : 12  |  Issue : 4  |  Page : 825-831  

Comparison of ultrasound-guided lumbar erector spinae plane block and transmuscular quadratus lumborum block for postoperative analgesia in hip and proximal femur surgery: A prospective randomized feasibility study

1 Department of Anesthesiology and Reanimation, Maltepe University Faculty of Medicine, Istanbul, Turkey
2 Department of Anesthesiology and Reanimation, Maltepe State Hospital, Istanbul, Turkey
3 Department of Medical Education, Maltepe University Faculty of Medicine, Istanbul, Turkey
4 Department of Orthopedic and Trauma Surgery, Maltepe University Faculty of Medicine, Istanbul, Turkey

Date of Web Publication18-Dec-2018

Correspondence Address:
Dr. Serkan Tulgar
Maltepe Universitesi Hastanesi, Feyzullah Caddesi No: 39 Maltepe, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_142_18

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Study Objective: Lumbar Erector spinae Plane block (L-ESPB) is a modification of a recently described block. Both L-ESPB and Transmuscular Quadratus Lumborum block (QLB-T) have been reported to provide effective postoperative analgesia in hip and proximal femur surgery. Herein, we compare the effectiveness of L-ESPB and QLB-T in providing postoperative analgesia in patients undergoing hip and femur operations. Design: Double-blinded, prospective, randomized, feasibility study. Setting: Tertiary university hospital, postoperative recovery room and ward. Methodology: A total of 72 patients (American Society of Anesthesiology physical status classification II-III) were recruited. After exclusion, 60 patients were allocated to three equal groups (control, L-ESB and QLB-t). Interventions: Standard multimodal analgesia was performed in the control group while L-ESPB or QLB-T was performed in the block groups. Measurements: Pain intensity between groups was compared using Numeric Rating Scores. Furthermore, tramadol consumption and additional rescue analgesic requirement was measured. Results: There was no difference between demographic data or type of surgery. While there was no difference in Numeric Rating Scale (NRS) score at any hour between the block groups; NRS scores at the 1st, 3rd and 6th h, tramadol consumption during the first 12 h and total tramadol consumption, the number of patient required rescue analgesic in 24 h were significantly higher in the control group compared to both block groups. Conclusion: While L-ESPB and QLB-T have similar effect, they improve analgesia quality in patients undergoing hip and proximal femoral surgery when compared to standard intravenous analgesia regimen.

Keywords: Erector spinae plane block, hip surgery, quadratus lumborum block

How to cite this article:
Tulgar S, Kose HC, Selvi O, Senturk O, Thomas DT, Ermis MN, Ozer Z. Comparison of ultrasound-guided lumbar erector spinae plane block and transmuscular quadratus lumborum block for postoperative analgesia in hip and proximal femur surgery: A prospective randomized feasibility study. Anesth Essays Res 2018;12:825-31

How to cite this URL:
Tulgar S, Kose HC, Selvi O, Senturk O, Thomas DT, Ermis MN, Ozer Z. Comparison of ultrasound-guided lumbar erector spinae plane block and transmuscular quadratus lumborum block for postoperative analgesia in hip and proximal femur surgery: A prospective randomized feasibility study. Anesth Essays Res [serial online] 2018 [cited 2019 Jun 18];12:825-31. Available from:

   Introduction Top

Orthopedic operations such as hip and femur fractures can lead to significant postoperative pain.[1] In these patients, different regional anesthesia techniques play an important role in multimodal analgesia plans. Nonopioid analgesia techniques are especially important in aging populations when comorbidities are considered.[2]

Erector Spinae Plane block (ESPB), first described by Forero et al.,[3] for analgesia in thoracic neuropathic pain has also been reported for the management of other causes of acute and postoperative pain.[4],[5],[6] In this ultrasound-guided (USG) technique, local anesthetic (LA) is applied between the erector spinae muscle and the transverse process of the thoracic vertebra leading to spread of LA cephalad, caudally and through the paravertebral space.[3],[4],[7]

This study was presented at the Best Free Papers session of 37th ESRA (European Society of Regional Anesthesia) Congress 2018, Dublin, Ireland.

Effective use of thoracic ESPB for postoperative analgesia has been reported in breast surgery and thoracic surgery. In addition, ESPB provides effective postoperative analgesia in upper abdominal surgery when performed at thoracic vertebra 8–9 level.[7],[8],[9],[10],[11] Forero et al. reported the use of ESPB for the treatment of chronic shoulder pain when applied at Th 2–3 vertebra level.[12] Despite many reports regarding the use of ESPB for various surgical procedures, there is only one case report and one case series in literature, in which ESPB performed at the 4th lumbar vertebra level, leading to effective postoperative analgesia in a patients undergoing hip and proximal femoral surgery.[13],[14]

Transmuscular Quadratus Lumborum Block (QLB-t) is also a recently described and widely used regional anesthesia technique. It has been reported for use in postoperative analgesia of hip surgery in any age group.[15],[16],[17]

In this study, we aimed to compare the postoperative analgesic effect of USG QLB-t and Lumbar ESPB (L-ESPB) in patients undergoing hip and proximal femur surgery.

   Methodology Top

Study design

This study was designed to be a randomized, double-blinded, prospective efficiency study. Written informed consent was obtained from all patients who were included in this study. Institutional Review Board approved the study and it was registered at clinicaltrials. gov (Registration No: NCT03508544).

Patients were recruited for the study between April 2018 and June 2018. CONSORT checklist was used for enrolment and allocation of patients and is shown in [Figure 1].
Figure 1: CONSORT diagram of study

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Patients undergoing hip or proximal femoral surgery under general anesthesia, aged between 18-65 years with the American Society of Anesthesiology physical status classification score (ASA) I-III were included in the study. Exclusion criteria were as follows: refusal at enrolment, request for removal from the study, inability to give informed consent, the presence of contraindications to LA agents used in this study, known solid organ diseases, pathologies of medication use leading to bleeding diathesis, chronic use of opioids or corticosteroids, condition leading to inability to operate patient-controlled analgesia (PCA) system and psychiatric disorders. For better standardization of data, surgical procedures lasting <60 min or >180 min were also excluded from the study.

Study and control groups

Three groups were present in the study: L-ESPB group, QLB-t group and the control group in which no block was performed. Each group consisted of 20 patients each. Patients were assigned a random identification number before surgery and all data was collected using this identification number. Group assignments were determined using simple randomization using the sealed envelope technique. All data were collected blindly. Blocks were performed by the authors (ST or O. Senturk) who did not play any role in data collection or analysis.

General anesthesia management

All patients received the same anesthesia and analgesia protocol. All subjects were premedicated with intravenous midazolam 0.03 mg/kg, and received antibiotic prophylaxis, according to the hospital's protocol. Induction was performed using propofol 2-3 mg/kg, fentanyl 100 μg and rocuronium bromide 0.6 mg/kg. 0.6 MAC sevoflurane and 0.08 mg/kg/min remifentanil infusion was used for anesthesia maintenance. Remifentanil dosage was adjusted according to hemodynamic parameters.

Standard analgesia protocol

Our perioperative intravenous analgesia protocol includes paracetamol 1 gr, tenoxicam 20 mg, and morphine 0.05 mg/kg. All patients are followed using a standardized postoperative analgesia protocol which includes IV paracetamol every 8 h and tramadol PCA. PCA is commenced when the patient arrives at the recovery room (RR). During follow-up of 60 min in the RR, 25 μg fentanyl is administered if numeric rating scale (NRS) ≥4/10. The dosage is repeated every 30 min if NRS >4/10. Paracetamol 1 gr per 8 h is given during ward follow-up. For rescue analgesia during 1–24 h, intramuscular diclofenac sodium 75 mg was administered if NRS ≥4.

Ultrasound guided blocks

All blocks were performed under general anesthesia in the lateral position under sterile conditions before the commencement of the surgical procedure. All blocks were performed under ultrasonographic guidance using a convex ultrasound transducer (Mindray DP 9900 plus; Mindray Bio-Medical Electronics, Shenzhen, China).

Lumbar erector spinae plane block

The 4th lumbar vertebral level was determined using the conventional method (imaginary line between two crista iliacas). The convex USG transducer was placed at the mid-vertebral line in the sagittal plane. The transducer was shifted from the midline, 3.5–4 cm laterally to the side of the surgery to visualize the erector spinae muscle and transverse process. Using the out-plane technique a 22G/80-mm block needle (Stimuplex A, Braun, Melsungen, Germany) was advanced until it reached the transverse process. 0.5–1 ml of the prepared LA solution (20 ml bupivacaine 0.5%, 10 ml lidocaine 2%, 10 ml normal saline was administered leading to hydrodissection to confirm correct location. The needle was repositioned by pulling back a few millimeters if resistance occurred when administering local anesthesia. All LA was administered to this location between the transverse process and the erector spinae muscle [Figure 2]d, [Figure 2]e, [Figure 2]f.
Figure 2: (a-c) Performing of QLB-t, (d-f) Performing of L-ESPB, QLM: Quadratus Lumborum muscle, PM: Psoas muscle, ESM: Erector spinae muscles, L4: Transvers process of 4th lumbar vertebra, L5: Transvers process of 5th lumbar vertebra, Sc: Sacrum, Yellow arrow: injection point, Black arrows: Spread are of local anesthetics

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Transmuscular quadratus lumborum block

A convex transducer was placed in the transverse plane on the flank of the patient cranial to the iliac crest. The 4th lumbar vertebral transverse process, erector spinae muscles, psoas muscle, transverse abdominis muscle, internal and external oblique muscles, and the quadratus lumborum muscle were identified. A 15 cm 22G insulated needle was inserted on the posterior corner of the convex transducer. A volume of 40 ml of LA (20 ml bupivacaine 0.5%, 10 ml lidocaine 2%, and 10 ml normal saline was administered between the quadratus lumborum and psoas muscles into the fascial plane. We observed the LA compressing the psoas muscle by the ultrasound image [Figure 2]a, [Figure 2]b, [Figure 2]c.

Control group

Patients underwent the same surgical procedures but received no block. The same preoperative and postoperative analgesia protocols were performed in this group.

Evaluation of pain

The NRS was used to evaluate postoperative pain. The NRS is a segmented numeric version of the visual analog scale (VAS) in which a respondent selects a whole number (0–10 integers) that best reflects the intensity of his/her pain. It is considered a unidimensional measure of pain intensity in adults. The 11-point numeric scale ranges from “0” representing one pain extreme (“no pain”) to “10” representing the other pain extreme (“pain as bad as you can imagine” or “worst pain imaginable”). NRS pain score was evaluated at the 30th min and 1st, 3rd, 6th, 9th, 12th, 15th, 18th, 21st, and 24th h.

Outcome measures

Primary outcome measures were postoperative NRS pain score at 30th min, and 1st, 3rd, 6th, 12th, 15th, 18th, 21st, and 24th h both at rest. Secondary outcome measures were analgesic requirement including tramadol consumption administered by PCA and/or rescue analgesic use within the first 24 h.

In addition to the above measures, the presence of postoperative nausea and vomiting was noted. The severity of both nausea and sedation was assessed by patients on a 4-point scale (none, mild, moderate, and severe). Nurses noted any vomiting in the RR or on the ward. Finally, the number of patients receiving ondansetron was recorded.

Sample size

There are no previous clinical studies on the effects on postoperative analgesia for L-ESPB or QLB-t. As we expected the effect of perioperative analgesia to decrease by the 3rd h at which time the effect of the block would be more discenable, we considered a reduction of the NRS pain score by 2 or more at 3rd h to be statistically significant, with standard deviation (SD) of 1.76, when compared to the control group. Sample size calculation with a power of 0.80, a significance level of 0.05, the effect size of 0.5 with three groups for Analysis of variance (ANOVA) revealed a sample size for each group of 14 patients. Considering these calculations and drop-outs, the study was designed to have 20 patients in each group.

Statistical analysis

SPSS 16.0 Statistical package program (SPSS, Chicago, IL, USA) was used for statistical analysis. All analysis was performed by an author (D.T. Thomas) who was blinded to the study. Descriptive statistics were expressed as mean ± SD. The univariate analysis compared in groups means using a two-sample, independent t-test assuming equal variances for continuous variables. For data without normal distribution, Mann–Whitney U-test was performed. Ratios were compared using Chi-Square test. Categorical variables were compared using the Fisher's exact test. Continuous variables were tested for normality via the Shapiro–Wilk test. One-way ANOVA was used to compare average NRS scores and tramadol consumption between groups. Post hoc Tukey analysis was performed to determine differences between groups, when ANOVA revealed a significant difference.

A P < 0.05 was considered statistically significant. For NRS scores, Bonferroni correction was applied, and statistical significance was accepted as P < 0.005, for measurements from 10-time points. NRS was also analyzed using repeated measures analysis.

   Results Top

Inclusion and exclusion criteria are shown in the CONSORT diagram of the study [Figure 1] Hip or proximal femur surgery was performed in 72 patients of which all were ASA II or III. Seven patients were excluded for utilization of spinal or combined spinal-epidural anesthesia, four patients were excluded for neurological pathologies such as dementia and Alzheimer's disease and one patient was excluded for routine opioid use. Age and gender distributions, type, and duration of surgery are shown in [Table 1]. There was no statistically significant difference between the three groups regarding these parameters.
Table 1: Demographics and surgical information of study subjects, according to groups

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All procedures were completed uneventfully and no complications due to L-ESPB, QLB-t or general anesthesia were observed. Nausea was observed in four patients in the control group, and two patients in each group for L-ESPB and QLB-t groups. Nausea requiring ondansetron was seen in only 1 patient in the control group.

When 24 h average NRS scores were compared between groups, no statistically significant difference was found (P > 0.05). Average NRS scores at different time points were compared between the groups with Bonferroni correction. NRS scores were statistically significantly higher in the control group when compared to both block groups at the 1st, 3rd, and 6th h. At these times, post hoc analysis revealed statistically significant difference between control and two block groups (comparison between control group vs. L-ESPB and control group vs QLB-t at 1st h: P =0.001 and P < 0.001, 3rd h P = 0.006 and P < 0.001 and 6th h P = 0.012 and P = 0.001, respectively). No difference was found between the two block groups (P > 0.005). Average NRS scores at different times are shown in [Table 2].
Table 2: Average Numeric Rating Scale scores at various time points according to groups (mean±standard deviation)

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The number of patients requiring fentanyl in the RR was 4, 3, and 3 for the control, ESPB and QLB-t groups, respectively. Tramadol consumption via PCA was statistically significantly different between these groups. [Table 3] demonstrates the tramadol consumption for the first 12 h, second 12 h, and cumulative 24 h. Tramadol consumptions were significantly different in total and for the first 12 h (P < 0.05). In post hoc analyses, the first 12 h and total tramadol consumption were similar between the two block groups (P > 0.05), but significantly higher in the controls when compared to both block groups (comparison between control group vs L-ESPB and control group vs QLB-t at first 12 h P < 0.001 and P < 0.001, first 24 h P < 0.001 and P < 0.001, respectively). The number of patients requiring rescue analgesic in the first 24 h were 11, 4 and 4 for the control, ESPB and QLB-t groups, respectively, with a statistically significant difference (P < 0.05). In the post hoc analyses, the number of patients required rescue analgesia were similar between the two block groups (P > 0.05), but significantly higher in the controls when compared to both block groups (P < 0.05) [Table 3].
Table 3: Analgesic consumption of patients according to groups

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Although the block performance times are similar, we did not statistically compare all time evaluations since they were not noted in detail.

   Discussion Top

In this study, we have revealed that USG guided L-ESPB with 40 ml of LA mixture, performed at the 4th lumbar vertebral level leads to effective postoperative analgesia. QLB-t performed with the same volume also leads to similar analgesic effects. Both blocks significantly decreased NRS pain scores in the 1st postoperative hours and analgesic requirement during the first 24 h compared to standard intravenous analgesia regimen.

Different regional anesthesia techniques can be used as part of multimodal analgesia in hip surgeries.[2],[16] Although epidural analgesia is accepted as the gold standard for hip surgery, other options that lead to effective analgesia include quadratus lumborum block (QLB), paravertebral block, psoas compartment block, and transverse abdominal plane block.[2],[15],[18],[19] Among these techniques, it is reported that LA administered in psoas compartment block and QLB spreads to the lumbar plexus and leads to analgesia.[15],[19],[20] L-ESPB was first introduced by our institute. We have demonstrated in our imaging study that LA spreads to the lumbar plexus in L-ESPB.[13],[14]

The possibility of complications such as hematoma formation in USG guided L-ESPB occurring may be relatively low. As there is no direct contact, there is no risk of mechanical nerve damage. As is possible with all regional anesthesia techniques, L-ESPB can fail. However, we determined no failures in this study group. It should be kept in mind that mistakes in technique and anatomical variations leading to disruption of local anesthesia spread may lead to unsuccessful peripheral nerve blocks, including ESPB. In addition, we may have missed block failures due to effective and reliable multimodal analgesia in both groups of blocks, and we did not perform sensory block performance assessments.

While ESPB was first described for use in thoracic neuropathic pain, its use has been widely accepted. It is performed at different levels for different pathologies such as chronic shoulder pain (T2), breast surgery and thoracic surgery (T4-5) and upper abdominal surgery (T7-8).[3],[5],[8],[12] Despite its recent description in literature, ESPB is reported to be used in both adults and children, and many new indications have been described.[21],[22],[23],[24]

It is reported that when ESPB is performed from the thoracic level, the LA spreads to the paravertebral space leading to somatic and visceral analgesia.[7] In a cadaver model, 20 ml of LA applied at T7 level spread from to C7-T2 cranially and L2-3 level caudally.[4] However, there are two consecutive reports from our clinic, in which L-ESPB leads to effective analgesia in a patient undergoing total hip arthroplasty.[13],[14] In our previous studies, we demonstrated that sensorial block is achieved between T11 and L5 in L-ESPB[14] and in a radiological image; we have shown the spread of LA both anteriorly and posteriorly, surrounding the psoas muscle and lumbar plexus.[13] In our first application we injected 30 ml of LA.[14] We later performed ESPB with 40 ml of LA.[13] When we consider that 25–35 ml of LA is applied close to the lumbar plexus in USG guided psoas compartment block confirmed with nerve stimulator, we believe that a higher volume would be suitable for the LA to spread further.

Although ESPB is a new technique and its mechanism of action is not fully understood, several recent studies have reported that it can be used when the lumbar plexus block cannot be performed or has failed.[25],[26]

QLB-t is another recently described and popular peripheral nerve block. There are limited case reports regarding the use of QLB-t[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] and there is only one clinical study reporting the use of QLB-t as part of multimodal analgesia in hip surgery.[31] Our study has demonstrated that when compared with a control group, QLB-t decreases analgesia requirement. The study is the first prospective trial to evaluate the effectiveness of both L-ESPB and QLB-t.

Our patients' pain scores and the requirement for analgesia within the first postoperative 24 h were low in both block groups. While this supports that L-ESPB and QLB-t are effective analgesia methods, a prospective randomized controlled study that determines the effective concentration and dosage of local anesthesia is required.

Our study has several limitations that may affect our results.

In the postoperative 1st h, the NRS score was higher in the control group; our multimodal analgesia regimen may be inadequate. Had all patients been under spinal anesthesia, perhaps low dose intrathecal morphine or an epidural catheter may be effective for preventing patients from suffering more pain in the control group in the early postoperative period. In addition, both L-ESPB and QLB-t are not gold standard techniques in hip surgery analgesia, and both are relatively new block techniques. It would be more appropriate to perform noninferiority studies by comparing both techniques with a gold standard technique (such as epidural analgesia, lumbar plexus block). The sample size is not enough for a standard noninferiority study, and this was not the goal of this study.

We determined a decrease in the NRS score in different frames as the primary outcome in our study. This can be regarded as a methodological problem. In fact, it would be better if we could determine the 24 h morphine requirement as the primary outcome. In the present study, we evaluated the use of fentanyl in the RR, and tramadol requirement in the first 24 h. Fentanyl and tramadol requirement quantities could be calculated as opioid equivalents, and it might be more appropriate to determine the difference between groups in the first 24 h. Considering that, the requirement for fentanyl in the collection room may be related to the amount of perioperative remifentanil use, we evaluated the 24 h tramadol requirement separately rather than the 24 h opioid total requirement.

We did not collect any data to compare perioperative remifentanil use or other analgesic agents. Further studies evaluating the perioperative effect and the time of commencement of block effect are required.

In our study, surgical procedures were not standard or homogenous. Larger studies with patients undergoing hip or proximal femoral surgery with a standard technique will yield better data and results. Although our patients all underwent either hip or proximal femur surgery, different surgeries can lead to different pain. The similarity of the sensory innervations of the applied surgeons does not preclude our limitations on the necessity of homogeneous patient selection.

As we performed L-ESPB and QLB-t under general anesthesia at the beginning of the surgical procedure, we added lidocaine to our LA mixture. We wanted to shorten the onset time of the block by adding lidocaine to the LA mixture and to benefit from the block analgesic effect during the surgery. Thus, we aim to reduce the amount of opioid to be used in surgery. Although we observed a marked reduction in perioperative remifentanil requirement in patients with the blockade, we did not statistically analyze the remifentanil dosage, as we determined the hemodynamic index rather than the bispectral index. Further studies must also include other LAs such as ropivacaine, liposomal bupivacaine, and other LAs, alone and in combinations.

We did not evaluate the sensorial block distribution of patients in this study. While this could have been performed using pinprick or cold tests, our aim was not to determine sensorial block distribution but to evaluate the effect of these blocks on pain and analgesia requirement. This does not effect our take-home message but would been have added to our study. In previous studies sensorial block in L-ESPB and QLB-t have been revealed.[14],[32],[33],[34] We could not evaluate the NRS scores in the passive motion of the hip joint because our orthopedists usually keep the hip prostheses immobile during the first postoperative 24 h.

Our sample size was calculated aiming a decrease in NRS score. This may have led to a sample size not large enough to determine block related effects or complications such as nausea and vomiting. Both blocks evaluated in this study have the potential of causing motor weakness. However, we did not evaluate lower extremity muscle strength.

   Conclusion Top

When performed preoperatively under general anesthesia, L-ESPB and QLB-t blocks decrease postoperative analgesia requirement and improve the quality of multimodal analgesia when compared to a control group. Further studies comparing the two blocks with a standardized surgical technique as well as studies evaluating effective volume and concentration of LA are required.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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