Incidence of epidural spread after Chayens approach to lumbar plexus block: a retrospective study / Incidência de dispersão peridural após bloqueio do plexo lumbar com técnica de Chayen: estudo retrospectivo

Abstract Background and objectives: The lumbar plexus block (LPB) is a key technique for lower limb surgery. All approaches to the LPB involve a number of complications. We hypothesized that Chayen's approach, which involves a more caudal and more lateral needle entry point than the major techniques described in the literature, would be associated with a lower rate of epidural spread. Method: We reviewed the electronic medical records and chart of all adult patients who underwent orthopedic surgery for Total Hip Arthroplasty (THA) and hip hemiarthroplasty due to osteoarthritis and femoral neck fracture with LPB and Sciatic Nerve Block (SNB) between January 1, 2002, and December 31, 2017, in our institute. The LPB was performed according to Chayen's technique using a mixture of mepivacaine and levobupivacaine (total volume, 25 mL) and a SNB by the parasacral approach. The sensory and motor block was evaluated bilaterally during intraoperative and postoperative period. Results: A total number of 700 patients with American Society of Anesthesiologists (ASA) physical status I to IV who underwent LPB met the inclusion criteria. The LPB and SNB was successfully performed in all patients. Epidural spread was reported in a single patient (0.14%;p < 0.05), accounting for an 8.30% reduction compared with the other approaches described in the literature. No other complications were recorded. Conclusions: This retrospective study indicates that more caudal and more lateral approach to the LPB, such as the Chayen's approach, is characterized by a lower epidural spread than the other approach to the LPB.

Resumo Justificativa e objetivos: O bloqueio do plexo lombar (BPL) é uma técnica fundamental para a cirurgia de membros inferiores. Todas as abordagens do BPL são associadas a uma série de complicações. Nossa hipótese foi de que a abordagem de Chayen, que envolve um ponto de entrada da agulha mais caudal e mais lateral do que as principais técnicas descritas na literatura, estaria associada a menor incidência de dispersão peridural. Método: Revisamos os prontuários médicos eletrônicos e em papel de todos os pacientes adultos submetidos à artroplastia total do quadril (ATQ) e hemiartroplastia do quadril devido a osteoartrite ou fratura do colo do fêmur empregando-se BPL associado ao bloqueio do nervo ciático (BNC), entre 1 de janeiro de 2002 e 31 de dezembro de 2017 em nossa instituição. Realizamos o BPL usando a técnica de Chayen e uma mistura de mepivacaína e levobupivacaína (volume total de 25 mL) e o BNC pela abordagem parassacral. Testes sensorial e motor bilaterais foram realizados no intra e pós-operatório. Resultados: Os critérios de inclusão foram obedecidos pelo total de 700 pacientes classe ASA I a IV submetidos ao BPL. Os BPL e BNC foram realizados com sucesso em todos os pacientes. A dispersão peridural foi relatada em um único paciente (0,14%; p < 0,05), representando uma redução de 8,30% quando comparada às outras abordagens descritas na literatura. Nenhuma outra complicação foi registrada. Conclusões: Este estudo retrospectivo indica que a abordagem mais caudal e mais lateral do BPL, como a técnica de Chayen, é caracterizada por menor dispersão peridural do que outras abordagens do BPL.

Comparison between ‘three in one femoral nerve block’ and psoas compartment block for post-operative pain relief following lower limb surgical procedures.

Aim of this study was to compare anterior approach (‘three in one block’) and posterior approach (psoas compartment block) of lumbar plexus block in relieving the post-operative pain in patients operated for unilateral hip, femur or knee surgery under spinal anaesthesia. 40 patients undergoing elective orthopedic procedure in hip, femur or knee were randomized into group A and group B. Surgery was done under spinal anaesthesia. At the end of the surgery, single shot lumbar plexus block was given by anterior approach (3 in 1 block) in group A and by posterior approach (psoas compartment block) in group-B patients with 30 ml of 0.25% of bupivacaine. Pain was assessed using verbal rating scale. The time for first rescue analgesic, need of additional analgesic and overall satisfaction of post-operative pain relief were noted. Both the groups were comparable in age, sex, weight, height, vital signs, duration and type of surgery. There is no significant difference in pain level between two groups. The mean time for first rescue analgesia was 9.10 (± 1.52) and 9.90 (± 1.21) hours in group A and group B respectively (p>0.05 not significant). Requirement of additional analgesic was reduced in both groups. More than 90% of patients expressed overall satisfaction of post-operative pain relief in both groups. Both approaches of lumbar plexus block by Three in one femoral nerve block (Group A) and psoas compartment block (Group B) were effective in providing post-operative analgesia after hip, femur, or knee surgery.

Combined Continuous Psoas Compartment Block and Sciatic Nerve Block for Revision Arthroplasty of the Hip in a Patient with Ankylosing Spondylitis : A case report / 대한마취과학회지

Ankylosing spondylitis is a chronic and systemic disease invloving the axial skeleton. In patient with involved cervical spine of the ankylosing spondylitis, endotracheal intubation by direct laryngoscope may be difficult or impossible because they have a limitation of cervical movement and anatomical anomalies. Additionally, ossification of the interspinous ligaments and the formation of bony bridges (syndesmophytes) between vertebrae, resulting in a classic "bamboo spine" appearance make difficult or impossible placement of an epidural or spinal needle. We report a case of a patient with long standing ankylosing spondylitis who underwent revision arthroplasty of the hip using combined continuous psoas compartment block and sciatic nerve block.

Effect of Psoas Compartment Block in Low Extremity Neuropathic Cancer Pain: Three case reports / 대한마취과학회지

Psoas compartment block is an excellent method of pain control due to tumor invasion of the lumbar plexus or a pathologic fracture of the femur. Three patients with advanced cancer complained of pain in their legs, and this was effectively blocked using a bupivacaine and triamcinolone psoas compartment block. The psoas compartment block is a useful procedure and can be of particular use in patients who have not responded to opiates or find the side-effects of opiates intolerable.

Anatomical Review and Clinical Effect of Psoas Compartment Block

OBJECTIVE: The purposes of this study were to evaluate the relation of the lumbar plexus with the psoas compartment, to measure the distance from skin to psoas compartment, and to determine the efficacy of psoas compartment block for the unilateral leg pain and/or low back pain. METHOD: Six cadavers were dissected and the computed tomography of the lumbar region were performed in 22 subjects. The psoas compartment block of 10 ml of 0.5 percent lidocaine were performed in 31 patients with unilateral leg pain and/or low back pain. Visual Analog Scale (VAS) and sensory, motor functions were assessed before the block and 5, 30 minutes, and 1, 2, 3 hours and 1 week after the block. The distance from skin to psoas compartment were measured during the procedure. The questionnaires on the procedure were completed after 1 week. RESULTS: Cadaver dissections demonstrated that the 3 main nerves of lumbar plexus were within the psoas compartment between the level of L4 and L5. Computed tomography provided that the average distances of anterior and posterior borders of psoas major from the low back skin were 10.8 & 6.3 cm and that of medial & lateral borders from the median sagital plane were 2.9 & 7.1 cm respectively. There were statistically significant correlations between distance from skin to psoas compartment and body weight, abdominal circumference as well as body mass index (p<0.0001). The VAS was 7.7 before the block and 5.4 1 week after the block (p<0.05) and satisfactory outcomes were shown in 71 percent of the subjects. CONCLUSION: Psoas compartment block was effective for the patients with unilateral leg pain and/or low back pain without major side effects and complications.

Psoas Compartment Block for Hip Arthroplasty in Geriatric Patients / 대한마취과학회지

Psoas compartment block for hip arthroplasty was evaluated clinically in 32, either sex, geriatric patients. To perform the block, the patient was placed in a lateral decubitus position and a line was drawn, connecting both iliac crests (intercristal line). 22G teflon-coated needle of 10cm-length was inserted at a point 3cm caudad to the intercristal line and 5cm lateral to the spinal midline on the side to be blocked. The nerve stimulator (1-3mA, 1Hz), Pajunk (GMBH, Geisingen, West-Germany), was used to elicit paresthesia or muscle twitching on the patient's ipsilateral leg. The block was performed with administration of a mixture of 15 ml of 1.5 % lidocaine, 15 ml of 0.5 % bupivacaine and 0.15 mg of epinephrine. The onset time of the block was 4.4+/-1.6 minutes and its duration was 3.8+/-1.5 hours. The mean value of the lowest mean arterial pressure during the first 1 hour after the injection of local anesthetics, 85.7+/-9.8 mmHg was lower, compared to the preanesthetic baseline value, 98.2+/-16.5 mmHg. The failure rate was 9.4% and any significant systemic toxicity was not seen. There were some intraoperative complaints such as the discomfort due to position bars. However, there was no remarkable problem intraoperatively. The results indicate that psoas compartment block is a recommendable safe anesthetic technique for hip arthroplasty in geriatric patients.

Prevention of Obturator Nerve Reflex during Transurethral Surgery of Bladder Tumor / 대한비뇨기과학회지

Adductor contraction from obturator nerve stimulation occurs frequently in certain situations during transurethral operations. Bladder perforation is a common result. A simple and safe technique involving use of a nerve stimulator for accurate obturator blockade and psoas compartment block are described. Only one of seven cases has obturator nerve stimulation after psoas compartment block. But there were no adductor contractions in more than seventeen transurethral resections during one year interval. There were no complications from the block itself or use of the nerve stimulator. Herein we introduce these safe methods for prevention of obturator nerve stimulation during transurethral resection.