Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks

Lee, Edward M.; Murphy, Kevin P.; Ben‐David, Bruce

doi:10.1016/j.jclinane.2008.04.012

Cited by 58 publications

(52 citation statements)

References 15 publications

(15 reference statements)

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“…The readmission rate for management of problems associated with the CLPB [one pt with presumed epidural spread, one pt with LAST (0.9%)] was lower than the reported rates of unplanned admission or readmission for pain control following orthopedic surgical procedures (4% -17%) [31]. In addition, hip arthroscopy may be associated with significant postoperative pain, with pain scores ranging from 8/10 to 10/10 at one institution [32]. Therefore, our data suggested that ambulatory continuous lumbar plexus block may serve to reduce the risk of hospital readmission following painful ambulatory surgery.…”

Section: Discussionmentioning

confidence: 94%

Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases

Nye

Horn

Crittenden

et al. 2013

Journal of Clinical Anesthesia

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Section: Discussionmentioning

confidence: 94%

Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases

Nye

Horn

Crittenden

et al. 2013

Journal of Clinical Anesthesia

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“…Incomplete analgesia may perhaps be due to the various components of the lumbar plexus being physically separated by muscle tissue such that the infused local anesthetic solution cannot reach them all [1,2,10]. The case reports of Lee et al [12] demonstrated that L1-L2 PVBs provided adequate pain relief in patients undergoing hip arthroscopy; however, the study of Bogoch et al [6] demonstrated that opioid consumption was significantly less during the first 4 hours after performing paravertebral blocks compared to a sham procedure in patients undergoing THA, but no significant difference was seen in opioid consumption thereafter. We found no differences in pain scores at rest or during physical therapy for the first 24 hours between the PVB and LPB groups, and morphine consumption was only slightly less in the LPB group than in the L2 PVB group (Fig.…”

Section: Discussionmentioning

confidence: 99%

“…Lee et al [12] published two case reports where L1-L2 PVBs were performed in an attempt to limit quadriceps motor weakness and thereby permit early discharge. They argued that L1-L2 PVBs held the potential for neural block with a relatively specific and limited sensory block and the possibility of greater preservation of quadriceps strength and highquality analgesia [12]. The motor preservation aspect of the L2 PVBs was not noted in our study, even though the pain relief was comparable.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, the use of an L2 PVB has been described as an effective postoperative analgesic technique in the case of hip arthroscopy. Lee et al [12] chose L2 PVB over the more commonly used LPB in an attempt to limit quadriceps motor weakness and thereby permit early discharge in patients undergoing hip arthroscopy. The L1 through L2 PVBs held out the potential for neural block with a relatively specific and limited sensory block and the possibility of greater preservation of quadriceps strength [12].…”

Section: Introductionmentioning

confidence: 99%

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Is L2 Paravertebral Block Comparable to Lumbar Plexus Block for Postoperative Analgesia After Total Hip Arthroplasty?

Wardhan

Auroux

Ben‐David

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Background Continuous lumbar plexus block (LPB) is a well-accepted technique for regional analgesia after THA. However, many patients experience considerable quadriceps motor weakness with this technique, thus impairing their ability to achieve their physical therapy goals. Questions/purposes We asked whether L2 paravertebral block (PVB) provides better postoperative analgesia (defined as decreased postoperative opioid consumption and lower pain scores), better preservation of motor function, and decreased length of hospital stay (LOS) compared to LPB in patients undergoing THA. Methods Sixty patients undergoing minimally invasive THA under standardized spinal anesthesia were enrolled in this randomized controlled study. After exclusions, 53 patients were randomized into the L2 PVB (n = 27) and LPB (n = 26) groups. Patient-controlled analgesia was available for 24 hours. Motor and pain assessments were performed in the recovery room and at the end of 24 hours. LOS was also noted. Results Postoperative opioid consumption during the first 24 hours was less in the LPB group (mean ± SD: 24 ± 15 mg morphine) than in the L2 PVB group (32 ± 15 mg morphine; p = 0.005); however, postoperative pain scores were not different between groups. Postoperative motor and rehabilitation outcomes and LOS were also similar. Conclusions Our study demonstrates that use of a LPB results in slightly less morphine consumption but comparable pain scores when compared with continuous L2 PVB. No difference was noted in terms of motor preservation or LOS. Although the difference in morphine consumption was only slightly in favor of the LPB group, the advantage of L2 PVBs noted by previous authors as preservation of motor function, was not seen. At our institute where LPBs have been performed for years, there seems to be no real advantage in switching to L2 PVBs. However, L2 PVB could be a reasonable alternative for operators who are wary of LPBs due to their high potential for complications and/or requiring advanced skills for its placement. But, since L2 PVBs are relatively new, not much is known about their complication profile. We recommend a thorough understanding of both techniques before attempting to place them.

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“…We've recently described the use of L1 to L2 single-shot lumbar paravertebral blocks for hip arthroscopy. 2 This approach has a number of advantages, including the lack of need for nerve stimulation, low risk for epidural spread, and the facility with which it can be performed. Moreover, the lumbar paravertebral block seems to provide far better preservation of hip flexor and quadriceps strength than the lumbar plexus block-a significant advantage towards early ambulation and discharge.…”

Section: Lumbar Plexus or Lumbar Paravertebral Blocks?mentioning

confidence: 99%

Lumbar Plexus or Lumbar Paravertebral Blocks?

Ben‐David

Lee²

2009

Anesthesiology

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In Reply:-Drs. Parker and Behringer correctly point out that in our review 1 on the potential toxic effects of nitrous oxide we did not cover its contribution to the greenhouse effect; this omission was predicated by considerations of space, direct relevance to patient care, and a lack of relevant data that is less than 20 yr old. Correctly, Drs. Parker and Behringer indicate that nitrous oxide contributes to the greenhouse effect (Ϯ0.05%); however, as 99% of the nitrous oxide in the atmosphere originates from industrial and agricultural sources, the total elimination of medical use of nitrous oxide will likely have a negligible effect on the greenhouse effect. What also needs to be considered is the effect of increased use of another greenhouse gas, namely halogenated anesthetics, as a possible replacement for nitrous oxide. Furthermore, we need to understand the totality of the environmental impact of the volatile gases, and that includes its manufacture, transport, and storage. In absence of reliable data on these issues, it would be too simplistic to state that there would be an environmental benefit were we to abandon the anesthetic use of nitrous oxide. Lumbar Plexus or Lumbar Paravertebral Blocks?To the Editor:-We read with interest the report of Gadsden et al. 1implicating the role of high-pressure injection during the performance of lumbar plexus blocks in producing contralateral and epidural spread of local anesthetic in more than 50% of their patients. We wish to make three points regarding this report.1. Does one or more of the authors have any financial interest in the device used in the study? If so, it would have been proper to disclose this. 2. It is important to emphasize that both injection under a higher pressure and a large volume of injectate (35 ml in this study) constitute "necessary but insufficient conditions" for epidural/ contralateral spread of local anesthetic. That is, high pressure alone with a small volume injectate will likely not lead to epidural/contralateral spread of the local anesthetic. Likewise, as the authors showed, one can inject substantial amounts of local anesthetic under low pressure without significant risk of this complication. In our practice nearly all lumbar plexus blocks involve placement of a continuous catheter, and it has been our experience that even large-volume injection through these catheters does not lead to bilateral blockade. Of course, it is impossible to generate high pressures with such an injection because of the high resistance offered by the catheter, thereby obviating the need for an injection pressure monitoring device. 3. A lumbar plexus block is not a procedure with a consistently defined anatomic end point and really consists of two separate blocks-the psoas sheath block and the psoas compartment block-either of which result in blockade of the lumbar plexus. To add to the confusion, these terms are often used incorrectly and interchangeably. The former involves injection within the psoas sheath and into the body of the psoas muscle. The ...

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Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks

Cited by 58 publications

References 15 publications

Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases

Ambulatory continuous posterior lumbar plexus blocks following hip arthroscopy: a review of 213 cases

Is L2 Paravertebral Block Comparable to Lumbar Plexus Block for Postoperative Analgesia After Total Hip Arthroplasty?

Lumbar Plexus or Lumbar Paravertebral Blocks?

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