QL vs LP Blocks for Analgesia Following THA

Utilization of Quadratus Lumborum Versus Lumbar Plexus Blocks for Postoperative Analgesia Following Hip Arthroplasty: A Prospective, Randomized Clinical Trial

Purpose: Evaluate difference in postoperative opioid consumption when subjects receive a quadratus lumborum (QL) or lumbar plexus (LP) block preoperatively for total hip arthroplasty (THA).

Hypothesis: Preoperative QL and LP blocks will result in similar postoperative opioid consumption following hip arthroplasty.

Study Overview

• Status: Completed
• Conditions: Surgery
• Intervention / Treatment: Procedure: LP Block; Procedure: QL Block

Detailed Description

With the goal of improving physical function and quality of life, the demand for total hip arthroplasty (THA) continues to grow. However, postoperative pain associated with THA remains a serious concern for patients. In the middle of a growing opioid epidemic, multimodal approaches utilizing both non-opioid analgesics and regional anesthetic techniques are being increasingly sought.

Regional anesthetic techniques are associated with both decreased opioid consumption and pain scores compared with systemic analgesia alone. However, regional techniques for THA are seldom compared. Lumbar plexus blocks are commonly performed for postoperative analgesia for THA. However, more recent case reports have described utilizing quadratus lumborum blocks for analgesia following hip fracture and THA.

This prospective study would randomize subjects to receive a lumbar plexus block or quadratus lumborum block prior to THA. The primary end point would be opioid consumption at 12 hours postoperative. Our hypothesis is that opioid consumption will not differ between groups.

The quadratus lumborum block is a fascial plane block. Originally described for abdominal surgery, numerous case reports and editorial publications have highlighted the effectiveness of quadratus lumborum (QL) blocks as an analgesic technique for hip fracture and hip arthroplasty. However, prospective randomized studies comparing QL blocks to other regional techniques for THA analgesia are lacking.

The lateral approach to the QL block is performed by injecting local anesthetic deep to the transversus abdominus abdominus apnoneurosis and superficial to the fascia transversalis with direct ultrasound guidance. After completing consent, placing monitors and providing mild sedation, the subject is positioned laterally and the muscular anatomy (external oblique, internal oblique, transverse abdominis, quadratus lumborum and latissimus dorsi muscles) identified. After placing a subcutaneous skin wheal with lidiocaine, a blunt regional anesthesia needle is inserted using in-plane ultrasound guidance. Local anesthetic is deposited incrementally with frequent aspiration in the anterolateral border of the quadratus lumborum muscle at the junction of the transversalis fascia, outside the anterior layer of the thoracolumbar fascia and superficial to the fascia transversalis.

Risks of anterior approach to the quadratus lumborum block are similar to most truncal blocks and include infection, bleeding, bowel perforation or local anesthetic toxicity (LAST). Infection risk is minimized by utilizing appropriate antiseptic and sterile technique as is standard for any regional procedure. Risk of a retroperitoneal hematoma is increased with the posterior approach to the quadratus lumborum block because of its transmuscular approach and likelihood of abdominal branches of lumbar arteries in the path of the needle. For this reason, the posterior approach to the quadratus lumborum block will not be used for this study. The risk of LAST is a risk with any regional procedure and is minimized by frequent aspiration, incremental local anesthetic injection and vital signs monitoring throughout.

The quadratus lumborum block is already a block utilized for a variety of surgical procedures to decrease postoperative pain. Potential benefits to the QL block over the common lumbar plexus block include more superficial block placement and ultrasound visualization. The investigator hypothesize that preoperative QL blocks will reduce opioid consumption similar to lumbar plexus blocks following elective hip arthroplasty.

Information regarding the study will be presented to subjects in the surgical clinic or preoperative anesthesia clinic in the preoperative period. Subjects will be educated on the role of regional anesthesia in postoperative analgesia. Subjects will be able to consider the study until the day of surgery. On the day of surgery, subjects may then choose to provide written consent or decline to participate.

Subjects will be enrolled on the day of surgery in the preoperative holding area.

After discussion in the preoperative holding area regarding risks and benefits of both the lumbar plexus and QL block, subjects will be consented if they choose to participate. Consent will be obtained from subject by an IRB approved CITI certified study team member that has been trained on the protocol. Written consent with a witness will be completed once all questions are answered and exclusion and inclusion verified. Copies of all documents will be provided to the subjects. Once subjects are consented, they will be assigned an enrollment number. Prior to subject enrollment, randomization will done by a statistician and randomized group (lumbar plexus block (current practice) or QL block) assigned based on the subject enrollment number.

Design: This prospective, single blinded clinical trial will randomize subject to receive a lumbar plexus or QL block prior to THA. The randomization will be created by a statistician prior to subject enrollment.

Groups: Subjects will be randomized to receive a preoperative lumbar plexus (n = 100) or QL (n = 100 ) block prior to THA.

Potential participants that are on the operating room schedule for THA will be screened for eligibility via chart review.

Once subjects have signed an informed consent, they will be assigned an enrollment number. Numbers would be assigned sequentially with the first enrolled subject receiving "001," the second subject receiving "002," and the last subject receiving number "184." Randomization will be created prior to the study starting by a statistician with half of the research subject number being assigned to receive a QL block and the other half assigned to receive a lumbar plexus block, which is our current standard of care. The regional anesthesia team will open the envelope labeled with the subject's assigned number to reveal the randomization.

Following informed consent, all subjects will be positioned, prepped and sedated for the randomized regional anesthesia procedure in the preoperative holding area. The subject will be positioned in the lateral decubitus position with the operative side up and pulse oximetry and blood pressure cuff placed for monitoring. As part of routine care, the subject will receive sedation for their comfort. All subjects would receive 20 ml of 0.5% ropivacaine in their nerve block regardless of randomization. The relevant anatomy will then be identified using either surface landmarks (lumbar plexus block) or an ultrasound (quadratus lumborum block). All participants, regardless of group assignment, will be positioned, have an area on their back and side cleaned, have an ultrasound placed, and numbing medication placed just below the skin at both block sites (skin wheal). This will be done so that participant and the team collecting result will be blinded. Subject, surgeon, intraoperative anesthesia team and data collectors would all be blinded to the allocated group.

Subjects randomized to the lumbar plexus block group will receive a subcutaneous lidocaine skin wheal 3-4 cm lateral to midline on the operative side along the intercristal line. A nerve stimulator will be sent to 1-1.5mA and a stimulating needle inserted perpendicular to the skin. The needle will be advanced slowly until the quadriceps muscle is stimulated and maintained at less than 0.6mAs. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement.

Subjects randomized to the quadratus plexus block group will receive a subcutaneous lidocaine skin wheal that will be placed after ultrasound identification of external oblique, internal oblique, transverse abdominus and quadratus lumborum muscles. A needle will then be advanced under ultrasound guidance below the internal oblique aponeurosis and lateral to the quadratus lumborum muscle. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement. Local anesthetic injection will also be observed with real time ultrasound guidance.

The participant's chart will be reviewed for data collection.

Participants will also be asked to perform a Visual Analog Scale pain score preoperatively (baseline), postoperatively (once awake) and approximately 24 hours post operatively.

Care in the perioperative period will otherwise be standardized. In the post-anesthesia care unit (PACU), hydromorphone or morphine will be titrated by the PACU nurse for the subject's comfort.

• Study Type: Interventional
• Enrollment (Actual): 111
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • South Carolina
    • Charleston, South Carolina, United States, 29425
      • Medical University of South Carolina

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age greater than or equal to 18 years-old
• Undergoing elective hip arthroplasty.

Exclusion Criteria:

• Local anesthetic allergy
• Chlorhexidine allergy
• Subjects with a weight less than 40kg
• Subjects that are unable or choose not to give informed consent
• Emergency surgery
• Known preoperative substance abuse
• Allergy to all opioids

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Receives LP Block; Subjects randomized to the lumbar plexus block group will receive a subcutaneous lidocaine skin wheal 3-4 cm lateral to midline on the operative side along the intercristal line. A nerve stimulator will be sent to 1-1.5mA and a stimulating needle inserted perpendicular to the skin. The needle will be advanced slowly until the quadriceps muscle is stimulated and maintained at less than 0.6mAs. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement.	Procedure: LP Block; Subjects randomized to the lumbar plexus block group will receive a subcutaneous lidocaine skin wheal 3-4 cm lateral to midline on the operative side along the intercristal line. A nerve stimulator will be sent to 1-1.5mA and a stimulating needle inserted perpendicular to the skin. The needle will be advanced slowly until the quadriceps muscle is stimulated and maintained at less than 0.6mAs. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement.
Active Comparator: Receives QL Block; Subjects randomized to the quadratus plexus block group will receive a subcutaneous lidocaine skin wheal that will be placed after ultrasound identification of external oblique, internal oblique, transverse abdominus and quadratus lumborum muscles. A needle will then be advanced under ultrasound guidance below the internal oblique aponeurosis and lateral to the quadratus lumborum muscle. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement. Local anesthetic injection will also be observed with real time ultrasound guidance.	Procedure: QL Block; Subjects randomized to the quadratus plexus block group will receive a subcutaneous lidocaine skin wheal that will be placed after ultrasound identification of external oblique, internal oblique, transverse abdominus and quadratus lumborum muscles. A needle will then be advanced under ultrasound guidance below the internal oblique aponeurosis and lateral to the quadratus lumborum muscle. Ropivacaine (20ml, 0.5%) will be injected slowly with frequent aspiration to rule out inadvertent intravascular needle placement. Local anesthetic injection will also be observed with real time ultrasound guidance.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid consumption	Opioid consumption including intraoperative consumption	12 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Opioid consumption 8 hours postoperative	Opioid consumption including intraoperative consumption	8 hours

Collaborators and Investigators

• Sponsor: Medical University of South Carolina
• Investigators: Principal Investigator: Sylvia H Wilson, MD, Medical University of South Carolina

Publications and helpful links

General Publications

• Hockett MM, Hembrador S, Lee A. Continuous Quadratus Lumborum Block for Postoperative Pain in Total Hip Arthroplasty: A Case Report. A A Case Rep. 2016 Sep 15;7(6):129-31. doi: 10.1213/XAA.0000000000000363.
• Hansen CK, Dam M, Bendtsen TF, Borglum J. Ultrasound-Guided Quadratus Lumborum Blocks: Definition of the Clinical Relevant Endpoint of Injection and the Safest Approach. A A Case Rep. 2016 Jan 15;6(2):39. doi: 10.1213/XAA.0000000000000270. No abstract available.
• La Colla L, Ben-David B, Merman R. Quadratus Lumborum Block as an Alternative to Lumbar Plexus Block for Hip Surgery: A Report of 2 Cases. A A Case Rep. 2017 Jan 1;8(1):4-6. doi: 10.1213/XAA.0000000000000406.
• La Colla L, Uskova A, Ben-David B. Single-shot Quadratus Lumborum Block for Postoperative Analgesia After Minimally Invasive Hip Arthroplasty: A New Alternative to Continuous Lumbar Plexus Block? Reg Anesth Pain Med. 2017 Jan/Feb;42(1):125-126. doi: 10.1097/AAP.0000000000000523. No abstract available.
• Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007 Oct 27;370(9597):1508-19. doi: 10.1016/S0140-6736(07)60457-7.
• Bruyere O, Ethgen O, Neuprez A, Zegels B, Gillet P, Huskin JP, Reginster JY. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Arch Orthop Trauma Surg. 2012 Nov;132(11):1583-7. doi: 10.1007/s00402-012-1583-7. Epub 2012 Jul 28.
• Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004 May;86(5):963-74. doi: 10.2106/00004623-200405000-00012.
• Singh JA, Lewallen D. Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskelet Disord. 2010 May 13;11:90. doi: 10.1186/1471-2474-11-90.
• Becchi C, Al Malyan M, Coppini R, Campolo M, Magherini M, Boncinelli S. Opioid-free analgesia by continuous psoas compartment block after total hip arthroplasty. A randomized study. Eur J Anaesthesiol. 2008 May;25(5):418-23. doi: 10.1017/S026502150700302X. Epub 2007 Nov 21.
• Biboulet P, Morau D, Aubas P, Bringuier-Branchereau S, Capdevila X. Postoperative analgesia after total-hip arthroplasty: Comparison of intravenous patient-controlled analgesia with morphine and single injection of femoral nerve or psoas compartment block. a prospective, randomized, double-blind study. Reg Anesth Pain Med. 2004 Mar-Apr;29(2):102-9. doi: 10.1016/j.rapm.2003.11.006.
• Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth. 2009 Sep;103(3):335-45. doi: 10.1093/bja/aep208. Epub 2009 Jul 23.
• Stevens RD, Van Gessel E, Flory N, Fournier R, Gamulin Z. Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology. 2000 Jul;93(1):115-21. doi: 10.1097/00000542-200007000-00021.
• Harvey NR, Wolf BJ, Bolin ED, Wilson SH. Comparison of analgaesia with lumbar epidurals and lumbar plexus nerve blocks in patients receiving multimodal analgaesics following primary total hip arthroplasty: a retrospective analysis. Int Orthop. 2017 Nov;41(11):2229-2235. doi: 10.1007/s00264-017-3465-7. Epub 2017 Apr 11.
• Wilson SH, Wolf BJ, Algendy AA, Sealy C, Demos HA, McSwain JR. Comparison of Lumbar Epidurals and Lumbar Plexus Nerve Blocks for Analgesia Following Primary Total Hip Arthroplasty: A Retrospective Analysis. J Arthroplasty. 2017 Feb;32(2):635-640. doi: 10.1016/j.arth.2016.07.042. Epub 2016 Aug 10.
• Wilson SH, Auroux AS, Eloy JD, Merman RB, Chelly JE. Ropivacaine 0.1% versus 0.2% for continuous lumbar plexus nerve block infusions following total hip arthroplasty: a randomized, double blinded study. Pain Med. 2014 Mar;15(3):465-72. doi: 10.1111/pme.12309. Epub 2013 Dec 11.
• Johnston DF, Sondekoppam RV. Continuous quadratus lumborum block analgesia for total hip arthroplasty revision. J Clin Anesth. 2016 Dec;35:235-237. doi: 10.1016/j.jclinane.2016.08.002. Epub 2016 Sep 26. No abstract available.
• Ueshima H, Yoshiyama S, Otake H. RETRACTED: The ultrasound-guided continuous transmuscular quadratus lumborum block is an effective analgesia for total hip arthroplasty. J Clin Anesth. 2016 Jun;31:35. doi: 10.1016/j.jclinane.2015.12.033. Epub 2016 Mar 22. No abstract available.
• Capdevila X, Macaire P, Dadure C, Choquet O, Biboulet P, Ryckwaert Y, D'Athis F. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002 Jun;94(6):1606-13, table of contents. doi: 10.1097/00000539-200206000-00045.
• Kelly T, Wolla CD, Wolf BJ, Hay E, Babb S, Wilson SH. Comparison of lateral quadratus lumborum and lumbar plexus blocks for postoperative analgesia following total hip arthroplasty: a randomized clinical trial. Reg Anesth Pain Med. 2022 Sep;47(9):541-546. doi: 10.1136/rapm-2022-103598. Epub 2022 Jun 10.

Study record dates

Study Major Dates

• Study Start (Actual): July 23, 2020
• Primary Completion (Actual): June 4, 2021
• Study Completion (Actual): June 4, 2021

Study Registration Dates

• First Submitted: May 20, 2020
• First Submitted That Met QC Criteria: May 22, 2020
• First Posted (Actual): May 26, 2020

Study Record Updates

• Last Update Posted (Actual): August 2, 2022
• Last Update Submitted That Met QC Criteria: August 1, 2022
• Last Verified: August 1, 2022

More Information

Terms related to this study

• Other Study ID Numbers: Pro00098482

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No