Pain Relief Comparison: Pericapsular Nerve Group Versus Quadratus Lumborum Block for Positioning in Femur Fracture Surgery

Comparative Evaluation of Analgesic Efficacy of Ultrasound Guided Pericapsular Nerve Group Block and Quadratus Lumborum Block During Positioning of Patients With Proximal Femur Fractures for Spinal Anesthesia

This study aims to compare the analgesic efficacy of Ultrasound Guided Pericapsular Nerve Group Block and Quadratus Lumborum Block for pain relief During patient Positioning for Spinal Anesthesia in proximal femur fracture surgeries. A total of 42 patients enrolled and randomly assigned to either the PENG or QLB group (n=21 each). pain relief will be assessed using the visual analog scale (VAS) at rest and during movement before and after the block, as well as the time of first rescue analgesia and total analgesic consumption. the study will also evaluate the ease of spinal positioning and anesthesiologist satisfaction. patient will be monitored intraoperatively and postoperatively for pain scores. adverse events, and analgesic requirement.

Study Overview

• Status: Completed
• Conditions: Hip Fracture; Quadratus Lumborum Block; Regional Anaesthesia; Acute Post Operative Pain
• Intervention / Treatment: Procedure: Pericapsuler nerve group block; Procedure: Quadratus lumborum block

Detailed Description

The study aim to compare between ultrasound guided pericapsular nerve group block ( PENG) and quadratus lumborum (QLB) block using VAS score to assess the overall efficacy for pain relief during patient positioning for spinal anesthesia.

After approval of anesthesiology department scientific and ethical committees in Ain Shams University Hospitals, 42 patients will be included in the study, and will be divided into two groups (n=21; each); group PENG and QLB group.

The two groups will be adequately monitored and assessed before spinal anesthesia and post-operatively and they will be compared regarding analgesic outcome by using the visual analogue scaling system, besides, recording time for first call for rescue analgesia and total amount of analgesia require.

Preoperative setting:

Complete history taking and full physical examination. Routine preoperative investigations will be done to all patients including laboratory investigations (complete blood picture, liver function tests, prothrombin time and partial thromboplastin time) and other as needed by the patient condition ( e.g. kidney function, ECHO, ECG, chest X-ray Written informed consent will be obtained from all participants prior to the study.

In the preoperative room: pain score at rest (VAS-R) and at 15-degree passive limb elevation in the supine position to assess pain during movement (dynamic VAS (VAS-D)) will be recorded before giving block.

The two blocks will be performed by the most experienced anesthesiologist in the group.

In group A (PENG): the regional block will be performed with the patient in the supine position. Ultrasound machine with low frequency curvilinear probe (2-5MHz) covered with sterile sheath (Sonoscape® SSI 6000, China) will be initially placed in a transverse plane over the Anterior Inferior Iliac Spine (AIIS) and then aligned with the pubic ramus by rotating the probe counter-clockwise approximately 45 degrees. In this view, the Iliopectineal Eminence (IPE), the iliopsoas muscle and tendon, the femoral artery, and pectineus muscle will be observed. A 22-gauge, 80-mm needle (B- Braun Medical Inc., Bethlehem, PA, USA) will be inserted from lateral to medial to place the tip in the musculofascial plane between the psoas tendon anteriorly and the pubic ramus posteriorly. Following negative aspiration, the local anesthetic solution (30ml of bupivacaine 0.25%) will be injected in 5-mL increments while observing for adequate fluid spread in this plane, without exceeding the toxic dose (3 mg/kg).

In group B (QLB): the block will be performed with the patient in the supine position. Under ultrasound guidance with a low frequency curvilinear probe (2-5MHz) covered with sterile sheath (Sonoscape® SSI 6000, China), the probe will be placed in coronal plane at midaxillary line between subcostal margin and iliac crest. A 22-gauge, 80-mm needle (B- Braun Medical Inc., Bethlehem, PA, USA) will be inserted distal to subcostal margin and advanced under curvilinear probe. The needle will be advanced through external oblique aponeurosis, internal oblique, and transversus abdominis muscles. Visualizing the tip penetrating the posterior epimysium of QLM and entering anterior thoracolumbar fascia (ATLF). A small volume of local anesthetic will be injected after locating the needle tip and a negative aspiration for blood. After the distribution of the local anesthetic will be seen, the rest of the 30 mL of 0.25 % of bupivacaine will be injected.

Following the block, heart rate and mean blood pressure will be recorded every 5 min to ensure the blockade is adequate and to monitor the sign of local anesthetic toxicity for 15 min.

If local anesthetic toxicity occurred, cardiovascular and respiratory support and 20% intralipid bolus of 1.5 ml/kg over 2-3 min will be given.

VAS will be assessed at rest (VAS-R) and 15-degree limb elevation (VAS-D) every 10 min for 30 min. After 30 min, patients will be shifted to the operative room.

The median reduction in the VAS score from baseline to 30 minutes will be recorded.

Intraoperative setting:

An intravenous ringer lactate infusion (10-20 ml/kg for 15-20 minutes ) prior to the administration of spinal anesthesia. The patient will be monitored during the procedure using pulse oximetry, non-invasive blood pressure and electrocardiogram.

Patients will be asked to sit for spinal anesthesia. At that time, comfort during sitting for spinal anesthesia will be assessed by the ease of spinal position score (EOSP) (1-sitting without pain and minimal help, 2-mild pain detected by grimacing or verbal expression, 3-severe pain but tolerates positioning with help, 4-unable to sit, requires additional analgesia) . The anesthesiologist who perform spinal anesthesia will be surveyed by team members for operator satisfaction (excellent, good, average, poor) regarding the patient's position. If the patient cannot sit due to pain and VAS was ≥ 4, it will be considered block failure. The patient will be excluded from the study, then patient will receive general anesthesia.

All patients will receive the standard technique of spinal anesthesia in the sitting position after 30 min from the performance of the block by an expert anesthesiologist who is blind and different from the anesthesiologist who perform the two blocks.

For the two groups, spinal anesthesia will be performed under complete aseptic conditions using spinal needle of 25-G, 3 ml bupivacaine 0.5% (heavy Marcaine). Intraoperative antiemetic will be routinely administered, in form of dexamethasone 8 mg IV and ondansetron 4 mg I.V unless contraindicated.

The VAS score will be measured immediately postoperatively and every 2 hours during the first 6 hours and then every 6 hours for only first 24 hours postoperative while patients still at hospital.

If the VAS score is > 4, rescue analgesia will be given; a nalbuphine 0.2 mg/kg IV ; first analgesic request time and the total dose of nalbuphine will be recorded.

• Study Type: Interventional
• Enrollment (Actual): 42
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Egypt
  • Abassya
    • Cairo, Abassya, Egypt, 00202
      • Ain shams university

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adult patients aging > 21 years of both sexes.
• Patients scheduled for fixation of proximal femur fracture under spinal anesthesia.
• ASA Physical Status Class I, II or ш.

Exclusion Criteria:

• Patient refusal to participate.
• Patients receiving opioids for chronic analgesic therapy.
• in ability to comprehend the visual analog scale.
• Coagulopathy ( INR > 1.4, platelets < 80000/mm3, or bleeding disorder).
• Infection at the injection site.
• Allergy to local anesthetics.
• Polytroma patients ( e.g., concurrent major thoracic/ abdominal injuries)
• Severe cardiopulmonary disease (e.g., low fixed cardiac output, NYHA class 3/4).
• Neurological disease (e.g., peripheral neuropathy, multiple sclerosis).

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Pericapsular nervegroup block; the regional block will be performed with the patient in the supine position. Ultrasound machine with low frequency curvilinear probe (2-5MHz) covered with sterile sheath will be initially placed in a transverse plane over the Anterior Inferior Iliac Spine (AIIS) and then aligned with the pubic ramus by rotating the probe counter-clockwise approximately 45 degrees. In this view, the Iliopectineal Eminence (IPE), the iliopsoas muscle and tendon, the femoral artery, and pectineus muscle will be observed. A 22-gauge, 80-mm needle will be inserted from lateral to medial to place the tip in the musculofascial plane between the psoas tendon anteriorly and the pubic ramus posteriorly. Following negative aspiration, the local anaesthetic solution (30ml of bupivacaine 0.25%) will be injected in 5-mL increments while observing for adequate fluid spread in this plane, without exceeding the toxic dose (3 mg/kg)	Procedure: Pericapsuler nerve group block; A single shot pericapsular nerve group block preformed under ultrasound guidance with a local anesthetic agent ( Marcaine )
Active Comparator: Quadratus lumborum block; the block will be performed with the patient in the supine position. Under ultrasound guidance with a low frequency curvilinear probe (2-5MHz) covered with sterile sheath, the prob will be placed in coronal plane at midaxillary line between subcostal margin and iliac crest. A 22-gauge, 80-mm needle will be inserted distal to subcostal margin and advanced under curvilinear probe. The needle will be advanced through external oblique aponeurosis, internal oblique, and transversus abdominis muscles. Visualizing the tip penetrating the posterior epimysium of QLM and entering anterior thoracolumbar fascia (ATLF). A small volume of local anaesthetic will be injected after locating the needle tip and a negative aspiration for blood. After the distribution of the local anesthetic will be seen, the rest of the 30 mL of 0.25 % of bupivacaine will be injected	Procedure: Quadratus lumborum block; A single shot Quadratus lumborum block preformed under ultrasound guidance with a local anesthetic agent ( Marcaine )

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
difference in dynamic visual analog scale (VAS - D) scores at 30 minutes post. - block	comparison of median reduction in VAS - D scores ( during 15 - degree limb elevation ) between ultrasound - guided pericapsular nerve group block and quadratus lumborum block at 30 minutes after block administration. scale: VAS ( 0 - 10 cm; 0 = no pain, 10 = worst pain )	baseline ( pre - block ) to 30 minutes post block.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
ease of spinal positioning score (EOSP)	assessed during sitting for spinal anesthesia using a 4 - point ordinal scale; sitting without pain and minimal help.; mild pain detected by grimacing or verbal expression.; severe pain but tolerates positioning with help.; unable to sit, requires additional analgesia)	immediately before spinal anesthesia ( 30 minutes post - block )
operator satisfaction score	rated by the anesthesiologist preforming spinal anesthesia on a 4 - point scale: excellent, good, average, poor	immediately after spinal anesthesia placement.
postoperative pain score	visual analog scale score recorded at: 0 hour postoperative, 2 hour, 4 hour, 6 hour, 12 hour and 24 hour postoperatively.	first 24 hours post - surgery
time of first rescue analgesia	time ( minutes ) from block administration to first request for rescue analgesia ( nalbuphine )	up to 24 hours post - block
total rescue analgesia consumption	cumulative dose of nalbuphine ( mg ) administered in the first 24 hours postoperatively.	first 24 hours post - surgery

Collaborators and Investigators

• Sponsor: Ain Shams University

Study record dates

Study Major Dates

• Study Start (Actual): April 10, 2025
• Primary Completion (Actual): October 10, 2025
• Study Completion (Actual): January 10, 2026

Study Registration Dates

• First Submitted: March 6, 2025
• First Submitted That Met QC Criteria: April 4, 2025
• First Posted (Actual): April 9, 2025

Study Record Updates

• Last Update Posted (Actual): February 10, 2026
• Last Update Submitted That Met QC Criteria: February 8, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: clinical trial; nerve block; postoperative analgesia; regional anesthesia; Hip fracture; PENG block; QLB block; opioid sparing anesthesia; pain managment; acute pain control
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Wounds and Injuries; Postoperative Complications; Pathologic Processes; Leg Injuries; Fractures, Bone; Femoral Fractures; Hip Injuries; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Pain, Postoperative; Hip Fractures
• Other Study ID Numbers: MD02/2024/2025

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No