Comparison of the Postoperative Analgesic Effects between Ultrasound-Guided Transmuscular Quadratus Lumborum Block and Thoracic Paravertebral Block in Laparoscopic Partial Nephrectomy Patients: A Randomized, Controlled, and Noninferiority Study

Jin Wang, Xulei Cui, Liying Ren, Xu Li, Yuelun Zhang, Yi Xie, Zhigang Ji, Yuguang Huang, Jin Wang, Xulei Cui, Liying Ren, Xu Li, Yuelun Zhang, Yi Xie, Zhigang Ji, Yuguang Huang

Abstract

Background: This prospective, randomized, double-blinded, noninferiority study aimed to compare the effects of analgesia and recovery between transmuscular quadratus lumborum block (TMQLB) and paravertebral block (PVB).

Methods: Sixty-eight, American Society of Anesthesiologists level I-III patients, who underwent laparoscopic partial nephrectomy in Peking Union Medical College Hospital were randomly allocated to either TMQLB or PVB group (independent variable) in a 1 : 1 ratio. The TMQLB and PVB groups received corresponding regional anesthesia preoperatively with 0.4 ml/kg of 0.5% ropivacaine and follow-up at postoperative 4, 12, 24, and 48 hours. The participants and outcome assessors were blinded to group allocation. We hypothesized that the primary outcome, postoperative 48-hour cumulative morphine consumption, in the TMQLB group was not more than 50% of that in the PVB group. Secondary outcomes including pain numerical rating scales (NRS) and postoperative recovery data were dependent variables.

Results: Thirty patients in each group completed the study. The postoperative 48-hour cumulative morphine consumption was 10.60 ± 5.28 mg in the TMQLB group and 6.40 ± 3.40 mg in the PVB group. The ratio (TMQLB versus PVB) of postoperative 48-hour morphine consumption was 1.29 (95% CI: 1.13-1.48), indicating a noninferior analgesic effect of TMQLB to PVB. The sensory block range was wider in the TMQLB group than in the PVB group (difference 2 dermatomes, 95% CI 1 to 4 dermatomes, P=0.004). The intraoperative analgesic dose was higher in the TMQLB group than in the PVB group (difference 32 µg, 95% CI: 3-62 µg, P=0.03). The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups (all P > 0.05).

Conclusions: The postoperative 48-hour analgesic effect of TMQLB was noninferior to that of PVB in laparoscopic partial nephrectomy. This trial is registered with NCT03975296.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Copyright © 2023 Jin Wang et al.

Figures

Figure 1
Figure 1
Ultrasound-guided transmuscular quadratus lumborum block (a, b) and thoracic paravertebral block (c, d). AWM: abdominal wall muscle, EPF: extraperitoneal fat, ESM: erector spine muscle, PM: psoas muscle, QLM: quadratus lumborum muscle, P: pleura, PS: paravertebral space, L: lamina, ICM: intercostal muscle, ∗: LA, yellow arrows: needle.
Figure 2
Figure 2
Consolidated standards of reporting trials flow diagram showing patient progress through the study phases.
Figure 3
Figure 3
Range of dermatomal sensory block levels.
Figure 4
Figure 4
Noninferiority diagram of postoperative 48-hour cumulative morphine consumption differences in TMQLB and TPVB group. Error bar: 95% confidence interval.

References

    1. Børglum J., Moriggl B., Jensen K., et al. Ultrasound-guided transmuscular quadratus lumborum blockade. British Journal of Addiction: British Journal of Anaesthesia . 2013;111 doi: 10.1093/bja/el_9919.
    1. Elsharkawy H., El-Boghdadly K., Barrington M. Quadratus lumborum block: anatomical concepts, mechanisms, and techniques. Anesthesiology . 2019;130(2):322–335. doi: 10.1097/aln.0000000000002524.
    1. Børglum J., Gögenür I., Bendtsen T. F. Abdominal wall blocks in adults. Current Opinion in Anaesthesiology . 2016;29(5):638–643. doi: 10.1097/aco.0000000000000378.
    1. Dam M., Moriggl B., Hansen C. K., Hoermann R., Bendtsen T. F., Børglum J. The pathway of injectate spread with the transmuscular quadratus lumborum block: a cadaver study. Anesthesia & Analgesia . 2017;125(1):303–312. doi: 10.1213/ane.0000000000001922.
    1. Lee A. J., Yabes J. G., Hale N., et al. The comparative effectiveness of quadratus lumborum blocks and paravertebral blocks in radical cystectomy patients. The Canadian Journal of Urology . 2018;25(2):9255–9261.
    1. Hussain N., Brull R., Zhou S., et al. Analgesic benefits of single-shot versus continuous adductor canal block for total knee arthroplasty: a systemic review and meta-analysis of randomized trials. Regional Anesthesia and Pain Medicine . 2023;48(2):49–60. doi: 10.1136/rapm-2022-103756.
    1. Little C., Rahman S. Quadratus lumborum blocks in nephrectomy: a narrative review. Local and Regional Anesthesia . 2021;14:57–65. doi: 10.2147/lra.s290224.
    1. Dam M., Hansen C., Poulsen T. D., et al. Transmuscular quadratus lumborum block reduces opioid consumption and prolongs time to first opioid demand after laparoscopic nephrectomy. Regional Anesthesia and Pain Medicine . 2021;46(1):18–24. doi: 10.1136/rapm-2020-101745.
    1. Xulei C., Xu L., Minna L., et al. Ultrasound-guided transmuscular quadratus lumbar block reduces opioid consumption after laparoscopic partial nephrectomy. Chinese Medical Sciences Journal . 2020;35(4):289–296. doi: 10.24920/003759.
    1. Li H., Shi R., Wang Y. Use of transmuscular quadratus lumborum block for postoperative analgesia after laparoscopic nephrectomy. Regional Anesthesia and Pain Medicine . 2021;46(12):1118–1119. doi: 10.1136/rapm-2021-102478.
    1. Uppal V., Retter S., Kehoe E., McKeen D. M. Quadratus lumborum block for postoperative analgesia: a systematic review and meta-analysis. Canadian Journal of Anesthesia/Journal canadien d’anesthésie . 2020;67(11):1557–1575. doi: 10.1007/s12630-020-01793-3.
    1. Yuan Q., Lu S., Cui X., et al. Transmuscular quadratus lumborum block for postoperative pain and recovery after laparoscopic adrenalectomy: a randomized controlled trial. BMC Anesthesiology . 2021;21(1):p. 274. doi: 10.1186/s12871-021-01494-4.
    1. Renes S. H., Bruhn J., Gielen M. J., Scheffer G. J., van Geffen G. J. In-planeultrasound-guided thoracic paravertebral block: a preliminary report of 36 cases with radiologic confirmation of catheter position. Regional Anesthesia and Pain Medicine . 2010;35(2):212–216. doi: 10.1097/aap.0b013e3181c75a8b.
    1. Bauer M., Böhrer H., Aichele G., Bach A., Martin E. Measuring patient satisfaction with anaesthesia: perioperative questionnaire versus standardised face-to-face interview. Acta Anaesthesiologica Scandinavica . 2001;45(1):65–72. doi: 10.1034/j.1399-6576.2001.450111.x.
    1. Li M. N., Yu X. R., Li H. G., Pei L. J., Huang Y. G. Effect of brochure on patients’ anesthesia-related discomfort and satisfaction. Basic & Clinical Medicine . 2016;36:875–878.
    1. Bu X. S., Zhang J., Zuo Y. X. Validation of the Chinese version of the quality of recovery-15 score and its comparison with the post-operative quality recovery scale. Patient . 2016;9(3):251–259. doi: 10.1007/s40271-015-0148-6.
    1. Stark P. A., Myles P. S., Burke J. A. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology . 2013;118(6):1332–1340. doi: 10.1097/aln.0b013e318289b84b.
    1. Meier A. W., Auyong D. B., Yuan S. C., Lin S. E., Flaherty J. M., Hanson N. A. Comparison of continuous proximal versus distal adductor canal blocks for total knee arthroplasty: a randomized, double-blind, noninferiority trial. Regional Anesthesia and Pain Medicine . 2018;43(1):36–42. doi: 10.1097/aap.0000000000000692.
    1. Kirkpatrick J. J., Foutz S., Leslie S. W. StatPearls: Treasure Island (FL) St. Petersburg, FL, USA: StatPearls Publishing LLC; 2021. Anatomy, abdomen and pelvis, kidney nerves.
    1. Zhu M., Qi Y., He H., Lou J., Pei Q., Mei Y. Analgesic effect of the ultrasound-guided subcostal approach to transmuscular quadratus lumborum block in patients undergoing laparoscopic nephrectomy: a randomized controlled trial. BMC Anesthesiology . 2019;19(1):p. 154. doi: 10.1186/s12871-019-0825-4.
    1. Taketa Y., Irisawa Y., Fujitani T. Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery: a randomized controlled non-inferiority clinical trial. Regional Anesthesia and Pain Medicine . 2019;45(1):10–15. doi: 10.1136/rapm-2019-100827.
    1. Patnaik R., Chhabra A., Subramaniam R., et al. Comparison of paravertebral block by anatomic landmark technique to ultrasound-guided paravertebral block for breast surgery anesthesia: a randomized controlled trial. Regional Anesthesia and Pain Medicine . 2018;43(4):385–390. doi: 10.1097/aap.0000000000000746.
    1. Krediet A. C., Moayeri N., van Geffen G.-J., et al. Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology . 2015;123(2):459–474. doi: 10.1097/aln.0000000000000747.
    1. Cho T. H., Kim S. H., Kwon H. J., Kim K. W., Yang H. M. Anatomy of the thoracic paravertebral space: 3D micro-CT findings and their clinical implications for nerve blockade. Regional Anesthesia and Pain Medicine . 2021;46(8):699–703. doi: 10.1136/rapm-2021-102588.
    1. Bouman E. A., Sieben J. M., Balthasar A. J., et al. Boundaries of the thoracic paravertebral space: potential risks and benefits of the thoracic paravertebral block from an anatomical perspective. Surgical and Radiologic Anatomy . 2017;39(10):1117–1125. doi: 10.1007/s00276-017-1857-4.
    1. Kumar A., Sadeghi N., Wahal C., Gadsden J., Grant S. A. Quadratus lumborum spares paravertebral space in fresh cadaver injection. Anesthesia & Analgesia . 2017;125(2):708–709. doi: 10.1213/ane.0000000000002245.
    1. Tamura T., Yokota S., Ito S., Shibata Y., Nishiwaki K. Local anesthetic spread into the paravertebral space with two types of quadratus lumborum blocks: a crossover volunteer study. Journal of Anesthesia . 2019;33(1):26–32. doi: 10.1007/s00540-018-2578-5.
    1. Alper I., Yüksel E. Comparison of acute and chronic pain after open nephrectomy versus laparoscopic nephrectomy: a prospective clinical trial. Medicine (Baltimore) . 2016;95(16) doi: 10.1097/md.0000000000003433.e3433
    1. Jin S. J., Park J. Y., Kim D. H., et al. Comparison of postoperative pain between laparoscopic and robot-assisted partial nephrectomies for renal tumors: a propensity score matching analysis. Medicine (Baltimore) . 2017;96(29) doi: 10.1097/md.0000000000007581.e7581
    1. Li X., Xu Z. Z., Li Y. T., Lin Z. M., Liu Z. Y., Wang D. X. Analgesic efficacy of two approaches of ultrasound-guided quadratus lumborum block for laparoscopic renal surgery: a randomised controlled trial. European Journal of Anaesthesiology . 2021;38(3):265–274. doi: 10.1097/eja.0000000000001433.

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