The analgesic efficacy of the transversalis fascia plane block in iliac crest bone graft harvesting: a randomized controlled trial

Nicholas D Black, Laith Malhas, Rongyu Jin, Anuj Bhatia, Vincent W S Chan, Ki Jinn Chin, Nicholas D Black, Laith Malhas, Rongyu Jin, Anuj Bhatia, Vincent W S Chan, Ki Jinn Chin

Abstract

Background: Iliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting.

Methods: Fifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery.

Results: The TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively.

Conclusions: The TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.

Keywords: Anesthesia; Conduction; Fascia; Local anesthesia; Nerve block.

Conflict of interest statement

Conflicts of Interest

Dr. Vincent Chan has received honorarium from Aspen Pharma, BBraun, Smiths Medical, and SonoSite.

Figures

Fig. 1.
Fig. 1.
Pre-injection and post-injection sonograms of the TFP block. The local anesthetic (*) can be seen deep to the TA muscle and pushing the perinephric fat downwards. TFP: transversalis fascia plane, TA: transversus abdominis, EO: external oblique, IO: internal oblique, QL: quadratus lumborum, and LA: local anesthetic. Reproduced with permission from Ultrasound for Regional Anesthesia (USRA; Available from http://www.usra.ca).
Fig. 2.
Fig. 2.
Flow chart outlining patient inclusion. GA: general anesthesia.
Fig. 3.
Fig. 3.
The numbers of patients with sensory loss to touch at each dermatomal level. All patients had a block at L1; however, the block was limited to this dermatome in the majority (65%). One patient had a block that extended to T6.

References

    1. Morgan SJ, Jeray KJ, Saliman LH, Miller HJ, Williams AE, Tanner SL, et al. Continuous infusion of local anesthetic at iliac crest bone-graft sites for postoperative pain relief. A randomized, double-blind study. J Bone Joint Surg Am. 2006;88:2606–12.
    1. DeOrio JK, Farber DC. Morbidity associated with anterior iliac crest bone grafting in foot and ankle surgery. Foot Ankle Int. 2005;26:147–51.
    1. Todd BD, Reed SC. The use of bupivacaine to relieve pain at iliac graft donor sites. Int Orthop. 1991;15:53–5.
    1. Cowan N, Young J, Murphy D, Bladen C. Double-blind, randomized, controlled trial of local anesthetic use for iliac crest donor site pain. J Neurosci Nurs. 2002;34:205–10.
    1. Blumenthal S, Dullenkopf A, Rentsch K, Borgeat A. Continuous infusion of ropivacaine for pain relief after iliac crest bone grafting for shoulder surgery. Anesthesiology. 2005;102:392–7.
    1. Singh K, Phillips FM, Kuo E, Campbell M. A prospective, randomized, double-blind study of the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after posterior spinal arthrodesis: a minimum of 4-year follow-up. Spine (Phila Pa 1976) 2007;32:2790–6.
    1. Brull SJ, Lieponis JV, Murphy MJ, Garcia R, Silverman DG. Acute and long-term benefits of iliac crest donor site perfusion with local anesthetics. Anesth Analg. 1992;74:145–7.
    1. Hebbard PD. Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block. Can J Anaesth. 2009;56:618–20.
    1. Chin KJ, Chan V, Hebbard P, Tan JS, Harris M, Factor D. Ultrasound-guided transversalis fascia plane block provides analgesia for anterior iliac crest bone graft harvesting. Can J Anaesth. 2012;59:122–3.
    1. López-González JM, López-Álvarez S, Jiménez Gómez BM, Areán González I, Illodo Miramontes G, Padín Barreiro L. Ultrasound-guided transversalis fascia plane block versus anterior transversus abdominis plane block in outpatient inguinal hernia repair. Rev Esp Anestesiol Reanim. 2016;63:498–504.
    1. Choudhary J, Mishra AK, Jadhav R. Transversalis fascia plane block for the treatment of chronicpostherniorrhaphy inguinal pain: a case report. A A Pract. 2018;11:57–9.
    1. Tulgar S, Serifsoy TE. Transversalis fascia plane block provides effective postoperative analgesia for cesarean section: New indication for known block. J Clin Anesth. 2018;48:13–4.
    1. Punekar IR, Koltz PF, Smith DI, Tran NH, Chibber AK, Sbitany H, et al. The evolution of iliac bone graft donor site analgesia in cleft patients: transversus abdominis plane block is safe and efficacious. Ann Plast Surg. 2018;81:441–3.
    1. Chin KJ. USRA: Advancing the Science of Ultrasound Guided Regional Anesthesia and Pain Medicine; Transversalis fascia plane block [Internet] [cited 2018 Nov 13]. Available from .
    1. Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987;30:191–7.
    1. Maruish ME. User’s manual for the SF-36v2 health survey. Quality Metric Incorporated, 2011. Available from .
    1. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft. Complications and functional assessment. Clin Orthop Relat Res. 1997;(339):76–81.
    1. Richebé P, Capdevila X, Rivat C. Persistent postsurgical pain: pathophysiology and preventative pharmacologic considerations. Anesthesiology. 2018;129:590–607.
    1. Chiono J, Bernard N, Bringuier S, Biboulet P, Choquet O, Morau D, et al. The ultrasound-guided transversus abdominis plane block for anterior iliac crest bone graft postoperative pain relief: a prospective descriptive study. Reg Anesth Pain Med. 2010;35:520–4.
    1. Sondekoppam RV, Ip V, Johnston DF, Uppal V, Johnson M, Ganapathy S, et al. Ultrasound-guided lateral-medial transmuscular quadratus lumborum block for analgesia following anterior iliac crest bone graft harvesting: a clinical and anatomical study. Can J Anaesth. 2018;65:178–87.
    1. Børglum J, Jensen K, Christensen AF, Hoegberg LC, Johansen SS, Lönnqvist PA, et al. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. Reg Anesth Pain Med. 2012;37:294–301.
    1. Lee TH, Barrington MJ, Tran TM, Wong D, Hebbard PD. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesth Intensive Care. 2010;38:452–60.
    1. Chin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of our current understanding: abdominal wall blocks. Reg Anesth Pain Med. 2017;42:133–83.
    1. Lee S, Goetz T, Gharapetian A. Unanticipated motor weakness with ultrasound-guided transversalis fascia plane block. A A Case Rep. 2015;5:124–5.
    1. Ueshima H, Hiroshi O. Incidence of lower-extremity muscle weakness after quadratus lumborum block. J Clin Anesth. 2018;44:104.
    1. Manatakis DK, Stamos N, Agalianos C, Karvelis MA, Gkiaourakis M, Davides D. Transient femoral nerve palsy complicating “blind” transversus abdominis plane block. Case Rep Anesthesiol. 2013;2013:874215.
    1. Walker G. Transversus abdominis plane block: a note of caution! Br J Anaesth. 2010;104:265.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren