Anesth Pain Med.  2023 Oct;18(4):397-405. 10.17085/apm.23011.

Single puncture combined lumbar erector spinae plane and quadratus lumborum block (SEQ block) in acetabular fracture surgeries: randomized clinical trial

• Ahmed AMM
• Moustafa MA
• Alabd AS

• KMID: 2550920
• DOI: http://doi.org/10.17085/apm.23011

Abstract

Background
Acetabular fracture surgery can cause severe postoperative pain. A combined lumbar erector spinae plane block and paraspinous sagittal shift quadratus lumborum block may augment analgesia. Methods: Fifty two patients undergoing posterior column acetabular surgery were divided into: Group Single puncture combined lumbar Erector spinae and Quadratus lumborum block (SEQ), patients who received SEQ block before anesthesia; and Group morphine (MOR), those who received general anesthesia (GA) and morphine. Results: Demographic characteristics were comparable. The heart rate and mean arterial blood pressure were significantly lower in the SEQ group than in the MOR group between 60 and 180 min intraoperatively (P < 0.001). Postoperative resting and dynamic visual analogue scale scores in the SEQ group were significantly lower than those in the MOR group at all studied periods (P = 0.022-0.001), except at 20 and 24 h postoperatively. Fentanyl was required in all MOR group patients at a mean dose of 110.0 ± 28.42 µg while 18 patients required fentanyl in SEQ group at a mean dose of 60.55 ± 25.54 µg. Postoperative morphine consumption was significantly less in SEQ group (6.33 ± 2.37 mg) than MOR group (17.0 ± 2.55 mg). Postoperative nausea and vomiting were recorded in eight and four patients in MOR and SEQ group, respectively. No complications associated with the block technique were observed. Conclusions: The SEQ block reduces the postoperative opioid consumption and provides stable intra and postoperative hemodynamics without observed complications in posterior column acetabular surgery.

Keyword

Nerve block; Pain; Postoperative; Regional anesthesia

Figure

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  Fig. 1. Consort flow diagram. SEQ: Single puncture combined lumbar Erector spinae and Quadratus lumborum block, MOR: morphine.

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  Fig. 2. Probe position during SEQ block technique. (A) Probe in the parasagittal plane about 4 cm lateral to the lumbar vertebrae spinous processes with needle entry point at the cephalic end of the probe; (B) caudal end of the probe has been rotated medially towards the lumbar spine until the hypoechoic shadow of the transverse process of L4 appears in the ultrasound image; (C) probe position corresponding to (A); (D) probe position corresponding to (B). SEQ, Single puncture combined lumbar Erector spinae and Quadratus lumborum block.

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  Fig. 3. Real ultrasound image of the steps of SEQ block. (A) Probe position about 4 cm parallel to lumbar vertebrae with transverse processes appearing in view; (B) characteristic sonographic image of three muscle layers from posterior to anterior: erector spinae, quadratus lumborum and psoas major muscle: (C) PSSS QL block, red arrow represents needle path to the endpoint of injection into the plane between QL and PM muscles in a craniocaudal direction with LA spreading caudally; (D) lumbar ESP block after the caudal end of the probe is rotated medially, here, transverse process of L4 appears in view. The red arrow represents needle path towards transverse process of L4. SEQ: Single puncture combined lumbar Erector spinae and Quadratus lumborum block, PSSS: paraspinous sagittal shift, QL: quadratus lumborum, PM: psoas muscle, LA: local anesthetic, ESP: erector spinae plane, ES: erector spinae muscle, Psoas: psoas major muscle, tr pr L4: transverse process of lumbar vertebra 4, tr pr L5: transverse process of lumbar vertebra 5.

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  Fig. 4. Comparison of the intra-operative and post-operative hemodynamics between the two groups. MOR: morphine, SEQ: Single puncture combined lumbar Erector spinae and Quadratus lumborum block, BP: blood pressure, HR: heart rate. *P < 0.05 was considered statistically significant.

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  Fig. 5. Comparison between of the resting and dynamic VAS scores between the two groups. MOR: morphine, SEQ: Single puncture combined lumbar Erector spinae and Quadratus lumborum block, VAS: visual analogue scale. *P < 0.05 was considered statistically significant.

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