(SEQ Block): Single Puncture Combined Lumbar Erector Spinae Plane Block and Quadratus Lumborum Block for Perioperative Analgesia in Acetabular Surgeries
Phase: PHASE3
Conditions: Anesthesia, Local, Nerve Pain, Pain, Postoperative, Acetabular Fracture
Sponsor: Alexandria University

Dear Clinical trial registry Board, 
        I’d like to register my record titled “ (SEQ block): Single puncture combined lumbar 
erector spinae plane block and quadratus lumborum block for perioperative analgesia in 
acetabular surgeries “ in the Clinical trial registry 
Best Regards, 
     Yours 
     Moustafa Abdelaziz Moustafa 
     Professor of Anesthesia and Surgical Intensive Care 
     Faculty of Medicine, Alexandria University, Egypt 
     25th, December 2020 
 
 
 
 
 
 
 
 
 
 
 
 

(SEQ block): Single puncture combined lumbar erector spinae 
plane block and quadratus lumborum block for perioperative 
analgesia in acetabular surgeries 
 
Introduction: Acetabular fractures represent relatively infrequent traumatic injuries that can 
lead to a progressive impairment of hip articular function. Surgical treatment of these fractures 
may require extensive surgical dissections and frequently is associated with significant 
postoperative pain, delay in rehabilitation, and prolonged hospital stay. Innervation of the 
acetabular region is mainly provided by branches of lumbar and sacral plexuses, in addition to 
dorsal rami of lumbar nerve roots supplying the tissues to be dissected during posterior approach 
for acetabular fractures.(1) We suggest a novel approach for combined lumbar erector spinae plane 
block and PSSS quadratus lumborum block for perioperative analgesia in hip/acetabular surgeries 
using a single puncture technique (SEQ block). 
 
Aim of the study: The primary aim of this study is to compare the total postoperative opioid 
(morphine) consumption after posterior column acetabular surgery when providing ultrasound 
guided SEQ block: single puncture combined lumbar erector spinae plane block and paraspinous 
sagittal shift (PSSS) quadratus lumborum block versus conventional intravenous morphine 
analgesia. 
The secondary aims of this study are; sensory assessment in the block group for 
(dermatomal distribution), intraoperative and postoperative hemodynamics (MAP and HR), 
resting visual analogue scale (VAS), dynamic VAS, postoperative complications. 
Methods: After obtaining approval from Alexandria university ethics committee, this study 
will be carried out starting from November 2020 for 1 year in El-Hadara university hospital on 
American Society of Anesthesiologists (ASA) physical status I-III patients scheduled for unilateral 
posterior wall/column acetabular fractures surgery using posterior approach. The exclusion criteria 
will include; BMI > 35 kg/m2, pre-existing neurological deficit, spine deformity, 
pregnancy/lactation, significant renal or hepatic impairment, known contraindications to 
peripheral nerve block (coagulopathy or infection at the site of injection), or chronic opioid 
users/abusers. 
Patients will be divided into 2 groups. Group SEQ; patients will receive ultrasound guided 
SEQ block preoperatively before the induction of general anaesthesia (GA). Group MOR; patients 
will receive GA and analgesia will be based on opioids mainly intravenous morphine. 
Upon arrival to the operating room (OR), a multichannel monitor will be attached to 
patients, followed by the administration of 2 mg midazolam IV after securing an IV cannula. 
SEQ block: It is a combination of paraspinous sagittal shift (PSSS) quadratus lumborum (QL) 
block and erector spinae plane block (ESPB). Before the induction of GA in group SEQ, patients 
will lay laterally on the healthy side with the fracture side independent, a curvilinear ultrasound 

transducer  (2–5 MHz) (Sonosite, M-turbo, Bothell, WA, USA) will be placed in a parasagittal 
plane 3-4 cm lateral to the  lumbar spinous process of L4 (which is almost opposite to the iliac 
crest), producing a longitudinal scan of the lumbar paravertebral region, thus identifying the 
transverse processes of L3 and L4 with psoas muscle (PM) in-between and erector spinae muscle 
(ESM) posteriorly (superficial to transverse processes), the probe is shifted slowly to the lateral 
side till  the transverse processes disappear and quadratus lumborum (QL) muscle is evident in its 
long axis attached caudally to the iliac crest with a characteristic sonographic image of three 
muscle layers appearing from posterior to anterior as : ESM, QL, and PM muscles respectively. 
Here, anterior layer of thoracolumbar fascia (ATLF) - which is considered as continuation of fascia 
transversalis - is seen separating PM and QL muscles. 
After subcutaneous local infiltration with lidocaine 1% at the cephalic end of the probe, the 
block needle is advanced in a cephalo-caudal direction, through the erector spinae and QL muscles, 
untill it pierces the epimysium of the QL muscle. Local anaesthetic (LA) is injected anterior to the 
QL, observing it’s spread in a caudal direction towards the iliac crest between the QL and psoas 
muscles.  
Then the caudal end of the probe is rotated slowly medially towards lumbar spine till the 
hypoechoic shadow of transverse process of L4 appears in the ultrasound image. The needle is 
withdrawn to subcutaneous tissue, then advanced in plane towards transverse process of L4. After 
contacting it, LA is deposited in the plane between transverse process and overlying ESM. Total 
volume of LA used will be 50 ml of 0.25 % bupivacaine, 25 ml for each injection. 
Figure 1. (a) Diagrammatic representation of probe position during SEQ block technique. (a) probe is in para-
sagittal plane about 4 cm lateral to lumbar vertebrae spinous processes with needle entry point at cephalad end of the 
probe, (b) caudal end of the probe is rotated medially towards lumbar spine till the hypoechoic shadow of transverse 
process of L4 appears in the ultrasound image. 
 

Thirty minutes after block performance, sensory assessment will be performed using a pin 
prick test for dermatomal distribution, followed by the induction of GA. While, in group M; no 
block will be given. 
Anaesthesia will be induced with propofol 2 mg/kg, atracurium 0.5 mg/kg, and fentanyl 
1µg/kg, followed by endotracheal intubation, anaesthesia will be maintained by isoflurane 1 MAC 
in 100% oxygen. Multimodal analgesia protocol will be provided including intravenous 
dexamethasone 8 mg, paracetamol 1 gm, and ketorolac 60 mg. Increments of 0.5 µg/kg of fentanyl 
will be given intraoperatively if there is an increase in HR/MAP above 20% of the basal value.  
Postoperatively, multimodal analgesia regimen will be continued in the form of 
paracetamol 1 g /8 hours and ketorolac 30 mg /8 hours intravenously for 48 hours. Intravenous 
morphine in a dose of 0.05 mg/kg will be given as a rescue analgesic when the VAS ≥4. 
Measurements: 
1. HR and MAP will be recorded preoperatively (baseline), every 30 minutes during the 
surgery, and every hour postoperatively for the first 4 hours, then every 4 hours for the 
remaining 24 hour postoperative follow up. 
2. Resting VAS every hour for the first 4 hours, then every 4 hours for the remaining 24 hour 
postoperative follow up. 
3. Dynamic VAS every hour for the first 4 hours, then every 4 hours for the remaining 24 
hour postoperative follow up. 
4. Total analgesic requirement (intraoperative fentanyl and postoperative morphine). 
5. Postoperative complications (block or opioid related complications). 
References: 
1. Chelly JE, Casati A, Al-Samsam T, Coupe K, Criswell A, Tucker J. Continuous lumbar plexus block for 
acute postoperative pain management after open reduction and internal fixation of acetabular fractures. 
Journal of orthopaedic trauma. 2003;17(5):362-7