Effect of Different Truncal Blocks Under Ultrasound-Guidance on Pain Management After Open Reduction of Pediatric Developmental Dysplasia of the Hip: a Randomized Trial
Phase: NA
Conditions: Developmental Dysplasia of the Hip (DDH)
Sponsor: Second Affiliated Hospital of Wenzhou Medical University

 
 
 
 
 
Effect of different truncal blocks under ultrasound-guidance on pain 
management after open reduction of pediatric developmental 
dysplasia of the hip: a randomized trial 
 
 
Background: 
 
Transversus abdominis plane block(TAP block) 
The abdominal wall and parietal peritoneum are innervated by the ventral rami of the 
spinal nerves T6–L1[5]. The nerves run in a fascial layer that exists between the internal 
oblique (IO) and transversus abdominis(TA) muscles in the anterior abdominal wall. That 
is the transversus abdominis plane (TAP)[5].The entry points of the nerve in TAP are 
variable which may effect the analgesia and limit the clinical practice[6].The twelfth thoracic, 
 
ilioinguinal, and iliohypogastric nerves travel over the anterior surface of the quadratus 
lumborum muscle, which inserts on the 12thrib and the transverse processes of the 
vertebrae L1-L4. The twelfth thoracic nerve then continue runs a short distance deep to 
the aponeurotic which is the posterior extension of the transversus abdominis muscle 
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before going into the TAP[7].The ilioinguinal and iliohypogastric nerves continue run deep 
to the transversus muscle aponeurosis and later penetrate the aponeurosis in a more 
anterior and highly variable position[8].So it is difficulty to cover the twelfth thoracic, 
ilioinguinal, and iliohypogastric nerves when performing posterior transverses abdominis 
plane (TAP) block[9],while posterior injections in the triangle of Petit. 
Quadratus lumborum block(QLB) 
 
Different approaches of transversus abdominis plane blocks techniques cause 
variations in analgesia features. With the recent description of the quadratus lumborum 
(QL)block, it seems to be an increasingly more popular alternative than the traditional TAP 
block, for postoperative pain management [10-14].Many see the various QL block 
techniques as a natural continuation of the original TAP block approach at the triangle of 
Petit [15].However, quadratus lumborum block and TAP block are essentially different 
categories of nerve blocks. A posterior TAP block is per definition superficial to the TAP 
and the transversus abdominis aponeurosis. The lateral QLB is deep to the transversus 
abdominis aponeurosis. Unlike the TAP block, the target point of the QLB is more 
posteriorly at the junction of the TA and the QL muscle just deep to the transversalis 
fascia. It can provide extensive abdominal wall and visceral analgesia(T7–L1)as a result 
local anesthetic secondary spreading to the paravertebral space [16].The analgesia 
characteristics of QLB attracts our attention. Blanco et al. performed a randomized 
controlled trial comparing a single shot injection of local anesthetic versus saline injection 
at the QL for caesarean section postoperative analgesia and showed a significant 
decrease in postoperative opioid consumption and dynamic pain scores [13],and also 
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believed the local anesthetic placed under QLM can be transported to paravertebral 
space along tissue plane. QLB is the extension of TAP block toward the dorsal region. A 
single shot injection of local anesthetic under posterior approach of TAP block covers all 
the dermatome segments from caudally L2 to cranially till T4 segments as the drug is 
expected to travel from the QL to the higher paravertebral spaces [17] .They also found the 
contrast enhancement from T4-L2 using magnetic resonance imaging(MRI)[17].The 
coverage of the dermatome segments depends on volume used. There are no guidelines 
on the volume of drug to be injected, especially in pediatric. McDonnell et al conducted a 
research on the analgesic efficacy of TAP block in the landmark technique, and 
demonstrated a single bolus dose (20ml of 0.375% levobupivacaine) were able to cover 
the incisions above and below umbilicus in adults undergoing large bowel resection [18]. 
Kadam VR reported 25ml 0.5% ropivacaine in ultrasound-guided quadrates lumborum 
block for laparotomy only covered sensory block T8-L1[19]. Based on a radiological 
study[17],0.3ml/Kg doses of local anesthetic maybe the low volume for adults and 0.6ml/Kg 
doses maybe the high volume which could have produced high systemic levels in 
landmark-guided TAP block[17]. Theoretically, it should be possible as the block spreads to 
the paravertebral space to cover the nerves as they exit. In an ultrasound-guided contrast 
study by Barrington et al [20], on cadavers demonstrated that multiple injections could 
involve more nerves. Believeing that accumulated up to at least 30-40ml in adults, local 
anesthetic spreaded to as high as T4 level and expected to last longer [20]. However, the 
experience of others suggests that these doses are safe and well tolerated. Two cases 
report showed that the ultrasound-guided continuous trans-muscular QLB by suing 0.3% 
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levobupivacaine 25 mL which has covered the dermatome segments from thoracic 11th to 
lumbar 4th and thoracic 12th to lumbar 2nd respectively is an effective analgesia for total 
hip arthroplasty (THA)[1].The local anesthetic injected between the PM and the QB spread 
to the paravertebral space and played the role of both a transverses abdominis plane 
block and a lumbar plexus block[1].A double-blind randomised controlled trial 
demonstrated that the quadratus lumborum block and the transversus abdominis plane 
block posterior approach are effective analgesic options, the similar action as the femoral 
block for patients undergoing femoral neck fracture[2].The sensory and motor blockade, 
satisfaction, and adverse effects, were similar in both groups[2].(figure 1) 
Transversalis fascia plane block (TFP block) 
 
Another kind of truncal block similar to TAP block is the transversalis fascia plane 
(TFP) block, which targets T12 and L1 nerve branches between the fascia of the 
transversus abdominis muscle and the transversalis fascia resulting in reliable blockade of 
the iliohypogastric and ilioinguinal nerves [3,21]. Technically similar to the TAP block, the 
needle tip is directed just deep to the fascia of the transversus abdominis muscle, 
anterolateral to the quadratus lumborum (QL). It has been demonstrated effectively for 
analgesia in iliac crest bone graft harvest, inguinal hernia repair, and appendectomy[3， 
4,28].A patient undergoing left distal radius osteotomy with iliac crest bone graft harvest 
was given a single shot ultrasound-guided infraclavicular and TFP blocks who 
experienced unanticipated quadriceps and hip flexor weakness [4]. Steven Lee et 
al.[4]suspected that patients receive TFP block had a partial lumbar plexus block as a 
result of proximal spread of the LA. This is certainly credible because the lumbar plexus 
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plane is anatomically contiguous with the TFP. In fact, Hebbard [21]has suggested opening 
the TFP with fluid as an alternative lateral approach to lumbar plexus blockade. Previous 
work by Carney et al [17] has shown the spread of contrast into the paravertebral space in 
posterior TAP block. It follows that the TFP block, so technically similar, may also have the 
tendency for central and proximal LA spread. Borglum et al [10] advocate the trans-muscular 
QL block to deposit LA between psoas major (PM) and QL to achieve thoracolumbar 
anesthesia via cranial spread to the thoracic paravertebral spaces. This clearly 
demonstrates the existence of a “potential space” between the PM and QL where the 
presence of LA can emerge amazing anesthetic properties. We hypothesize that in the TFP 
block, proximal spread of LA to the potential space between the PM and QL can occur and 
contributed to the present clinical scenario. While investigating the mechanism, Rosario et 
al[22] performed a cadaver study and demonstrated that the plane between the transverses 
abdominis muscle and the transversalis fascia is continuous to the tissue plane deep to the 
fascia iliacus. This tissue plane incidentally houses the femoral nerve.(figure 2) 
 
 
Potential benefits: 
 
A major advantage of this technique compared to thoracic epidural 
analgesia(TEA)includes the avoidance of permanent neurologic sequelae in an 
anesthetized child. 
Optimal acute perioperative pain management: Regional anesthetic techniques is a key 
component of multimodal pain regimen[23],which can effectively lower pain scores, lower 
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perioperative opioid consumption, decrease length of stay and improve the patient 
experience. 
Potential risks: 
 
The TFPB and QLB which technically similar to TAP and its variants are easy to 
perform and complications are rare. The most devastating complication of these block 
results from incorrect needle advancement through the peritoneum causing injuries to the 
organs beneath, such as liver laceration or bowel perforations [24]. Extra care may be 
necessary to avoid trauma to kidney. Toxic reaction of local anesthesia. (Toxicity is a 
concern to use such high volumes.) Lateral femoral cutaneous and cluneal nerve injuries 
[25,26]. ilioinguinal nerve injury [27]. 
 
Risk/Benefit Analysis:  
 
Risk and benefit analysis are always assessed prior to block placement, as the risk 
may overweigh the benefit in patients with poor identification of anatomy. For example, 
patients with previous abdominal surgeries with distortion of normal abdominal 
musculature, air in tissues after laparoscopic surgeries or extreme body habitus. 
Study design and purpose: 
    The aim of the study is to evaluate the effectiveness of ultrasound-guided 
transversalis fascia plane block (TFPB) and quadratus lumborum block (QLB) on post-
operative analgesia in pediatric patients with Developmental Dysplasia of the Hip (DDH) 
undergoing open reduction surgeries（Salter acetabular osteotomy，combined with 
proximal femoral rotation osteotomy）.The effectiveness of TFPB/QLB for 
perioperative analgesia in lumbar nerves (L1) innervated surgery have been 
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demonstrated in recent studies[1-4]. However, this regional technique rarely applied to 
children. The objective of our research is to assess the quality of postoperative 
analgesia in pediatric patients who had received a preoperative TFPB/QLB for hip 
surgery. 
Study duration: 
We estimate that the entire study will require 2 years, including patient recruitment, 
data collection, analysis, and report writing. 
Abstract: 
Methods: 
 
90 pediatric patients(age 2-10 years) in the BeiJing Jishuitan Hospital and The 
Second Affiliated Hospital of Wenzhou Medical University with American Society of 
Anesthesiologists (ASA) physical status I or II, who are scheduled to undergo open 
reduction surgeries （Salter acetabular osteotomy，combined with proximal femoral 
rotation osteotomy）are selected and divided into 3 equal groups with 30 subjects.The 
consent forms are approved by the institutional Ethics Committee. 
Inclusion Criteria: 
 
Pediatric patients aged between 2 years and 10 years with DDH, scheduled for 
unilateral open reduction surgeries（Salter acetabular osteotomy，combined with proximal 
femoral rotation osteotomy）. 
Exclusion Criteria: 
Patients will be excluded if they meet any of the following criteria: patients with known 
allergy to local anaesthetics, mental disability, peripheral neuropathy, a coagulopathy 
disorder, localized infection in the area, and any reason cause reoperation. 
Sample Size: 90 
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    Based on assumed 60% difference in the pain status between three groups by a 
priori study sample size calculation. A sample size of 30 would be expected to have an 
80% power to check a minimum 60% difference between these three treatment groups 
by an uncorrected χ2 test with an α of 0.05. 
Study population: 
    Pediatric patients aged between 2 years to 10 years diagnosed with 
Developmental Dysplasia of the Hip (DDH)with American Society of Anesthesiologists 
(ASA) physical status I or II, who are scheduled to undergo unilateral open reduction 
surgeries （Salter acetabular osteotomy，combined with proximal femoral rotation 
osteotomy） 
An a priori study sample size calculation was performed based upon assumed 60% 
 
difference in the pain status between three groups. Applying an uncorrected χ2 test with 
an α of 0.05, a sample size of 30 would be expected to have an 80% power to detect a 
minimum 60% difference between these three treatment groups. 
Electrocardiogram, non-invasive blood pressure, pulse oximetry, temperature, 
capnography, and end tidal anesthetic concentration values are monitored in patients 
Parental presence will be allowed if requested for the induction of anesthesia. Pediatrics 
without vein access will receive general anesthesia which induces with 8% sevoflurane in 
70% nitrous oxide and 30% oxygen, via a facemask. When loss of consciousness is 
achieved, we need to establish vein access routinely. Intravenous induction for general 
anesthesia with endotracheal intubation is commenced using intravenous propofol 3 
mg/kg, cis-atracurium 0.2 mg/kg, fentanyl 2. ug/kg. Anesthesia will be maintained using 
remifentanil, and a volatile anesthetic(sevoflurane). The inhaled concentration of 
sevoflurane will be adjusted to maintain hemodynamic stability, which is defined as a 
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change in systolic blood pressure and heart rate of no more than 20% of baseline 
parameters. The use of opioids during the perioperative periods at the discretion of the 
anesthetist. Some anesthetists administer opioids preemptively, however, in the majority 
of cases the decision is based on the cardiovascular response to stimulation; an increase 
in heart rate of 10% from baseline is usually interpreted as insufficient analgesia and is 
treated with opioids. Patients will be given either fentanyl in doses of 1-2mcg/kg, 
remifentanil as continuous infusion 0.01–0.03 mcg/ (kg.min) or a combination of these. 
 
TFPB group 
 
Patients in transversalis fascia plane block group (Group T) will receive 
 
ultrasound-guided transversalis fascia plane blockusing0.3% ropivacaine(0.7ml/kg) after 
general anesthesia. A high-frequency probe (Sono-Site HFL50x, 15- 6 MHz, 55-mm 
broadband linear array) connected to an S-nerve ultrasound machine (Bothell, WA, USA) 
was positioned with a transverse orientation, between iliac crest and costal margin. With 
the patient in a supine position, the needle is advanced from the anterior using an in-plane 
technique. A linear ultrasound probe is orientated transversely over the lateral abdomen 
between the iliac crest and the costal margin. The external oblique, internal oblique, and 
transversus abdominis muscles are imaged, and the more posterior transversus 
aponeurosis is isolated from these muscles. The reflection of the peritoneum curving 
away from the muscles from anterior to posterior, and the perinephric fat, which lies 
behind the peritoneum and deep to the transversalis fascia, are both identified. The 
perinephric fat is generally more prominent closer to the iliac crest. The quadratus 
lumborum is identified medial to the aponeurosis of the transversus abdominis. The end 
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point is more visible if the needle is passed through the posterior ‘‘tail’’ of the transversus
muscle, as the transversus aponeurosis is thinner and less distinct as a separate layer. 
After passing through the deep surface of transversus abdominis muscle, local anesthetic 
is injected to separate the transversalis fascia from the transversus muscle. The correct 
needle position was confirmed by injection of 2 ml of normal saline solution that was 
spreading antero-posteriorly between the anterior border of QLM and its fascia, in addition 
to a minimal anterior spread in TAP plane. After negative aspiration, 1 ml/Kg of 
ropivacaine 0.3%was injected. 
QLB group 
Patients in quadratus lumborum block group（Group Q） will receive 
ultrasound-guided quadratus lumborum block using0.3%ropivacaine(0.7 ml/kg).after 
general anesthesia. The TFPB is performed with the patient in the lateral position using a 
curvilinear low-frequency ultrasound probe. This is orientated transversely at the posterior 
axillary line between the iliac crest and the costal margin using a 22G 100-mm needle. 
The needle is directed in the posterior to anterior orientation with the practitioner standing 
behind the patient. The triangular quadratus lumborum (QL) muscle is adherent to the 
apex of the transverse process of L3 vertebra. Using the Shamrock method, a new 
transmuscular quadrates lumborum block technique, developed by Børglum (British 
Journal of Anaesthesia, 2013), the needle penetrates the QL muscle with an in-plane 
approach from the posterior side of the ultrasound probe. The target point is the inter 
fascial plane between the QL and the psoas major muscle just deep to the transversalis 
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fascia, in order to lessen the risk of unintentional penetration of the peritoneal cavity 
contrary to the technique. The correct needle position was confirmed by injection of 2 ml 
of normal saline solution that was spreading anteri-posteriorly between the QL and the 
psoas major muscle. After negative aspiration, 0.7 ml/Kg of ropivacaine 0.3%was injected. 
Control group 
Patients in the third group as control (Group C)receive no nerve block. Patients will 
be extubated based on clinical criteria. 
 
 
Patients will then be transported to the post-operative anesthesia care unit (PACU) 
after extubation. All pediatric patients will receive 6-hourly paracetamol postoperatively for 
two days and receive sufentanyl via nurse-controlled analgesia (NCA) or patient-controlled 
analgesia (PCA). The prescription of postoperative NCA/PCA is also at the discretion of the 
anesthetist. Children under the age of 6 years will receive sufentanyl via NCA continuously 
at a rate of 2 mcg kg-1 48h-1 with a bolus option of 0.01 mcg kg-1 every 15 minutes. Older 
children will receive sufentanyl via PCA continuously at a rate of 2 mcg kg-1 48h-1 with a 
bolus option of 0.01 mcg kg-1 every 15 minutes. 
 
Data collection will include the type of procedure, age, weight, type of truncal block 
 
(QLB group vs TFPB vs control), intra- and postoperative analgesia given, complications, 
mean arterial pressure and heart rate registered at the key steps in the surgeries，the 
duration of surgery and hospitalization time ,and pain scores up to 48 hours post-surgery 
（at 1h,4h,8h,12h,16h,24h，48h after surgery） using age-appropriate and validated tools 
(ie, the Face, Legs, Activity, Consolability Scale [FLACC] in children).The intensity of pain 
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utilizing FLACC was classified as none or mild (≤ 4), moderate (5-7), and severe (≥ 8). 
Overall use of rescue analgesics was calculated. The first use and the number of doses of 
rescue analgesics (morphine 0.05 mg/kg) in the postoperative period (48 h) will be 
recorded. Postoperative nausea and vomiting will be recorded in the same periods as 
those used for pain assessment. Rescue treatment of postoperative nausea and vomiting, 
will be treated with ondansetron (0.1 mg/kg) if needed. Side effects such as pruritus will 
also be noted. 
 
Statistics: 
 
 
 
Statistical analyses will be performed with a statistical package (SPSS version 11.0; 
SPSS, Chicago, IL).All data will be presented 
as mean±sd. Demographic data will be 
compared by using standard t-tests; comparison of incidence data between groups 
performed by using Fisher’s exact tests. A P value < 0.05 will be considered significant. 
 
Payment: 
 
There is NO financial benefit or reimbursement for participation in the study. 
 
 
 
 
 
 
 
References: 
 
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Figure 1: the QLB 
Cite from Hansen CK, A A Case Rep 2016; 6:39. 
The QL block is performed with the patientin the lateral position. The triangular quadratus 
lumborum (QL) muscleis adherent to the apex of the transverse process of vertebraL4. 
Theneedle penetrates the QL muscle with an in-plane approachfrom the posterior side of 
theultrasound probe. The target point isthe interfascial plane between the QL and the psoas 
major musclejust deep to the transversalis fascia. Note: A deep recess coveredby peritoneum 
extends between the abdominal wall muscles andthe psoas major muscle to the anterior side 
of the QL muscle. Ananterior approach to QL blockade carries a risk of puncture of thisrecess. 
PC = peritoneal cavity; TP = transverse process. 
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Figure 2: the TFPB 
Cite from：Peter D,Can J Anesth/J Can Anesth (2009) 56:618–620 
The red marks and red arrow labeled by this paper’s author. 
The white marks and white arrow shows transverse diagram through the abdomen above 
the iliaccrest. The course of the subcostal nerve (SCN) is indicated, includingthe lateral 
cutaneous branch (LCB) and the anterior cutaneous branch(ACB). The nerve does not 
actually pass along this transverse plane asit inclines downwards. The location of the local 
anesthetic (LA)across the anterior surface of the quadratus lumborum (QL) andbehind the 
transversalis fascia (TF) is shown, and the needle position(N), perinephric fat (PNF), 
peritoneum (P), and transversalis fascia(TF) are indicated. The following muscles are 
involved: rectusabdominis (R), erector spinae (ES), psoas (PM), transversus abdominis(TA), 
internal oblique (IO), and external oblique (EO) 
The red marks and red arrow shows QLB(quadratus lumborum block). A needle approach 
through the quadratus lumborummuscle with the patient placed in the lateral position. The 
transmuscular approach avoids the risk of unintentionalpenetration of the peritoneal 
recessbetween the abdominal wall muscles and the psoas major. 
QLB
N
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