Erector Spinae Plane Versus Quadratus Lumborum Block for Patient Undergoing Open Nephrectomy
Condition: Renal Disease
MeSH terms: Kidney Diseases
Study type: Interventional

Summary: 
      The postoperative pain after open nephrectomy remains a major concern because some patients
      still demonstrate acute pain that may develop chronic pain that lasts for months following
      the surgery.

      Epidural analgesia is the gold standard for abdominal surgery including for open nephrectomy,
      however, it has unfavorable side effects such as paresthesia, hypotension, hematomas, an
      impaired motor of lower limbs and urinary retention that could delay recovery.

      Various techniques have tried to replicate the analgesic efficacy of epidural analgesia. They
      include transversus abdominis plane analgesia (TAP), rectus sheath analgesia (RS), wound
      infusion analgesia (WI) and transmuscular quadratus lumborum (TQL) analgesia. However, each
      of these techniques has specific limitations that prevent them from being the analgesic
      technique of choice for all open abdominal surgeries.

      Up to the investigator's knowledge, there is no study done to compare ESPB versus QLB as
      pre-emptive analgesia in patients undergoing open nephrectomy.
    

Detailed description: 
      Open surgery remains basic surgery for patients requiring radical or partial nephrectomy and
      is associated with a high incidence of intense immediate postoperative pain and chronic pain
      the months following surgery [1]. The physiopathology of acute pain is explained as it is
      mediated by inflammatory cell infiltration, activation of the pain pathways in the spinal
      cord, and also reflexive muscle spasm. All of these three mechanisms of acute pain are
      typically ameliorated during the postoperative recovery [2].

      Regional anesthesia techniques are commonly enhanced for pain management in open nephrectomy
      as they decrease parenteral opioid requirements and improve patient satisfaction [3].

      Erector Spinae Plane block (RSPB), first described by Forero et al.,[4] for analgesia in
      thoracic neuropathic pain, has also been reported for the management of other causes of acute
      and postoperative pain [5,6,7]. In this ultrasound-guided (USG) technique, a local anesthetic
      (LA) is applied between the erector spinae muscle and the transverse process of the thoracic
      vertebra leading to the spread of LA cephalad, caudally and through the paravertebral space
      [4,5,8].

      Quadratus Lumborum block (QLB) was initially described by R.Blanco as an abstract at the
      annual European Society of Regional Anaesthesia (ESRA) congress in 2007, where the LA was
      injected at the anterolateral aspect of the QL muscle (type 1 QLB) [9]. Later, J. Børglum
      used the posterior transmuscular approach by detecting Shamrock sign and injecting the LA at
      the anterior aspect of the QL (type 3 QLB) [10]. Recently, R. Blanco described another
      approach by injecting the LA at the posterior aspect of the QL muscle (type 2 QLB), which may
      be easier and safer as the LA is injected in a more superficial plane, so the risk of
      intra-abdominal complications and lumbar plexus injuries is less [11]. Finally, the
      intramuscular QLB (type 4 QLB) was done by injecting LA directly into the QL muscle [12].

      The investigators hypothesize that performing ultrasound-guided ESPB block will be more
      superior to or equal to QLB in providing postoperative analgesia for patients undergoing open
      nephrectomy under general anesthesia.
    

Intervention name(s): control group; quadratus lumborum block type 3; erector spinae plane block
Intervention type(s): Other; Procedure; Procedure
Intervention description(s): the patient will receive general anesthesia; patients will receive ultrasound-guided quadratus lumborum block type 3 with 30 ml of bupivacaine 0.25% followed by general anesthesia.; patients will receive ultrasound-guided quadratus lumborum block type 3 with 30 ml of bupivacaine 0.25% followed by general anesthesia.
Other intervention name(s): QLB; ESPB
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The patients will be divided randomly by a computer-generated randomization table into three equal groups
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: erector spinae plane block; ,Quadratus Lumborum block; open nephrectomy; analgesia