SEQ Block for Perioperative Analgesia in Acetabular Surgery
Condition: Anesthesia, Local; Nerve Pain; Pain, Postoperative; Acetabular Fracture
MeSH terms: Neuralgia; Pain, Postoperative
Study type: Interventional
Phase: Phase 3

Summary: 
      The study will evaluate ultrasound guided SEQ block: single puncture combined lumbar erector
      spinae plane block and paraspinous sagittal shift (PSSS) quadratus lumborum block when
      compared with conventional intravenous morphine analgesia in patients undergoing posterior
      column acetabular fracture surgery
    

Detailed description: 
      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. Investigators 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; intraoperative and postoperative hemodynamics; Mean
      arterial blood pressure (MAP) and heart rate (HR), resting visual analogue scale (VAS),
      dynamic VAS and postoperative complications.

      Methods: After obtaining approval from Alexandria university ethics committee, this study
      will be carried out starting from December 2020 for 1 year in Alexandria university hospital
      on 52 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; Body mass index (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 randomly by closed envelope method 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.

      Group SEQ: SEQ block 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 a 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, until 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.

      While, in group MOR; no block will be given. General 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 Minimum Alveolar Concentration
      (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 24 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).
    

Intervention name(s): Single puncture combined lumbar erector spinae plane block and quadrates lumborum block; Morphine Sulfate
Intervention type(s): Procedure; Drug
Intervention description(s): Patients will lay laterally with the fracture side independent, a curvilinear transducer will be placed in a parasagittal plane 3-4 cm lateral to the lumbar spinous process of L4.The probe is shifted slowly to the lateral side till the transverse processes disappear. After subcutaneous local infiltration with lidocaine 1% at the cephalic end of the probe, the block needle is advanced through the erector spinae and QL muscles, until it pierces the epimysium of the QL muscle. LA is injected anterior to the QL, between the QL and psoas muscles.
Then the caudal end of the probe is rotated slowly medially towards lumbar spine till the 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 between transverse process and overlying ESM.; Patients will receive GA and analgesia will be based on opioids mainly intravenous morphine
Other intervention name(s): SEQ group; MOR group
Intervention MeSH terms: Morphine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Other