Lumbar Plexus vs Quadratus Lumborum Block in Post-operative Pain Following Total Hip Replacement
Condition: Hip Osteoarthritis
MeSH terms: Osteoarthritis, Hip; Pain, Postoperative
Study type: Interventional
Phase: Phase 4

Summary: 
      The Lumbar Plexus (LP) block is currently used as the standard-of-care regional anesthesia
      technique to provide postoperative pain management after primary hip replacement surgery at
      UPMC Shadyside Hospital. However, the LP technique is complex and can be associated with
      potentially serious side effects, including nerve injury, major bleeding, retroperitoneal
      hematoma, and intrathecal injection of local anesthetic. In rare instances the LP block can
      also lead to motor blockade, interfering with early ambulation. There are several case
      reports of Quadratus Lumborum inter-fascial block (QL3) giving equally adequate pain relief
      after total hip replacement surgery, and this QL3 block is performed routinely at this
      institution. The benefits to inter-fascial administration of local anesthetic include the
      avoidance of theoretical nerve injury, bleeding and intrathecal anesthetic administration
      associated with the direct interaction between the nerve and the nerve block needle. The
      purpose of this study is to show that QL3 block is non-inferior to the standard-of-care
      lumbar plexus block and should be used more regularly in hip replacement surgery. The study
      will be conducted as a prospective, randomized (1:1), double-blind, non-inferiority,
      active-comparator trial. The investigators plan to enroll 40 subjects, 20 in each treatment
      group. This study will prospectively investigate the efficacy of QL3 versus Classic LP block
      for post-operative pain management in subjects undergoing primary, unilateral hip replacement
      surgery and prospectively compare QL3 versus Classic LP block in time to mobilization and
      physical therapy response. Primary outcome measures include pain at rest and with movement at
      6, 12 and 24 hours after surgery. Secondary outcomes will be time for first request for pain
      medication, total pain medications (narcotics and non-narcotic analgesics) given in 24 hours
      and the time of participant's ability to walk 100 feet as recorded by a physical therapist.
    

Detailed description: 
      Eligible patients will be approached for the study by the PI or Sub-I in the pre-operative
      area on their day of surgery. The anesthesiology investigator will speak with the patient
      about the study behind a closed drape and the patient will have adequate time to consider the
      consent and ask questions regarding risk factors associated with each type of block. Once
      consented, the patient will be randomized by computer generated random number to one of the
      two treatment groups. Once assigned the treatment allocation, only the clinician
      administering the block will be unblinded to the randomization outcome. If randomized to the
      LP block, an anesthesiologist on the Acute Interventional Perioperative Pain Service (AIPPS)
      will administer the block with this approach: Patient will be positioned in lateral decubitus
      position with side to be blocked facing upwards. Midline will be identified by palpating the
      spinous process. Intercristal line will be drawn connecting iliac crests. The point of needle
      insertion will be 4 cm lateral to the intersection of both lines. The transverse process will
      first contact with a finder needle. Subsequently an 18 gauge 10 cm insulated needle will be
      used and advanced until it contacted the transverse process. Needle will then be redirected
      cephalad or caudad and advanced 1 cm, until the quadriceps femoris twitch is obtained. Local
      anesthetic will then be injected after confirming a motor response between 0.3-0.5 milli
      amperes.If randomized to the QL3 block, an anesthesiologist on the Acute Interventional
      Perioperative Pain Service (AIPPS) will administer the block with this approach:Patient will
      be placed in a lateral position with the side to be blocked facing up. A low frequency
      transducer will be used to identify three layers of abdominal musculature, probe will be then
      moved posteriorly till the transverse abdominus aponeurosis is visualized, the QL muscle is
      then identified by tracing the aponeurosis posteriorly. The transducer is then moved more
      posteriorly to visualize the shadow of transverse process and the origin of QL muscle. Psoas
      muscle is then identified lying anterior to the QL muscle. A 22 gauge 8 cm is inserted in
      plane posterior to the probe and advanced intramuscularly through the QL to interfacial plane
      between QL and psoas major and local anesthetic is deposited. For both treatment groups, the
      local anesthetic used will be 100 mg 0.5% ropivacaine. After surgery, the patient will be
      followed by the blinded research team for incidence of adverse events, as well as the
      collection of the primary outcome measures. These include pain at rest and with movement at
      6, 12 and 24 hours after surgery, time for first request for pain medication, total pain
      medications (narcotics and non-narcotic analgesics) given in 24 hours and the time of
      participant's ability to walk 100 feet as recorded by physical therapist. This information
      will be captured from the patient's electronic medical record.

      Minor changes were made to the outcome measures after the original approval of this
      submission. This was only to clarify the specific measures from the more general descriptions
      in the original.
    

Intervention name(s): Lumbar plexus block; Quadratus lumborum type 3 block; Ropivacaine injection
Intervention type(s): Procedure; Procedure; Drug
Intervention description(s): Patient will be positioned in lateral decubitus position with side to be blocked facing upwards. Midline will be identified by palpating the spinous process. Intercristal line will be drawn connecting iliac crests. The point of needle insertion will be 4 cm lateral to the intersection of both lines. The transverse process will first contact with a finder needle. Subsequently an 18 gauge 10 cm insulated needle will be used and advanced until it contacted the transverse process. Needle will then be redirected cephalad or caudad and advanced 2 cm, until the quadriceps femoris twitch is obtained. Local anesthetic will then be injected after confirming a motor response between 0.3-0.5 milli amperes.; Patient will be placed in a lateral position with the side to be blocked facing up. A low frequency transducer will be used to identify three layers of abdominal musculature, probe will be then moved posteriorly till the transverse abdominus aponeurosis is visualized, the QL muscle is then identified by tracing the aponeurosis posteriorly. The transducer is then moved more posteriorly to visualize the shadow of transverse process and the origin of QL muscle. Psoas muscle is then identified lying anterior to the QL muscle. A 22 gauge 8 cm is inserted in plane posterior to the probe and advanced intramuscularly through the QL to interfacial plane between QL and psoas major and local anesthetic is deposited.; 0.5% ropivacaine 20 ml (100 mg) will be injected for both groups.
Intervention MeSH terms: Ropivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Lumbar plexus block vs Quadratus lumborum type 3 block
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: lumbar plexus block; quadratus lumborum block; total hip arthroplasty