Quadratus Lumborum Block vs Erector Spinae Plane Block in Laparoscopic Hysterectomy

Study Overview
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Brief Summary
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Postoperative pain following laparoscopic hysterectomy is a challenging concern as some patients suffer acute pain that could let to chronic pain over time following the surgery. Epidural analgesia which is the gold standard for postoperative pain management in abdominal surgeries including laparoscopic hysterectomy has side effects such as hypotension, hematoma, motor weakness of lower limbs, paresthesia, intrathecal placement of the epidural catheter and urinary retention that could prolong hospital stay. Since high frequency ultrasound machines' usage has increased in postoperative analgesia management, ultrasound guided fascial plane blocks has been performed by clinicians with high success rate. To avoid possible complications of epidural catheter placement and epidural analgesia, various techniques has been applying for an analgesic effect close to the effectiveness of epidural analgesia. These techniques include transversus abdominis plane block, rectus sheath block, wound infiltration of local anesthetics, erector spinae plane block and quadratus lumborum plane block . However, each of the plane blocks has limitations individually which prevent them to be the unique analgesic technique for postoperative analgesia following abdominal surgery. As far as the authors knowledge, there's no reported study which compares ultrasound guided erector spinae plane block versus ultrasound guided quadratus lumborum type III block (anterior quadratus lumborum block) as a preemptive analgesia technique in patients undergoing laparoscopic hysterectomy.

Detailed Description
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Total laparoscopic hysterectomy is the most preferred technique for hysterectomy in obstetric and gynecology clinics (1). The management of postoperative pain in gynecologic laparoscopic surgery is challenging (2, 3). Due to side effects of opioids such as nausea and vomiting, titration of opioid dosage for postoperative pain is difficult and effective postoperative analgesic regimes is needed (3-5). Ultrasound guided regional anesthesia techniques such as erector spinae plane block and quadratus lumborum block for postoperative pain management has an acceleration in usage as ultrasound guidance makes the interventions safer and easier to perform, and they contribute to better pain control and pain experience (6). Ultrasound guided quadratus lumborum block for postoperative pain management after abdominal surgery was firstly conceived by Blanco in 26th European Society of Regional Anesthesia Congress in 2007 as a variant of transversus abdominis plane (TAP) block (7). Later on he reported posterior quadratus lumborum block (QLB) in 2013 which is known as QLB II (8). Børglum et. al described the transmuscular quadratus lumborum block (TQL or QLB III) in 2013 which is frequently performed in abdominal wall surgeries (9). QLB III, transmuscular quadratus lumborum block (TQL) and anterior quadratus lumborum block; these are all synonyms and refers to injection of local anesthetic into the anterior thoracolumbar fascia (TLF) which lays between quadratus lumborum muscle and psoas major muscle (10). Erector spinae plane block has being performed by clinicians for abdominal and thoracic surgeries since it was firstly described by Forero et al. in 2016 for analgesia in thoracic neuropathic pain (11-13). In this ultrasound guided technique local anesthetic is applied between the transverse process of the relevant thoracic or lumbar vertebrae and the erector spinae muscle which leads to the spread of the local anesthetic cephalad, caudally and through the paravertebral space (14, 15). The investigators hypothesize that performing ultrasound-guided quadratus lumborum block will be more superior or equal to erector spinae plane block in providing postoperative analgesia for patients undergoing laparoscopic hysterectomy under general anesthesia.

Official Title
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Ultrasound Guided Quadratus Lumborum Block Versus Erector Spinae Plane Block For Postoperative Analgesia In Patient Undergoing Laparoscopic Hysterectomy: A Randomized Double Blinded Study

Conditions
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Gynecologic Disease

Intervention / Treatment
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* Procedure: Quadratus Lumborum Block Type III
* Procedure: Erector Spinae Plane Block
* Other: No Block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients who accepted to participate and signed written consent Aged between 18 and 75 American Society of Anesthesiologists (ASA) physical score I or II Elective laparoscopic hysterectomy operation Exclusion Criteria: Patients who declined to participate BMI > 35 kg/m2 Uncontrolled systemic disease <18 age and >75 age Unable to cooperate (mental retardation) Low cardiac capacity Hypersensitivity history to the agents to be used Coagulopathy Local infections Opioid addiction history

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: The patients will be divided randomly by a computer-generated randomization table into three equal groups.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Control group<br>Patients will be operated under general anesthesia. | Other: No Block<br>* The patients will receive general anesthesia.<br>* Other names: Control Group;|
| Active Comparator: Quadratus Lumborum Block Group<br>Patients will receive ultrasound-guided quadratus lumborum block type III bilaterally with 30 ml of bupivacaine 0.25% on each side, totally 60 ml of bupivacaine 0.25% followed by general anesthesia. | Procedure: Quadratus Lumborum Block Type III<br>* Patients will receive ultrasound-guided quadratus lumborum block type III with 60 ml of bupivacaine 0.25% followed by general anesthesia.<br>* Other names: QLB III;|
| Active Comparator: Erector Spinae Plane Block Group<br>Patients will receive ultrasound-guided erector spinae plane block bilaterally with 30 ml of bupivacaine 0.25% on each side, totally 60 ml of bupivacaine 0.25% followed by general anesthesia. | Procedure: Erector Spinae Plane Block<br>* Patients will receive ultrasound-guided erector spinae plane block type III with 60 ml of bupivacaine 0.25% followed by general anesthesia.<br>* Other names: ESPB;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total dose of opioid consumption (tramadol) | Total dose of tramadol consumption via patient controlled device | in the first 24 hour postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Visual Analog Scale | On a scale of 0-10, the patient will learn to quantify postoperative pain where 0= No pain and 10= Maximum worst pain. | measured at at 30 minute, 2, 6, 12, 24th hour postoperatively | 
| The 1st time to rescue analgesic need | The time to ask for postoperative analgesia is the time from the end of operation to patient reporting Visual Analog Scale ≥ 4. | recorded within the first 24 hour postoperatively | 
| Postoperative nausea and vomiting | Postoperative nausea and vomiting presence | recorded within the first 24 hour postoperatively | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Erector Spinae Plane Block, Quadratus Lumborum Block, Analgesia, Laparoscopic Hysterectomy, Ultrasound Guidance