Continuous L2 Paravertebral Block Versus Continuous Lumbar Plexus Block for Postoperative Analgesia

Study Overview
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Brief Summary
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This prospective study is intended to compare the analgesic efficacy, preservation of lower extremity motor power and side-effect profile of L2 Paravertebral lumbar plexus approach compared to Posterior nerve stimulation guided lumbar plexus approach, continuous local anesthetic infusion postoperative analgesia of Total Hip Arthroplasty. The L2 Paravertebral technique of lumbar plexus block, as part of a multimodal pain treatment, could be a cost-effective alternative with a equal profile of analgesic efficacy and motor power sparing with greater promotion of early achievement of postoperative physical therapy goals.

Detailed Description
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The nerve stimulator guided technique of continuous lumbar plexus block (LPB) is the accepted standard of care at University of Pittsburgh Medical Center (UPMC) for the management of postoperative analgesia after Total Hip Arthroplasty. Over 900 continuous lumbar plexus blocks were performed at UPMC Presbyterian Shadyside hospital within the last year alone. Continuous thoracic paravertebral block (TPVB) is also commonly performed at UPMC Presbyterian Shadyside . Over 2000 are performed annually for a wide variety of surgical procedures. Recently authors have suggested that a lumbar paravertebral block (LPVB) may represent an alternative approach to the lumbar plexus. Indeed the L2 paravertebral approach of the lumbar plexus has been described to provide adequate postoperative analgesia following hip arthroscopic surgery. However, to date, there is no prospective direct comparison between L2 Lumbar plexus approach and the posterior approach for postoperative analgesia after Total Hip Arthroplasty.

Official Title
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Continuous L2 Paravertebral Block Versus Continuous Lumbar Plexus Block for Postoperative Analgesia After Total Hip Arthroplasty

Conditions
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Total Hip Arthroplasty

Intervention / Treatment
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* Procedure: L2 Paravertebral catheter nerve block
* Procedure: Continuous Lumbar plexus nerve block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age between 18-75 years No contraindications to placement of a lumbar plexus posterior block or paravertebral block. ASA status I-III Scheduled for open total hip arthroplasty with the same surgeon. Patients without painful conditions or chronic use of opioid or antineuropathic medications. Patient who are not expected to receive therapeutic anticoagulation in the postoperative period. No Known allergies to the medications used in the study. Patients willing to receive spinal anesthesia Exclusion Criteria: Age under 18 years or older than 75 years. Any contraindication to a placement of continuous lumbar plexus Block. American Society of Anesthesiologist physical status IV or greater. Chronic painful conditions. Preoperative opioid tolerant use. Coagulation Abnormalities or patients who are expected to be on therapeutic anticoagulants postoperatively. Allergy to any of the drugs/agents used study protocol. Personal or family history of malignant hyperthermia. Serum creatinine greater than 1.4 mg/dl. Pregnancy Having an altered mental status (not oriented to place, person, or time) Any comorbid condition that, in the judgment of the consulting orthopedic surgeon, or intraoperative anesthesiologist, would proscribe the patient from any aspect of the study. Patient refusal. Lumbar plexus block performed with loss of resistance technique Patient requiring postoperative management in the ICU

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

Sexes Eligible for Study
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All

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
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: L2 Paravertebral peripheral nerve block<br>L2 paravertebral peripheral nerve block catheter will be placed. | Procedure: L2 Paravertebral catheter nerve block<br>* A continuous L2 paravertebral catheter will be placed according to UPMC standard of care practices.<br>|
| Active Comparator: Continuous Lumbar plexus peripheral nerve block<br>Continuous unilateral lumbar plexus peripheral nerve block catheter will be placed. | Procedure: Continuous Lumbar plexus nerve block<br>* A continuous unilateral lumbar plexus catheter will be placed according to UPMC standard of care practices.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative Opiate consumption | Postoperative Opiate consumption will be recorded as Morphine IV mg equivalent, for the first 24 hours. | 24 postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| NRS Pain Score (at rest) | Pain scores at Rest will be recorded at 24 and 48 Hours | 24 and 48 hours postoperatively | 
| NRS Pain Score during physical therapy | Pain scores at Rest and During physical therapy will be recorded at 24 and 48 Hours | 24 and 48 hours postoperatively | 
| TUG (Timed Up and Go) | The timed get up and go test is a measurement of mobility. It includes a number of tasks such as standing from a seating position, walking, turning, stopping, and sitting down which are all important tasks needed for a person to be independently mobile. | 24 hours postoperatively | 
| Straight Leg Raise(SLR) | In supine position with the extremity being tested and contralateral flexed LE with foot flat on surface. Patient is instructed to lift extremity to level of contralateral knee. Inability to lift entire LE off of the surface to the level of the contralateral knee would be indicative of hip flexor weakness. If the patient is able to lift LE off of the surface, however the knee flexes/unable to maintain full knee extension, this is indicative of quad weakness. | 24 hours postoperatively | 
| Long arc quad (LAQ) | In sitting position at the edge of the bed or chair. Patient is asked to extend lower leg fully on side that is being tested. If able, this is indicative that quad function is intact. If unable to fully extend knee, would indicate quad weakness. | 24 hours postoperatively | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Postoperative Pain, Nerve block, Total Hip Arthroplasty, Postoperative analgesia, Lumbar Plexus Catheters, L2 Paravertebral Catheters