An Easy Solution for Successful Lumbar Plexus Block in … · 2012-03-17 · Lumbar plexus block...

Article ID: WMC003161 ISSN 2046-1690

An Easy Solution for Successful Lumbar PlexusBlock in Arthroplasty Surgery of Patients withPoorly Defined LandmarksCorresponding Author:Dr. Ashok Jadon,Chief consultant Anaestheisa & Pain relief, Anaesthesia & Pain Relief Service, Tata Motors Hospital,Karangajhar, 831004 - India

Submitting Author:Dr. Ashok Jadon,Chief consultant Anaestheisa & Pain relief, Anaesthesia & Pain Relief Service, Tata Motors Hospital,Karangajhar, 831004 - India

Article ID: WMC003161

Article Type: Case Report

Submitted on:16-Mar-2012, 08:39:32 AM GMT Published on: 17-Mar-2012, 07:14:58 AM GMT

Article URL: http://www.webmedcentral.com/article_view/3161

Subject Categories:ANAESTHESIA

Keywords:Arthroplasty, Fluoroscopy, Lumbar plexus block, Nerve stimulator guided nerve block, Parasacralsciatic nerve block

How to cite the article:Jadon A . An Easy Solution for Successful Lumbar Plexus Block in Arthroplasty Surgeryof Patients with Poorly Defined Landmarks . WebmedCentral ANAESTHESIA 2012;3(3):WMC003161

Copyright: This is an open-access article distributed under the terms of the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalauthor and source are credited.

WebmedCentral > Case Report of 13

http://www.webmedcentral.com/article_view/3161

http://creativecommons.org/licenses/by/3.0/

http://creativecommons.org/licenses/by/3.0/

WMC003161 Downloaded from http://www.webmedcentral.com on 17-Mar-2012, 07:14:58 AM

An Easy Solution for Successful Lumbar PlexusBlock in Arthroplasty Surgery of Patients withPoorly Defined LandmarksAuthor(s): Jadon A

Abstract

Lumbar plexus block (LPB) provides excellentpostoperative analgesia after major joint surgeries oflower limb (Hip and Knee joint) and when combinedwith sciatic nerve block it provides excellent surgicalcondition for such surgeries even in high risk patients.Various techniques, i.e. anatomical landmarks, nervestimulator, ultrasound, CT (computed tomography) orMRI (Magnetic resonance imaging) guidance havebeen described for localization of lumbar plexus. Weused combination of nerve stimulator and fluoroscopyfor lumbar plexus block in six patients of arthoplasticsurgery scheduled under block anaesthesia and hadpoorly defined anatomical landmarks thus resultedfailed attempts for localization of transverse process of4th lumbar vertebrae with nerve stimulator needle.With help of fluoroscopy transverse process of 4thlumbar vertebra was identified and block was givenusing nerve stimulator. Block was successful in allpatients and no serious complication occurred in anyof the patients.Key words: Arthroplasty, fluoroscopy, lumbar plexusblock, nerve stimulator guided nerve block, parasacralsciatic nerve block.

Introduction

Background: Lumbar plexus block is becomingpopular regional anaesthetic technique for lower limborthopedic surgeries due to its efficacy to providestable hemodynamic and excellent postoperativeanalgesia in relatively older age group patients ofarthoplastic surgery. When combined with sciaticnerve block it gives excellent surgical condition even inhigh risk patients [1,2]. Lumbar plexus block is a safeand effective alternative for analgesia in hip and kneesurgery it provides effective postoperative analgesia ofthe lower extremity following joint arthroplasty.[3] Lumbar plexus block (LPB) is traditionally performedusing surface anatomical landmarks [4,5]. However;anatomical landmarks can vary among patients andcan result in a failure to contact the transverse processand also to elicit quadriceps muscle contraction which

is mainstay of successful lumbar plexus block [6,7].Repeated attempts to locate the transverse processmay result inadvertent renal or vascular injury. [8,9]Although ultrasound guidance is becoming standardfor nerve blocks but it is shown to be of limited value inlumbar plexus block due to difficulty in localization oflumbar plexus [10, 11]. Steep learning curve andnon-availability of ultrasound machine in most of theoperation theatre are also deterrent for its routine use.Availability of CT or MRI for every case is alsofarfetched possibility at present. As Image intensifier is now part and parcel of everyorthopaedic operation room. We have suggested theuse of image intensifier to identify transverse processof fourth lumbar vertebrae and nerve stimulator tolocate lumbar plexus in cases of arthroplasty surgerywhere anatomical landmarks could not be ascertainedwith surety due to either obesity or deformity. Thistechnique prevents multiple attempts to locatetransverse process and easily identifies lumbar plexus.

Patients and technique

We have used combined block (lumbar plexus blockwith parasacral sciatic block) in 28 patients scheduledfor arthoplastic surgery during January 2011 and April2011. In all patients anatomical landmarks were marked onthe skin with ink-marker (figure-1). In Six patients (2males, 4 females) of age group between 38 -89 yrswhere landmarks were not well defined (Table-1) andtransverse process of fourth lumbar vertebra (L4)could not be located after two attempts (with nervestimulator needle), were selected for this technique. Technique: Procedure and associated risks were discussed withpatients and their relatives during preoperative visitand an informed consent was obtained. Patients whodid not have any contraindication for regionalanaesthesia were selected for lumbar plexus block.Patients were sedated with Injection Fentanyl 1-2µg/kgand Midazolam 1-3mg titrated for comfortablepositioning and were turned to lateral position, with theoperated side up. The transverse process (TP) offourth lumbar vertebrae was identified using Capdevila



[5] modification of Winnie’s [4] technique. Aftercleaning and antisepsis preparation a skin wheal wasraised one cm medial and one cm cephalad to thepoint where intercristal line cuts the perpendicular linefrom posterior superior il iac spine [5] (pointcorresponding to lateral margin of transverse process)(figure-1). An insulated needle (Stimuplex A® 100-mmneedle (B. Braun Medical, Germany) was inserted andconnected to a nerve stimulator (Stimuplex® NHS12;B. Braun Medical, Germany). Needle was directedperpendicular to skin (up to 6-8cm depth). If TP couldnot be contacted needle was redirected cephalad orcaudad to contact TP of 4th lumbar vertebra. Oncetransverse process was contacted needle was pulledback 0.5 cm and advanced under the transverseprocess (with initial current setting of 1.5 mA) untilquadriceps femoris muscle twitches were elicited (i.e.,cephalad patellar movements). The position wasjudged adequate when quadriceps contractions werestill elicited by impulses of 0.3 to 0.5 mA. Localanaesthetic mixture 20ml of 1.5% xylocaine withadrenaline (1:200000) and bupivacaine 0.5% 10mlwas injected in 3-5ml aliquots with repeated aspirationto avoid inadvertent vascular injection. In six patients when two attempts (two separateneedle pass with each cephalad and caudalredirection) could not locate the transverse process of4th lumbar vertebra or an appropriate nervestimulation (quadriceps/patellar contraction)fluoroscopy was used. Image intensifier (Philips BVLibra) was placed in such a way to get AP view oflumbar area (figure-2). The transverse process offourth lumbar vertebrae was identified. A skin whealwas raised at point corresponding to lateral margin oftransverse process and an insulated needle(Stimuplex A® 100-mm needle (B. Braun Medical,Germany) was inserted and connected to a nervestimulator (Stimuplex® NHS12; B. Braun Medical,Germany). Needle was directed towards transverseprocess under fluoroscopic guidance (figure-3 A and B)till it contacted transverse process. The needle wasthen pulled back 0.5 cm and advanced under thetransverse process(figure-4 A and B) (with initialcurrent setting of 1.5 mA) until quadriceps femorismuscle twitches were elicited (i.e., cephalad patellarmovements). The position was judged adequate whenquadriceps contractions were still elicited by impulsesof 0.3 to 0.5 mA. Local anaesthetic mixture of 20ml of1.5% xylocaine with adrenaline (1:200000) and 10mlbupivacaine 0.5% was injected in 3-5ml aliquots withrepeated aspiration to avoid inadvertent vascularinjection. Sciatic nerve block was also given using nervestimulator and anatomical landmarks by parasacral

approach [12]. An entry point was taken 6cm caudadfrom Posterior superior iliac spine (PSIS) on a lineconnecting PSIS and Ischial tuberosity (figure-1).Sciatic nerve was located with initial current of 1.5mAand once targeted response of planter flexion at0.3-0.6mA was obtained 20ml of 1.5% xylocaine withadrenaline (1:200000) and 10ml bupivacaine 0.5%was injected in 3-5ml aliquots with repeated aspirationto avoid inadvertent vascular injection. Conduct of anaesthesia: Localization was possible at first needle pass in all sixpatients and all patients had effective anaesthesia tocarryout scheduled surgery. Supplementary sedationwas provided with 0.5 to 1.0mg of Injection Midazolamand 25µg of Injection Fentanyl whenever required. Nopatient required more than 200 µg of InjectionFentanyl and, 5.0mg of injection Midazolam duringtotal surgery time of 2hrs to 3hrs includingpre-procedure sedation.

Discussion

Understanding of Surface anatomy and Anatomicallandmarks is basic essential for successful nerveblocks. New gadgets like ultrasound, CT and MRIimproves precision and help in localization even indifficult anatomical situations. However, they only helpin anatomical localization whereas Nerve stimulatorhelps to locate functional component of nerve/block.The combination of nerve stimulator and ultrasoundhave shown better results in various nerve blocks.[13]Winnie’s [4] classical approach and Capdevila[5]modification is landmark based Posterior approach tolumbar plexus block. This is simple and effectiveapproach[14 ]results in high success rate.[15]However, sex dependent variation and patient topatient anatomical variation are limitation forsuccessful outcome.[6] Inclusion of fluoroscopy forvisualization of TP and use of nerve stimulator forfunctional localization of lumbar plexus resulted insuccessful block in our six patients where localizationbased on anatomical landmarks failed.Clinical implications: We have used this approach as a rescue techniquewhen conventional landmarks based approach havefailed to locate the transverse process of 4th lumbarvertebra and desired neural stimulation response. Withthe help of fluoroscopy cent percent successfullocalization was possible at first attempt. This made usto think that, if fluoroscopy is used as a standardcomponent of technique rather than a rescuetechnique in difficult situation during lumbar plexuslocalization with nerve stimulator, may increase



success rate and would decrease complications ofrepeated needle introduction which is associated withhigh risk of visceral injury.

Conclusion

During nerve stimulator guided lumbar plexus blockuse of fluoroscopy helps in localization of transverseprocess (TP) of 4th lumbar vertebra if localization isdifficult due to obesity or poorly defined landmarks. Itseems an easy solution to increase the success rateof lumbar plexus block. However, more studies arerequired to prove its definitive role.

References

1. Ho AM, Karmakar MK. Combined paravertebrallumbar plexus and parasacral sciatic nerve block forreduction of hip fracture in a patient with severe aorticstenosis. Can J Anaesth. 2002 Nov; 49(9):946-50.2. Asao Y, Higuchi T, Tsubaki N, Shimoda Y.Combined paravertebral lumbar plexus and parasacralsciatic nerve block for reduction of hip fracture in fourpatients with severe heart failure. Masui. 2005 Jun;54(6):648-52.3. Touray ST. De Leeuw MA. Zuurmond W. W. A.Perez R. S. G. M. Psoas compartment block for lowerextremity surgery: a meta-analysis Br J Anaesth.2008;101: 750-760. 4. Winnie AP, Ramamurthy S, Durani Z, Radonjic R.Plexus blocks for lower extremity surgery: newanswers to old problems. Anesthesiol Rev. 1974;1:11– 6.5. Capdevila X, Macaire P, Dadure C, et al.Cont inuous psoas compartment block forpostoperative analgesia after total hip arthroplasty:new landmarks, technical guidelines, and clinicalevaluation. Anesth Analg 2002; 94:1606 -13.6. Broadbent CR, Maxwell WB, Ferrie R, et al. Abilityof anaesthetists to identify a marked lumbar interspace.Anaesthesia 2000;55:1122-6.7. Dalens B, Tanguy A, Vanneuville G. Lumbar plexusblock in children: a comparison of two procedures in50 patients. Anesth Analg 1988;67:750-8.8. Aida S, Takahashi H, Shimoji K. Renal subcapsularhematoma after lumbar plexus block. Anesthesiology1996; 84: 452-5.9. Aveline C, Bonnet F. Delayed retroperitonealhaematoma after failed lumbar plexus block. Br JAnaesth 2004; 93: 589-91.10. Kirchmair L, Entner T, Wissel J, et.al. A study ofthe paravertebral anatomy for ultrasound-guided

posterior lumbar plexus block. Anesth Analg2001; 93:477–81.11. Morimoto M, Kim JT, Popovic J, Jain S, Bekker A.Ultrasound-guided lumbar plexus block for openreduction and internal fixation of hip fracture. PainPract 2006; 6: 124–6.12. Mansour NY. Re-evaluating the sciatic nerve block:another landmark for considerat ion. RegAnesth1993;18:322–323. 13. Orebaugh SL, Williams BA, Kentor ML. Ultrasoundguidance with nerve stimulation reduces the timenecessary for resident peripheral nerve blockade. RegAnesth Pain Med. 2007; 32(5):448-54.14. Farny J, Drolet P, Girard M. Anatomy of theposterior approach to the lumbar plexus block. Can JAnaesth 1994; 41: 480–5.15. Mannion S, O’Callaghan S, Walsh M, . Murphy DB, Shorten G D. In with the New, Out with the Old?Comparison of Two Approaches for PsoasCompartment Block. Anesth Analg 2005;101:259 –64.



Table shows demographical data, co-morbidity type of surgery, surgical time and plausible cause of

difficulty in localization of transverse process of 4th lumbar vertebra by nerve stimulator needle

Case

No#

Age & Sex Wight Surgery and

surgical time

(min)

Co-morbid

condition

Plausible cause of

difficulty in

localization

1 38 yrs Female 76 Kg THR 130 min Hypertension,

Diabetes Mellitus

Obesity

2 54 yrs Male Aprox 60kg DHS 120 min Severe COPD Degenerative spine

3 68 yrs Female 65kg THR 130 min Severe COPD,

LVF

Obesity

Illustrations

Illustration 1

Table 1



4 60 yrs Female Aprox

60Kg

TKR 180 min CVA, Fast AF Deviated midline

(scoliosis)

5 52yrs Female 60kg THR 110 min Hypertension,

Diabetes Mellitus,

Hypothyroid

Degenerative spine

6 89 yrs Male 60kg THR 150min Hypertension,

Diabetes Mellitus,

Parkinson’s’

Degenerative Spine,

Intervertebral space

could not be felt



Illustration 2

Figure 1



Illustration 3

Figure 2



Illustration 4

Figure 3a



Illustration 5

Figure 3b



Illustration 6

Figure 4a



Illustration 7

Figure 4b



DisclaimerThis article has been downloaded from WebmedCentral. With our unique author driven post publication peerreview, contents posted on this web portal do not undergo any prepublication peer or editorial review. It iscompletely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscriptbut also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions beforesubmitting any information that requires obtaining a consent or approval from a third party. Authors should alsoensure not to submit any information which they do not have the copyright of or of which they have transferredthe copyrights to a third party.

Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater tothe needs of an individual patient. The web portal or any content(s) therein is neither designed to support, norreplace, the relationship that exists between a patient/site visitor and his/her physician. Your use of theWebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harmthat you may suffer or inflict on a third person by following the contents of this website.


An Easy Solution for Successful Lumbar Plexus Block in … · 2012-03-17 · Lumbar plexus block...

Documents

Transcript of An Easy Solution for Successful Lumbar Plexus Block in … · 2012-03-17 · Lumbar plexus block...