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Ultrasound-guided lumbar selective nerve root
block plus T12 paravertebral and sacral plexus
block for hip and knee arthroplasty
Three case reports
Bin Mei, MD, PhD
a
, Yao Lu, MD, PhD
a
, Xuesheng Liu, MD, PhD
a
, Ye Zhang, MD, PhD
b
, Erwei Gu, MD
a
,
Shishou Chen, MD
a,∗
Abstract
Rationale: For hip or knee arthroplasty, it is essential to develop a satisfied peripheral nerve block method that will benefit elderly
patients or patients who are contraindicated to neuraxial anesthesia.
Patients concerns: Patient in Case 1 suffered from the right intertrochanteric fracture, combined with chronic obstructive
pulmonary disease; Patient in Case 2 suffered from hip osteoarthritis; combined with ankylosing spondylitis; Patient in Case 3
suffered from rheumatoid arthritis, combined with ischemic encephalopathy.
Diagnosis: Case 1: Right intertrochanteric fracture, chronic obstructive pulmonary disease. Case 2: hip osteoarthritis. Case 3:
rheumatoid arthritis.
Interventions: Ultrasound-guided lumbar selective nerve root block (SNRB) plus T12 paravertebral and sacral plexus block were
performed in 2 patients who received hip arthroplasty and 1 patient who received knee arthroplasty.
Outcomes: All patients successfully received surgeries with this peripheral nerve block method and no postoperative complication
was reported.
Lessons: Ultrasound-guided lumbar SNRB plus T12 paravertebral and sacral plexus block not only satisfied the analgesia
requirement of surgery, but also reduced the consumption of local anesthetic.
Abbreviations: AS =ankylosing spondylitis, ASA =American Society of Anesthesiologists, COPD =chronic obstructive
pulmonary disease, PACU =postanesthesia care unit, PCA =patient-controlled analgesia, SNRB =selective nerve root block, THA
=total hip arthroplasty, VAS =visual analogue scale.
Keywords: arthroplasty, hip, knee, paravertebral block, sacral plexus block, selective nerve root block, ultrasound
1. Introduction
Quick returning to functional training, early oral feeding,
reducing postoperative complications were thought to be vital
to recovery of patients who received hip and knee arthroplasty.
[1]
Regional anesthesia, especially peripheral nerve block, could be
the preferable anesthesia method to achieve these goals.
[2]
Lumbar selective nerve root block (SNRB) is an effective
diagnostic and treatment for patients with lumbar radicular
pain.
[3]
With the guidance of CT and ultrasound, the lumbar
SNRB has been widely used in pain clinical practice but not
anesthetic clinical practice.
[4]
In here, we described a novel regional anesthesia method—
ultrasound-guided lumbar SNRB plus T12 paravertebral block
and sacral plexus block, and reported its application on 3 patients
who received hip and knee arthroplasty.
2. Methods
2.1. Ethical approval and patient consent for publication
Ethical approval for this report (PJ2017-08-19) was provided by
the Ethical Committee of The First Affiliated Hospital of Anhui
Medical University, Hefei, China on August 7, 2015. Prior to
surgery, the written informed consent was obtained from the
patients and their relatives, and the case details were approved for
publication by all patients.
2.2. Anesthetic technique
After a monitor of vital signs was established, light sedation was
achieved with a bolus of dexmedetomidine (manufactured by
Editor: N/A.
This study was partly supported by National Natural Science Foundation of
China (No. 81770295).
The authors have no conflicts of interest to disclose.
a
Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical
University,
b
Department of Anesthesiology, The Second Affiliated Hospital of
Anhui Medical University, Hefei, Anhui Province, P.R. China.
∗
Correspondence: Shishou Chen, Department of Anesthesiology, The First
Affiliated Hospital of Anhui Medical University, Hefei 230022, Anhui Province, P.R.
China (e-mail: chenss1965@sina.com).
Copyright ©2019 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
from the journal.
Medicine (2019) 98:22(e15887)
Received: 8 December 2018 / Received in final form: 15 April 2019 / Accepted:
29 April 2019
http://dx.doi.org/10.1097/MD.0000000000015887
Clinical Case Report Medicine®
OPEN
1
Sichuan Guorui Medicine Co, Sichuan, China) at 0.6 to 0.8 mg/kg
(over a period of 20 min) and followed by an infusion at 0.2 to
0.5 mg/kg/h. All patients received the peripheral nerve block 30
minutes after the sedative drugs were infused. The patient was
placed in the lateral position with the operated side uppermost.
An Edge ultrasound (FUJIFILM SonoSite Inc, Bothell, WA) and a
2 to 5MHz convex transducer (FUJIFILM SonoSite Inc, Bothell,
WA) were used, and the surface anatomic landmarks were made
for reference (Fig. 1).
T12 paravertebral block was performed as described previ-
ously.
[5]
In brief, the ultrasound probe was placed parallel to
the posterior median line to identify the 12th rib, and then
rotated 90 degrees to visualize the transverse process of the
12th rib (Fig. 2F). After scanning slightly inferiorly, the
thoracic paravertebral space (TPVS) was found anterior to the
transverse process and appeared as a triangle space bordered by
the inferior articular process, intertransverse ligament, and
the diaphragm (Fig. 2B). A 9-cm 22G needle (KDL Medical
Company, Zhejiang, China) was inserted and advanced in
plane with the transducer, in a lateral-to-medial direction. After
the needle reached the TPVS, 3 mL of 0.4% ropivacaine was
injected.
Selective lumbar SNRB was performed in an order of L4, L3,
L2, and L1. To identify different spinal segments, longitudinal
facet views were obtained by placing the transducer parallel to the
posterior median line (Fig. 2E).
[6]
Started from L5 (Fig. 2A), at the
level of each segment, the probe was rotated 90 degrees to obtain
the transverse axial images in which the spinous process, facet
joint, and transverse process were found from medial to lateral,
respectively (Fig. 2G). Foramen intervertebral was identified as
the space between the facet joint and transverse process after
scanning slightly cephaladly (Fig. 2C). The needle was inserted
and advanced in plane with the transducer, in a lateral-to-medial
Figure 1. The surface anatomic landmarks for block. IC =iliac crest, PSIS=
posterior superior iliac spine.
Figure 2. Ultrasonography of blocks and positions of transducer. A, Identify the different spinal segments with longitudinal facet views when placing transducer as
in panel E. B, Ultrasonography for T12 paravertebral block, when transducer was positioned as in panel F. C, Ultrasonography for lumbar selective ner ve root block,
when transducer was positioned as in panel G. D, Ultrasonography for Sacral plexus block, when transducer was positioned as in panel H. AP =articular process,
FJ =facet joint, IAP =inferior articular process, ITL =intertransverse ligament, PBI =posterior border of ischium, SP =spinous process, TP =transverse process,
TPVS =thoracic paravertebral space.
Mei et al. Medicine (2019) 98:22 Medicine
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direction. Once the needle touched the lateral of the facet joint,
the angle of needle was increased to over facet joint and then
forwarded 1 cm deeper. C-arm was used to evaluate the position
of the needle tip (Fig. 3), and 3 mL of 0.4% ropivacaine was
injected for each segment.
Sacral plexus block was performed as described previously.
[7]
In brief, the pr obe was placed transversel y at the level of the sacral
hiatus lateral to the midline (Fig. 2H) to reveal the posterior
border of the ischium as a hyperechoic line. The greater sciatic
foramen was found as a gap after sliding the probe caudally. The
sacral plexus was identified as a hyperechoic structure, which
was deep to the piriformis (Fig. 2D). The needle was inserted and
advanced in plane with the transducer. 10 mL of 0.4%
ropivacaine was injected once the needle tip nearly reached the
target nerve.
The successful nerve block was confirmed by pinprick test 20
minutes after the block. The hip surgery was performed via a
posterior approach.
3. Cases description
3.1. Case 1
An 84-year-old female (body weight 56kg, ASA status III) was
scheduled for right artificial femoral head replacement. Her pelvic
X-ray revealed a right intertrochanteric fracture. She had
hypertension for 35 years and chronic obstructive pulmonary
disease (COPD) for 20 years. She took daily oral nifedipine for
hypertension, but did not take any treatment for COPD. The
result of pulmonary function test showed that the FEV1/FVC was
35% and the bronchodilator test was negative. Cardiac Doppler
ultrasonography indicated moderate pulmonary artery hyper-
tension. A chest X-ray revealed pulmonary infection of bilateral
lower lobes. Low-molecular-weight heparin was used for prevent
thrombus formation at 4000IU per day and stopped 24 hours
before surgery. The preoperative visual analog scale (VAS) score
of this patient was 6. The ultrasound guided lumbar SNRB plus
T12 paravertebral and sacral plexus blocks were performed on
this patient as described in the Methods section, and 25 mL of
0.4% ropivacaine was used for these blocks. The success of these
blocks was confirmed by pinprick test. The time of surgery was
42 minutes. She did not complain any painful during surgery and
in postanesthesia care unit (PACU). As postoperative analgesia
was achieved by patient-controlled analgesia (PCA), the
postoperative VAS scores were 0 to 1. This patient discharged
on the fifth day after surgery. No postoperative complication was
reported with her.
3.2. Case 2
A 46-year-old male (body weight 69 kg, ASA status II) was
scheduled for right total hip arthroplasty (THA). He suffered
from ankylosing spondylitis for 20 years. Physical examination
indicated that the cervical and lumbar spine was rigid and the
right hip joint was immobilized. The bamboo-like changes of
spine were found in the spinal anterioposterior and lateral
radiographs (Fig. 4). X-ray and CT examination indicated
degenerative osteoarthrosis of bilateral hip joints and sacroiliitis
on the right side. The patient appeared potentially difficult to be
intubated as the examination of airway revealed that the
interincisor distance was 2 cm and a Mallampati class III. The
preoperative visual analog scale (VAS) score of this patient was 4.
This patient received ultrasound-guided lumbar SNRB plus T12
paravertebral and sacral plexus blocks, and 25mL of 0.4%
ropivacaine was used. Pinprick test was used to confirm the
success of these blocks. The time of surgery was 1 hour and
26 minutes. He also did not complain any painful during surgery
and in PACU. With the PCA, the postoperative VAS scores were 0
to 1. This patient discharged on the second day after surgery. No
postoperative complication was reported with him.
3.3. Case 3
A 73-year-old fem ale (body weight 64 kg, ASA sta tus III) who
suffered from rheumatoid arthritis (RA) for 30 years was
scheduled for right total knee arthroplasty (TKA). X-ray of
her bilateral knee joint revealed that the joint cavity of bilateral
knee joints was narrow and osteophyte formatted in the right
Figure 3. Anatomical drawing of spinal nerve root and confirmation of tip of needle by C-arm. A, Anatomical drawing of spinal nerve root and other related
structures of lumbar. B, The final position of tip of needle was confirmed by C-arm in Case 1 when lumbar selective nerve root block was performed. FI =foramen
intervertebral, FJ=facet joint, SNR =spinal nerve root, TP =transverse process.
Mei et al. Medicine (2019) 98:22 www.md-journal.com
3
side. The patient had hypertension for 6 years and was treated
with oral nitrendipine. She also had a history of cerebral
infarction 3 years ago. MRI of brain revealed multiple old
softening foci in the right basal ganglia region. She had taken
aspirin and ginkgo tablets for anticoagulation therapy and
prevention of recurrent stroke. The preoperative visual analog
scale (VAS) score of this patient was 4. The ultrasound-guided
lumbar SNRB plus T12 paravertebral and sacral plexus blocks
were performed with 25 mL of 0.4% ropivacaine. Pinprick test
was used to confirm the success of these blocks. This technique
completely met the analgesic requirement of this patient during
surgery. The time of surgery was 1 hour and 12 minutes. With the
PCA, the postoperative VAS scores were 0 to 1. This patient
discharged on the third day after surgery. No postoperative
complication was reported with her.
4. Discussion
To our knowledge, the innervation of the hip joint was derived
from the lumbar plexus (L2–4) and part of the sacral plexus (L4-
S1). For analgesia requirement of skin incision of posterolateral
approach to hip surgery, it was necessary to block the lateral
femoral cutaneous nerve from the lumbar plexus (L2–3), lateral
cutaneous branch of iliohypogastric nerve (T12 and L1), and
subcostal nerve (T12 thoracic nerve).
[8]
For knee arthroplasty,
the primary relevant target nerves were femoral, obturator,
sciatic, and lateral femoral cutaneous.
[9]
To relieve the
uncomfortable stress of application of tourniquet, T12 para-
vertebral block also was necessary. The ultrasound-guided
lumbar SNRB plus T12 paravertebral and sacral plexus block
we performed on these 3 patients fully satisfied the analgesia
requirement of surgery.
The 3 patients had different clinical conditions, thus manage-
ments were slightly different. In case 1, the patient had a long-
term hypertension and COPD; artificial airway was avoided and
respiratory complications were avoided. In case 2, the patient had
ankylosing spondylitis; the probable difficulty of puncture of
neuraxial anesthesia was avoided. In case 3, the intraoperative
stable hemodynamics were important, which was not too difficult
to manage during operation with the blocking method. The nerve
blocks only on the side that received surgery facilitated early stage
derogation for these patients. However, although neuraxial
anesthesia is the most popular anesthesia method for patients
who received hip and knee surgery,
[10]
it has been reported that
complications and contraindications, for example, urinary
retention, hypotension, spinal hematoma perioperative anti-
coagulation, meningitis and spinal abscess, may limit the
application of neuraxial anesthesia in some patients.
[11,12]
Combination of lumbar plexus and parasacral plexus block for
hip surgery has been reported before. In previous studies, additional
largeamountofpropofolandinfiltration to the incision were used as
the supplement, and a large amount of local anesthetic was required
to obtain an effective block.
[8]
In the cases we reported here, we
performed multiple selective nerve blocks which satisfied the
required of surgery but used much less amount of local anesthetic.
Dexmedetomidine was used for intraoperative sedation in these
cases. Intraoperative sedation has benefits of avoiding postural
discomfort, preventing intraoperative recall, and reducing sympa-
thetic and parasympathetic reflexes. Recently, dexmedetomidine
was also reportedhaving positive effect on elderlypatients recovery
outcomes.
[13]
We believe that intraoperative light sedation is an
ethical practice and necessary for patient care.
The evidence from 3 cases may be not stronger enough to evaluate
the safety and effeteness of the block method described in this study.
Figure 4. The spinal anterioposterior and lateral radiographs of patient in Case 2. The bamboo-like changes of spine can be found in the radiograph.
Mei et al. Medicine (2019) 98:22 Medicine
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To avoid the probable nerve root injury and epidural infiltration,
controlling volume of local anesthetics and precisely placing the tip of
needle must be very important.
[6]
In the future, additional prospective
clinical trial is needed to supply adequate evidence.
Acknowledgments
The authors thank professor Ming Zhang (Department of
Anatomy, Otago School of Biomedical Sciences, New Zealand)
for suggestions and help regarding the writing in English. The
authors also thank all the staff of Department of Anesthesiology,
First Affiliated Hospital of Anhui Medical University for being
helpful in conducting and finishing this research.
Author contributions
Conceptualization: Bin Mei, Yao Lu.
Formal analysis: Bin Mei.
Investigation: Bin Mei.
Methodology: Ye Zhang, Erwei Gu.
Project administration: Shishou Chen.
Writing –original draft: Bin Mei.
Writing –review & editing: Yao Lu, Xuesheng Liu, Ye Zhang,
Erwei Gu.
Shishou Chen orcid: 0000-0003-3400-0466.
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