Spinals, Epidurals and Lumbar Plexus Blocks in Orthopaedic Surgery

Sugantha Ganapathy, FRCPC, FRCA
Professor, Department of Anaesthesiology and Perioperative Medicine,
Western University
Director, Regional and Pain Research
London, ON

Orthopaedic surgeries are some of the most painful procedures. Apart from trauma-related orthopaedic surgery, the most common operations are major arthroplasties. As a result of developing painful osteoarthritis, patients are unable to exercise adequately and this may lead to the development of significant comorbidities. These include obesity, hypertension, diabetes, ischemic heart disease, cerebrovascular disease and propensity for venous thromboembolism. Obesity is often associated with sleep apnea, which makes titrating analgesia with narcotics a challenge. Obesity also results in the propensity for gastroesophageal reflux. Many patients are already on narcotics to control osteoarthritis pain. These patients may present with opioid-induced hyperalgesia and thus pose major challenges with postoperative pain management. General anaesthesia is particularly challenging in these patients.

 

A recent study has documented significant cost saving and improved pain scores with the use of spinal anaesthesia. This is particularly important in the current climate of economic downturn1. Neuraxial techniques have also been an integral component to facilitate discharge of these patients on the day of surgery2,3. Neuraxial techniques in a retrospective study have also been documented to result in less surgical site infection after major arthroplasty as compared to general anaesthesia. The possible mechanisms for this improved outcome could be improved oxygenation, reduced inflammatory response and better postoperative analgesia4.

Because of the propensity for deep venous thrombosis (DVT), routine DVT prophylaxis is initiated on arrival following any trauma and, in many centres, the day before surgery, prior to elective arthroplasty. Although neuraxial techniques are reported to be associated with a lower incidence of DVT, we do not know if such a benefit is significant with the current medical therapy. Unfortunately, some of the medications used for DVT prophylaxis in the past have been associated with increased incidence of the dreaded neuraxial haematoma with resultant permanent paralysis. This can be as high as one in 50,000 with spinals and one in 10,000 with low-molecular-weight heparin started the day of surgery. The incidence of neuraxial haematoma in female patients with spinal stenosis seem to be as high as one in 3600, causing many to shy away from these techniques in this subset of patients5,6. Timing of initiation and discontinuation of neuraxial block seems to be crucial in avoiding such a catastrophic outcome. The newer anticoagulants such as rivaroxaban, dabigatran and fondoparinux have limited documentation in the literature7-9. Thus it is important to understand the pharmacokinetics of these newer anticoagulants before one initiates neuraxial block. In this respect, it is easier to time a spinal than a continuous epidural analgesia. The epidural analgesia is initiated with a bigger needle - the needle and catheter both at insertion and at removal can cause vascular injuries in the epidural space. Although many have reported on the successful use of these techniques10-12, the infrastructure for managing anticoagulation and the neuraxial block initiation and termination have to be coordinated. It is important to establish a mechanism of follow-up after the neuraxial blocks especially if the patients are discharged from the hospital early.

Apart from the worry of neuraxial haematomas, there is a certain failure rate with neuraxial techniques; epidural more than spinals13. Introduction of spine imaging before initiating spinal anaesthesia as a routine paradigm is long overdue both to avoid spinal cord injury and to reduce repeated needle passes, both of which could be contributing factors for neuraxial haematoma. If the block is performed in a separate block area, this may also contribute to better resource utilization of the operating room time. With epidurals, one also has to remember the potential for unilateral analgesia and the need for bladder catheterization during therapy.

There are adjuvants that have been documented to provide prolonged analgesia - some of them are well validated and approved such as spinal morphine, while others, such as dexamethazone and magnesium, are used and documented to provide marginal improvement in analgesia duration.

Neuraxial techniques may be contraindicated in a patient following trauma when there is associated bleeding, hypovolemia and other neurological injuries requiring close monitoring. Combined spinal and epidural facilitate early onset of block with capacity to continue analgesia for a few days. This is particularly useful for revision arthroplasty and major osteotomies as well as for manipulating a stiff joint. The hypotension associated with the epidural has been documented to reduce blood loss and reduce allogeneic transfusions.

These techniques are particularly useful in the elderly both to reduce pulmonary complications as well as to reduce postoperative cognitive dysfunction.

Although many centres use lumbar plexus blocks for hip surgery, the posterior lumbar plexus blocks have been associated with a total spinal, a dreaded complication that can occur one in 400 patients14-16. This block has been documented to reduce blood loss during surgery in one study. This is considered a deep block and the same guidelines used for epidural analgesia have been recommended with this block too. A recent study by Ilfeld et al17 has documented that femoral block provides equally good analgesia but with greater motor blockade impeding ambulation. Some centres such as Pittsburgh have been discharging patients within 24 hours with the use of lumbar plexus block following hip arthroplasty. This block might be particularly useful in the elderly with hip fracture. There have also been reports of kidney injury and flank haematoma with adverse outcomes. The introduction of ultrasonography might see a resurgence of this block especially for hip fractures. One of the major problems with this block is positioning for initiating the block with the injured side up. Definitely expertise is needed to initiate and continue the block. By comparison, the spinal or epidural is in every anaesthesiologist's repertoire.

References

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  2. Dorr L.D., Thomas D.J., Zhu J., Dastane M., Chao L., and Long W.T. Outpatient Total Hip Arthroplasty. The Journal of Arthroplasty Vol. 25 No. 4 2010.
  3. Ranawat A.S. and Ranawat C.S. Pain Management and Accelerated Rehabilitation for Total Hip and Total Knee Arthroplasty. The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 2007.
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  5. Douketis J., Wang J., Cuddy K., Wagler M., Kinnon K., Crowther M. The safety of co-administered continuous epidural analgesia and low-molecular-weight heparin after major orthopedic surgery: Assessment of a standardized patient management protocol. Letter to the Editor. Thromb Haemost 2006; 96: 387-9
  6. Horlocker T.T., Wedel D.J., Benzon H., et al. Regional anesthesia in the anticoagulated patient: Defining the risks (the Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172-92.
  7. Kwong L.M. Therapeutic potential of rivaroxaban in the prevention of venous thromboembolism following hip and knee replacement surgery: a review of clinical trial data. Vascular Health and Risk Management 2011:7 461-466.
  8. Freyburger G., Macouillard G., Labrouche S., Sztark F. Coagulation parameters in patients receiving dabigatran etexilate or rivaroxaban: Two observational studies in patients undergoing total hip or total knee replacement. Thrombosis Research 127 (2011) 457-465.
  9. Singelyn F.J., Verheyen C.C.P.M., Piovella F., Van Aken H.K., Rosencher N. for the EXPERT Study Investigators. The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study. Anesth Analg 2007; 105:1540 -7).
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  13. Weed J., Finkel K., Beach M.L., Granger C.B., Gallagher J.D., and Sites B.D. Spinal Anesthesia for Orthopedic Surgery. A Detailed Video Assessment of Quality. Regional Anesthesia and Pain Medicine & Volume 36, Number 1, January-February 2011
  14. Duarte L.T. Paes F.C. Fernandes Mdo C. Saraiva R.A. Posterior lumbar plexus block in postoperative analgesia for total hip arthroplasty: a comparative study between 0.5% Bupivacaine with Epinephrine and 0.5% Ropivacaine. Revista Brasileira de Anestesiologia. 59(3): 273-85, 2009 May-Jun.
  15. Stevens R.D., Van Gessel E., Flory N., Fournier R., Garnulin Z., Lumbar Plexus Block Reduces Pain and Blood Loss Associated with Total Hip Arthroplasty. Anesthesiology, V 93, No 1, Jul 2000
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