Comparison between 3 inter-fascial plane blocks on the postoperative analgesia in patients undergoing hip arthroplasty under spinal anesthesia

Total hip arthroplasty (THA) is a common surgical procedure that improves the health-related quality of life and functional status of patients. However, it is often associated with significant postoperative pain. This pain may decrease mobility, increase the risk of venous thromboembolism, impair rehabilitation, and delay recovery.  Therefore, adequate postoperative pain analgesia after THA is essential.

Regional anesthesia (RA) helps us to provide good pain management and recovery in hip arthroplasty. Central neuraxial blocks and general anesthesia have been the primary methods for anesthesia during hip arthroplasty. We have a wide range of peripheral nerve blocks (PNB) that have been seen with better outcomes in hip arthroplasty and significantly reduced complications in most outcome categories, such as cardiac, pulmonary, respiratory failure, and cognitive dysfunction complications.3 Newer approaches, such as quadratus lumborum block (QLB), suprainguinal fascia iliaca block (SIFIB), pericapsular nerve group (PENG) block and lumbar erector spinae block (ESPB) have also been described recently.Peripheral nerve blocks (PNBs) block the lumbar or sciatic nerve plexus after they exit the spinal column. The lumbar plexus innervates the skin dermatomes and femoral component for hip procedure, while the sciatic nerve plexus covers the acetabular innervation. These more distal approaches result in unilateral or no blockade of the sympathetic chain, resulting in lesser hemodynamic instability, neurological complications, or motor blockade post-arthroplasty.

US-guided SIFIB has been used as a reliable analgesic option for hip arthroplasty. SIFIB may lead to decreased motor strength of the surgical limb, thereby hindering postoperative mobilization and delaying discharge after outpatient hip Arthroplasty.

PENG selectively targets the articular branches of the femoral and accessory obturator nerves while sparing their motor components.The PENG block  is an easy regional technique to perform in the supine position with motor-sparing benefits. QLB has also been shown to provide good postoperative analgesia after hip arthroplasty.Lumbar erector spinae plane block (ESP) block is an upcoming anaesthetic modality for hip surgeries. It is a relatively safe technique, easy to perform, and associated with a lower risk of damage to surrounding nerves and vessels due to the USG based bony landmarks for the procedure and inadvertent intravascular injection. It can be given safely in anticoagulated patients or when spinal epidural is contraindicated. The large volume of local anesthetic deposited in the interfacial plane spreads to the lumbar plexus, along with spread to the L4-L5 nerve roots, blocking the sacral plexus as well.  Both continuous and single-shot lumbar ESP blocks have been proven to be promising analgesic alternatives in studies for reducing opioid consumption and ensuring early ambulation after hip surgeries.

Utilizing regional anesthesia helps to limit the use of opioids. However, which technique is best has yet to be determined.

In this randomized trial, we will compare four inter-fascial plane blocks, i.e., PENG, SIFI, QL3 and Lumbar ESP on the postoperative analgesia in patients undergoing hip arthroplasty under spinal anesthesia.