Regional Anaesthesia for Hip Surgeries

Abstract

Regional anaesthesia is essential for hip arthroplasty programmes and depends on anaesthesiologist’s experienced choice. Good analgesia and the avoidance of post-operative nausea and vomiting are prerequisites for early ambulation and patient compliance with post-operative protocols. Regional anaesthesia, both neuraxial and peripheral nerve blocks, is superior to systemic opioid analgesia at all-time points in the first 3 days following surgery and by avoiding opioids, the risks and incidence of opioid analgesia are removed. Safety of drugs for intrathecal injections and complications from spinal anaesthesia continue to be examined and re-examined in order to improve safety of the technique. Prevention of post-operative cognitive dysfunction and early mobilisation is a key part of the management of patients with hip fractures.

1. Introduction

The latest review articles on regional anaesthesia for hip surgery highlight the improvements made in perioperative care combined surgical, anaesthetic and analgesic protocols in order to demonstrate improved perioperative outcomes [1]. The combination of intraoperative spinal anaesthesia with non-opioid adjuvance or low-dose peripheral nerve block (PNB) appears to provide the “ideal” analgesia for hip replacement. The incidence of urine retention requiring catheterisation and post-operative nausea and vomiting is less by avoiding perioperative systemic and intrathecal opioids thus allowing earlier ambulation and discharge. The recent study of Cook et al. confirms that spinal anaesthesia is associated with minimal morbidity of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the majority of cases [2].

2. Sensory innervation of the hip joint

The hip joint is a typical ball-and-socket joint formed by an articulation between the head of the femur and the acetabulum surrounded by a cartilaginous labrum. The entire joint is enveloped by a joint capsule and additionally stabilised by ischiofemoral, iliofemoral and pubofemoral ligament, together with various muscles that either originate in, insert or just pass by this area [3]. Innervation of the hip joint derives from both lumbar (L1–L4) and sacral (L4–S4) plexuses and the variety of their muscular branches 4. The location of the origin from the main trunk of the nerves providing articular branches to the hip capsule appears to be variable and has only been recorded for the obturator and femoral nerves. There is though substantial discrepancy between studies. According to the studies, most frequent nerve to innervate the hip capsule is the nerve to quadratus femoris muscle followed by the obturator and then the femoral nerve. In general, the course of hip capsule articular branches follows the path of the vessels, but differences in innervation of the hip capsule appear to be present between individuals [4, 5]. Sensory innervation of the hip joint is shown in Figure 1.

Figure 1.

Sensory innervation of the hip joint.

3. Hip infringements and associated surgeries

Hip fracture implies a fracture of the upper quarter of the femoral bone. Fracture line stretches indifferent directions depending on the force that causes it. According to their anatomical location, hip fractures are classified as intracapsular (IF), which involves the femoral head and neck, and extracapsular (EF), which includes intertrochanteric, trochanteric and subtrochanteric fractures.

Blood loss from an IF at the time of injury is minimal because of the poor vascular supply at the fracture site and tamponade affected by the capsule. Occasionally, fractures without displacement may be treated conventionally, but there is a 30–50% risk of subsequent displacement. Current preference is for all intracapsular fractures without displacement to be treated by internal fixation with multiple screws or a sliding hip screw. Untreated disruption to the capsular blood supply of the head of the femur by a displaced intracapsular fracture can lead to avascular necrosis of the bone, resulting in a painful hip of limited function. Therefore, surgical treatment involves cemented hemiarthroplasty. Blood loss from an EF may exceed one litre; the larger the bone fragments, the greater the blood loss.

In addition, greater periosteal disruption causes EFs to be more painful than an IF. EF is fixed surgically using either a sliding hip screw, (intertrochanteric fractures) or less commonly, a proximal femoral intramedullary nail (subtrochanteric fractures).

In the developed countries, the number of hip replacements has rapidly increased throughout the twenty-one century [6]. This trend is mainly due to the population ageing and according to the lengthening of life expectancy [7].

The rational and the main features of Tissue Sparing Surgery (TSS) concept are maximum respect of anatomy, restoration of joint biomechanics, and removal of degenerated tissues, preserving the healthy ones. So, the prosthesis should just ‘integrate’ the joint instead of substitute it. The purposes of these techniques are to reduce blood loss, post-operative pain and hospital length of stay while improving recovery and ambulation [8, 9].

Hidden blood loss should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of total blood loss. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety [10].

3.1 Timing of surgery

Recommendations that have been introduced in 1989 by the Royal College of Scientists are that ideally, surgery should be performed within 48 h of hospital admission after hip fracture. In April 2010, new target of 36 h has been accepted in the first place in England and Wales. There are meta-analyses that indicate that delaying surgery beyond 48 h from admission is associated with prolonged in patient stay, increased morbidity (pressure sores, pneumonia, thromboembolic complications) and increased mortality. But, surgery is often delayed because of the need for additional investigation in elderly patients and their preoperative preparation, although there is no evidence to suggest that outcome is improved by delaying surgery to allow preoperative physiological stabilisation. However, the benefits of expedited surgery must be balanced against the risks of certain untreated conditions [11].

4. Central neuraxial anaesthesia in hip trauma and surgery

4.1 Pain in hip trauma and surgery

Pain sensation varies in this type of fractures and surgical reconstructions depending on intensity, quality and duration of pain stimuli involving nociception, inflammation and nerve cell remodelling [12]. Also, nociceptive information strongly influences brain centres for regulating homeostasis. This includes also psychological conditions, such as fear or anxiety that can significantly influence the experience of pain. So, understanding neuroanatomical organisation of central processing of nociceptive information is of great clinical importance.

Proximal femoral fractures are known for most painful injuries and in the elderly, this pain syndrome can even change the cognitive functions. Femoral fractures are usual emergency and characteristically happen in elderly population, which is most vulnerable to the deleterious effects of poorly managed pain, and adverse effects of both drugs and post-operative pain; thus, achieving effective analgesia is particularly difficult because it is necessary to personalise the treatments and, at the same time, the ineffective analgesia may lead to serious complications such as delirium. Untreated severe pain can increase patient’s fear and anxiety, lead to aggressive behaviour and disturbance of cognition, and have an unfavourable effect on physiological parameters [11]. These patients jeopardise of perioperative morbidity and mortality, which can be reduced with prompt surgical treatment and punctual quality rehabilitation.

4.2 Neuroendocrine and immune response

Patients with proximal femoral fractures show prolonged adrenocortical response to injury. It is known that elevated cortisol concentrations persist in elderly patients 2 to 3 weeks after injury than in young patients with similar injuries or even more severe. Significantly higher cortisol levels can last up to 8 weeks after injury [12]. The stress hormone cortisol affects the cognitive function, memory and learning, reduces immunity and bone density, and increases body weight, arterial pressure, cholesterol blood levels and heart diseases. Alterations of cognitive status after surgery may present in the form of delirium or, more delicately, as post-operative cognitive dysfunction (POCD). Hyperactivity of the hypothalamo-pituitary-adrenal (HPA) axis with higher cortisol levels is involved in the pathophysiology of delirium [6]; similarly, association between higher plasma cortisol levels and POCD in aged patients following hip fracture surgery occurs [7]. Delirium refers to observable changes in consciousness and attention, whereas POCD may refer to a patient exhibiting significant declines from patient’s own baseline level of performance in one or more neuropsychologic domains.

Surgery elicits broad alterations in haemodynamic, endocrine-metabolic and immune responses. The inflammatory response is essential for structural and functional repair of injured tissue, as complement, granulocytes, macrophages and many other mediators are required for appropriate wound healing. Injury, caused by trauma or surgery, is connected with the acute disorder of immunological system, which manifests as increased inclination to infections. The inflammatory response is an important determinant of outcome after major surgery. Perioperative excessive stimulation of the inflammatory and haemostatic systems plays a role in the development of post-operative ileus, ischaemia-reperfusion syndromes (e.g. myocardial infarction), hypercoagulation syndromes (e.g. DVT) and pain. Together, these represent a significant fraction of major post-operative disorders. Regional anaesthesia-administered local anaesthetics prevent or modulate many of these processes.

In the centre of interests, there are the serum-levels of T-helper-1 (Th-1) and T-helper-2 (Th-2) cytokines before and after regional and general anaesthesia and in such a way would like to confirm through the immunological status that the spinal anaesthesia is significantly more favourable for the patient.

Survival depends on the immune system’s ability to defend the body against attack from invading pathogens and injury. However, the extent of such a response is of critical importance; deficient responses may result in secondary infections from immunosuppression and excessive responses can be more harmful than the original insult.

Cytokine synthesis and release is an essential component of the innate immune system, but inappropriate, excessive production results in a generalised systemic inflammatory response, which damages distant organs.

The consequences of ageing on the immune system are thought to contribute considerably to morbidity and mortality in the elderly. Tumour necrosis factor-α (TNF-α) and intreleukine-6 (IL-6) concentrations are raised in the elderly, and studies have shown that, in response to surgical trauma, the elderly have a magnified and late inflammatory cytokine response [13].

4.3 Neuromodulation in neuraxial anaesthesia

Regional anaesthesia alone, without surgery, has periodical and minimum effects to immunological system. It is established that various anaesthesiological procedures in the same surgery cause various trend of alteration of cytokine level in serum. Spinal anaesthesia results in less immunosuppression, that is maintains the number of Th-1 cells, thus stimulating the cell immunity. Serious disorder of immunological system may cause complications as there are disorders in wound healing, increased number of infections, non-adequate response to the stress, multi-organic suppression and increased incidence of metastases [14, 15].

Surgery is the best analgesic for hip fractures. It can be performed under the general or regional anaesthesia. There are a great number of studies that analysed and compared the effects of both anaesthetic techniques. There are minimal evidence-based analyses for determining the optimal anaesthetic technique for patients undergoing hip fracture surgery.

Consequently, anaesthesiologists tend to use the technique which they are familiar with half, administering neuraxial anaesthesia and the latter general anaesthesia.

Administration of local anaesthetics was designed to provide intraoperative anaesthesia and post-operative analgesia. However, in recent years it has become clear that regional administered local anaesthetics have benefits far beyond anaesthesia and pain relief; indeed, the technique has significant impact on the outcome of major surgical procedures. A recently published meta-analysis suggests that neuraxial anaesthesia using local anaesthetics decreases overall mortality by approximately one-third, and reduces the odds of DVT by 44%, PE 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% [16]. There were also reductions in myocardial infarction and renal failure. In addition, epidural anaesthesia using local anaesthetics has been shown to attenuate the endocrine and metabolic response to upper abdominal surgery, to reduce post-operative ileus and to shorten duration of intubation and intensive care stay in patients undergoing abdominal aortic surgery.

Local anaesthetics modulate the inflammatory response in vivo. They prevent or reduce inflammatory disorders, such as reperfusion injury in heart. Beneficial effects of local anaesthetic treatment in inflammatory bowel diseases are well documented. In contrast to corticosteroids, which depress the inflammatory response and impact negatively on post-operative outcome, local anaesthetics selectively inhibit only overactive responses of the inflammatory and haemostatic systems without affecting normal function. Local anaesthetics decrease inflammation without increasing the susceptibility to infections and prevent post-operative thrombotic events without increasing bleeding.

Regional anaesthesia-analgesia attenuates perioperative immunosuppression. The hypothesis that patients who receive combined propofol/paravertebral anaesthesia-analgesia (propofol/paravertebral) exhibited reduced levels of protumorigenic cytokines and matrix metalloproteinases (MMPs) and elevated levels of antitumorigenic cytokines compared with patients receiving sevoflurane anaesthesia with opioid analgesia (sevoflurane/opioid). Regional anaesthesia-analgesia for cancer surgery alters a minority of cytokines influential in regulating perioperative cancer immunity. However, any reduction of immunosuppression is less expressed in regional—spinal anaesthesia. Local anaesthetics lidocaine and bupivacaine have influence on a release of IL-1 beta from human lymphocytes in vitro reducing chemotaxial and fagocite activity of neutrofiles and inhibits mitogen-induced proliferation of lymphocytes.

Both types of neuraxial anaesthesia, spinal and epidural and general anaesthesia, are associated with impulsive falls in intraoperative blood pressure. Epidural anaesthesia can be used as a sole continuous anaesthetic technique (as a perioperative analgesia and in the same time as an intra-operative anaesthesia) or as a combined spinal-epidural anaesthesia. This regional technique provides excellent analgesia, but may limit early mobilisation after surgery.

Matot et al. in their study from 2003 [17] make a comparison of the analgesic effect of systemic versus continuous epidural analgesia in patients with hip fracture and with high cardiac risk, and came to a conclusion that the incidence of cardiac complications was higher in patients with systemic versus continuous epidural analgesia (11 from 34 patients in systemic analgesia group vs. 2 from 34 patients in group with continuous epidural analgesia). In this study, epidural catheter was placed in early preoperative period due to patients’ admission. Few other studies demonstrated that perioperative analgesic management with continuous epidural analgesia started preoperatively reduced the incidence of myocardial ischemia in elderly patients with hip fractures surgery. These result due to sympatholytic effect of local anaesthetic, which in the same time relieves pain and decreases the stress response in perioperative period.

Performing epidural and spinal anaesthesia may be more difficult in elderly patients.

It is often not easy to position the elderly patient appropriately in the lateral position, and frequently, these patients have degenerative changes of the spine. Spinal (subarachnoid) anaesthesia is commonly used, with or without sedation.

Conceptually spinal anaesthesia for hip fracture fixation in elderly patients should be viewed distinctly from spinal anaesthesia for caesarean section in younger patients. Lower doses of intrathecal bupivacaine (< 10 mg) appear to reduce associated hypotension. Co-administration of intrathecal opioids prolongs post-operative analgesia; fentanyl is preferred to morphine or diamorphine, which are associated with greater respiratory and cognitive depression.

Sedation may be provided, but should be used cautiously in the very elderly. Midazolam and propofol are commonly used. Ketamine may be used, theoretically to prevent hypotension, but may be associated with post-operative confusion. Supplemental oxygen should always be provided during spinal anaesthesia.

To achieve general anaesthesia in this group of patients, reduced doses of intravenous induction agents should be administered. Inhalational induction is well tolerated by the elderly and allows for maintenance of spontaneous ventilation. There remains debate about whether mechanical ventilation is preferred to spontaneous ventilation. Paralysis and tracheal intubation are associated with greater physiological derangement than spontaneous ventilation, but proponents argue that mechanical ventilation reduces the risk of perioperative aspiration and allows greater control of arterial carbon dioxide levels. Intraoperative hypoxemia is common, and higher inspired oxygen concentrations may be required.

4.4 Beneficial effects of local anaesthetics

Local anaesthetics for spinal anaesthesia are not only used as drugs to block the sodium channel to provide analgesia and anti-arrhythmic action. Continuous infusion of local anaesthetics has been shown to be the most efficient means to control post-operative pain. Local anaesthetics are the only drugs, which can block almost all the pain pathways involved in post-operative pain. Distribution of local anaesthetics after subarachnoid injection is shown in Figure 2. Efficient post-operative pain will not only improve patient’s well-being but also accelerate ambulation and decrease the incidence of the post-operative chronic pain syndrome. Interestingly, local anaesthetics also possess anti-inflammatory effects, which may open new indications in different medical settings. Recent research has focused on the use of i.v. local anaesthetics to improve bowel function after surgery or trauma, to protect the central nervous system, to find new clues of local anaesthetic effect synchronic neuropathic pain and to investigate the long-term effect of anaesthesia/analgesia provided by local anaesthetics on cancer recurrence. There is growing evidence that local anaesthetics have a broad spectrum of indications aside analgesia and anti-arrhythmic effect. Most of them are still insufficiently known and investigated [18].

Figure 2.

Application of local anaesthetics after subarachnoid injection.

4.5 Adjuvants in regional anaesthesia

The adjuvants to neuroaxial anaesthesia and peripheral nerve blocks are used in clinical practice: opioids, vasoconstrictors, clonidine, N-methyl-D-aspartate (NMDA) antagonists, γ-aminobutyric acid (GABA) agonists, glucocorticoids, nonsteroidal anti-inflammatory drugs and neostigmine. Analgesia produced by neuraxial opioids alone, or as adjuvants to local anaesthetics, has been demonstrated for acute post-operative pain, obstetric, paediatric and cancer pain [20]. Besides morphine, a number of different opioides and other adjuvants have been introduced to improve the efficacy of neuraxial/regional analgesia, including NMDA antagonists (ketamine, magnesium), GABA agonists (midazolam) and adrenergic agonists (clonidine, adrenaline), COX-inhibitors (ketorolac), acetyl-choline-esterase inhibitor (neostigmine), etc. Any drug given intrathecally rapidly redistributes within the CSF; opioid is detectable in the cisterna magna after lumbar intrathecal administration within 30 min, even with lipophilic drugs like sufentanil.

Glucocorticoids are part of induction of anaesthesia in different clinical protocols achieving much improved analgesia and minimised inflammation with reduced opioid requirements and less adverse events after surgery. Dexamethasone is a long-lasting corticosteroid with effectiveness of 36–54 h [17]. Dexamethasone prolongs sensor and motor blockade with significantly reduced post-operative analgesic requirements, which means it can inhibit phospholipase-A2 and cyclooxygenase-2 expression during inflammation decreasing prostaglandin synthesis [18]. Dexamethasone administered intrathecally affects nuclear transcription in adrenergic receptors [19].

In the study by Bani-hashem et al., intrathecal addition of dexamethasone to bupivacaine for elective orthopaedic surgery on lower limbs significantly prolongs duration of sensory block and decreases opioid requirements in post-operative management. Administration of dexamethasone has the potential to inhibit a patient’s endogenous secretion of cortisol. Dexamethasone inhibits corticosterone binding to type II of adrenergic receptors in the pituitary gland passing through the cerebrospinal fluid bound to proteins. Irrelevant of the concentration, dexamethasone has a similar effect on type II of adrenergic receptors. It is possible to resorbs somewhere in the brain without effect on other types of receptors along the HPA axis not depending on the concentration [20]. Single shot of intrathecally administered dexamethasone with levobupivacaine received for surgical treatment of proximal femoral fractures reduces the stress response by decreasing plasma cortisol concentrations with longer lasting analgesic effect with better rehabilitation possibilities [21].

Based on a 2004 Cochrane systematic review of anaesthesia for hip fracture surgery, regional anaesthesia may reduce the incidence of post-operative confusion, the Scottish Intercollegiate Guidelines Network has produced the only recommendation concerning choice of anaesthetic technique, namely that ‘spinal, /epidural anaesthesia should be considered for all patients undergoing hip fracture repair, unless contraindicated’. Until such time as evidence is published that confirms regional anaesthesia is superior to general anaesthesia, the Working Party endorses this recommendation. This endorsement is supported by a recent meta-analysis suggesting that regional anaesthesia is the technique of choice (although) the limited evidence available does not permit a definitive conclusion to be drawn with regard to mortality or other outcomes [22].

5. Peripheral nerve blockade for perioperative pain

As explained above, the hip capsule is mainly innervated by the articular branches of the femoral and obturator nerve.

Blockade of the femoral, obturator and lateral cutaneous nerve of the thigh may be sufficient for perioperative analgesia for extracapsular fractures and some intracapsular fractures in trauma surgery.

When considering regional anaesthesia for hip surgery and pain management, there are several different approaches, such as lumbar plexus block/ psoas sheath block, lumbar plexus block/psoas compartment block, lumbar paravertebral block, femoral nerve block, superior gluteal nerve block/sciatic nerve block, spinal and epidural anaesthesia [23, 24, 25, 26].

A very reliable method of blocking all three is the psoas compartment block, although this risks a degree of neuraxial blockade and formation of a deep haematoma in recently anticoagulated patients.

Anterior approaches (femoral nerve blockade/fascia iliaca compartment block) do not block all three nerves, but reduce post-operative analgesia requirement, and are more suitable to ultrasound-guided placement and continuous catheter infusions post-operatively. Moreover, in few studies, authors and their colleagues evaluated that especially fascia iliaca compartment block is simple to perform, requires minimal training and also is an effective substitute for conventional treatment of pain in elderly patients with hip fractures. Fascia iliaca compartment block is starting to be used as a routine technique for clinically diagnose hip fracture in the emergency room in various clinical centres in Europe [3].

5.1 Performing the fascia iliaca compartment block (FICB)

The fascia iliaca compartment is a virtual space anteriorly limited by the posterior surface of the fascia iliaca, posteriorly by the iliacus muscle, and is cranially in continuation with the space between quadratus lumborum muscle and its fascia. Three important nerves for hip innervation and sensory innervation of the thigh are located in this space, the femoral nerve, obturator nerve and lateral femoral cutaneous nerve. Lateral femoral cutaneous nerve is a merely sensory nerve originating from the lumbar plexus (L2–L3), emerging from the lateral side of the psoas major muscle and crossing the iliacus muscle obliquely, continuing towards anterior superior iliac spine and passing under the inguinal ligament through the lacuna musculorum. It then divides into anterior branch responsible for sensory innervation of the anterior and lateral thigh as far as the knee, and posterior branch that passes backwards and innervates the skin superior to the greater trochanter down to the middle of the thigh. Additionally, the obturator nerve crosses through the psoas muscle and can be variably blocked by this type of approach. Landmarks for orientation when performing FICB are the anterior superior iliac spine and the pubic tubercle (inguinal ligament). When performing the infra-inguinal approach, this area is divided into thirds, and the injection site is located 1–2 centimetres below the inguinal ligament between the lateral and middle third. It can be performed without ultrasound guidance. When performing without ultrasound guidance, a characteristic ‘2 pops’ are felt that indicate access into the compartment. A study reported an increased frequency of sensory loss in the medial aspect of the thigh when using ultrasound-guided FICB. Similarly, ultrasound guidance increased the frequency of femoral and obturator motor block. Literature also depicts a supra-inguinal ultrasound-guided approach [23]. A supra-inguinal FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh when compared to infra-inguinal FICB. Likewise, supra-inguinal FICB leads to a more consistent spread in the cranial direction, thus spreading the anaesthetic more consistently towards the lumbar plexus and three targeted nerves. Authors suggest that a sufficient volume to reach femoral nerve, obturator nerve and lateral femoral cutaneous nerve using FICB should be 40 mL. However, the supra-inguinal approach has a superior post-operative analgesic efficacy compared with infra-inguinal approach along with significantly less morphine consumption in the first 24 hours following total hip arthroplasty. Figure 3a and 3b show positioning and longitudinal imaging for ultrasound guided proximal FICB, an in plane approach. Absolute contraindications for this technique are patient’s unwillingness to consent to the procedure, known allergy to local anaesthetics, local anaesthetic injection, which has already approached the maximum dosage, previous femoral bypass surgery or close positioning of a graft, local infection at the injection site and relative contraindications are use of anticoagulant therapy with INR >1.5, with need for consideration of recent clopidogrel/high-dose aspirin/low-molecular-weight heparin consumption.

Figure 3.

(a) Positioning for ultrasound guided proximal FICB. In plane approach with longitudinal (coronal) imaging. (3b) Longitudinal imaging for ultrasound guided fascia iliaca block.

Studies report on paramedics performing FICB on patients with suspected hip fracture at the scene of injury as well [24]. A systematic review on efficacy of prehospital analgesia with FICB for femoral fractures concluded that FICB is suitable for use in the prehospital environment for pain management, with few adverse effects, and can be performed with a high success rate by practitioners of any background. FICB proved to provide superior analgesia compared to intravenous use of fentanyl before positioning patients for spinal anaesthesia when undergoing surgery for femoral neck fractures of all types. Also, FICB reduced morphine requirement preoperatively for patients with femoral neck fractures, which can be indicated for hip arthroplasty, hip arthroscopy and burn management of the region innervated by nerves blocked by FICB as well. A study reports on reduced morphine consumption after total hip arthroplasty when a longitudinal high-dose supra-inguinal fascia iliaca compartment block was used. Furthermore, continuous femoral block was compared with FICB in patients undergoing hip arthroplasty, and it was concluded that both techniques have equivalent post-operative analgesic efficacy without any difference in functional outcome. Additionally, it was concluded that the fascia iliaca compartment catheter can be placed more quickly than the femoral nerve catheter, but the onset time of sensory and motor blockade is longer when performing the FICB.

5.2 Critical evaluation of quadratus lumborum block

Quadratus lumborum block (QLB), referred to as the ‘interfascial plane block’, was first described in 2007 as a block of the posterior abdominal wall performed exclusively under ultrasound guidance. It was defined as a variant of a transversus abdominis plane block for a wider analgesia distribution and long-lasting post-operative analgesia. Thoracolumbar fascia (TLF) embeds a thick network of sympathetic neurons and plays an important role in QLB analgesia. However, the true mechanism of analgesia of the QLB is not yet clarified. Local spread of anaesthetics along the TLF is assumed to be accountable for part of the analgesia. Literature describes four different types of QLB depending on the needle tip positioning in relation to QL muscle—anterior, posterior, lateral and intramuscular QLB. In anterior QLB, local anaesthetic is applied in front of the QL muscle, at the level of its attachment to the transverse process of the L4 vertebra. In intramuscular QLB, local anaesthetic is applied directly into QL muscle.

When considering hip surgery and post-operative management, the anterior QLB may play a role in analgesia. It can be performed in a manner that the patient is placed into a lateral position with the needle inserted through the QL in an anteromedial direction. QLB 3—anterior/transmuscular: LA applied in front of the QL muscle, at the level of insertion—transverse process of L4 vertebra.

The local anaesthetic is injected between the QL muscle and psoas major muscle under ultrasound guidance with dosage in the range of 0.2 to 0.4 ml/kg of 0.2 to 0.5% ropivacaine or 0.1 to 0.25% bupivacaine per side is recommended, minimum 15 mL of solution, and one must be aware on highly vascular region [27]. Figure 4 shows the scanning technique to identify QL, PM and erector spinae muscles at the level of transverse process (TP) with correlating ultrasound image on the right.

Figure 4.

Scanning technique to identify QL, PM and erector spinae muscles at the level of transverse process (TP) with correaltin ultrasound image on the right.

Few cases have shown QLB to be beneficial in the management of proximal femoral fractures in high-risk geriatric patients and a patient that underwent hemiarthroplasty after a femoral neck fracture. Few studies also suggest that QLB might provide similar analgesia in comparison with lumbar plexus block for total hip arthroplasty. A role for QLB is in multimodal pain management for hip surgery patients due to its potential for analgesic effectiveness and preservation of muscle strength, which makes it less likely to impair early functional rehabilitation. To summarise, QLB has shown potential for use in hip surgery perioperative pain management, but still lacks sufficient data from prospective studies to be accepted as a reliable treatment approach. Pre- or post-operative peripheral nerve blockade may be used to supplement either general or spinal anaesthesia.

6. Monitoring

Minimum standards for monitoring during the surgery include the continuous presence of the anaesthetist, pulse oximetry, capnography, electrocardiography ECG and non-invasive blood pressure monitoring. Core temperature monitoring should be used routinely. Further monitoring equipment such as invasive blood pressure monitoring, central venous pressure (CVP), cardiac output, bispectral index (BlS) and cerebral oxygen saturation depends of patient’s comorbidities.

7. Supplemental pain relief

Regular paracetamol administration should continue throughout the perioperative period. Non-steroidal anti-inflammatory drugs should be used with extreme caution in hip fracture patients and are contraindicated in those with renal dysfunction. Similarly, opioids (and tramadol) should be used with caution in patients with renal dysfunction: oral opioids should be avoided, and both, dose and frequency of intravenous opioids should be reduced (e.g. halved). Codeine should not be administered, as it is constipating, emetic and associated with perioperative cognitive dysfunction.

8. Conclusion

Hip replacement made of experienced surgeon is the best analgesic for hip fractures. Regional anaesthesia is essential for hip arthroplasty programmes depending on anaesthetist’s experience and choice. Good analgesia and the avoidance of post-operative nausea and vomiting (PONV) are prerequisites for early ambulation and patient compliance with post-operative protocols. Regional anaesthesia, both neuraxial and peripheral blocks, is superior to systemic opioid analgesia at all-time points in the first 3 days following surgery and by avoiding opioids the risks and incidence of opioid analgesia is removed. Early ambulation is a key part of the management of patients with hip fractures. Safety of drugs for intrathecal injections and complications from spinal anaesthesia continue to be examined and re-examined in order to improve the safety of the technique. More studies will be needed to further understand and improve the clinical use of spinal anaesthesia.