Anesth Analg 2002;95:1428-1431
© 2002 International Anesthesia Research Society
REGIONAL ANESTHESIA
Lumbar Plexus Posterior Approach: A Catheter Placement Description Using Electrical Nerve Stimulation
Pierre C. Pandin, MD,
Arlette Vandesteene, MD PhD, and
Alain A. d’Hollander, MD PhD
Department of Anesthesiology and Resuscitation, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
Address correspondence and reprint requests to Pierre C. Pandin, Department of Anesthesiology and Resuscitation, Erasmus Hospital, Lennik Street 808, B-1070 Brussels, Belgium. Address e-mail to ppandin{at}ulb.ac.be
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Abstract
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IMPLICATIONS: The authors describe a modified technique of posterior approach to the lumbar plexus in the psoas compartment which allows nerve stimulation for the location of the plexus and catheter placement for extended-duration surgery and postoperative patient-controlled regional analgesia. A frequent incidence of total lumbar plexus block was observed.
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Introduction
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Lumbar plexus anesthesia for major hip and knee surgery is becoming a standard technique (1–4). The inguinal paravascular, or three-in-one, technique is adapted to knee surgery, providing mainly peripheral blockade of the femoral nerve and third lumbar dermatome (5–8). However, at the hip level, blockade of at least the L1 to L4 dermatomes and osteotomes is needed (4). For this, the posterior approach to the lumbar plexus seems more appropriate. A catheter technique allows perioperative top-up injection and postoperative static and dynamic analgesia (2,6,7,9). We have tried to obtain a frequent incidence of total lumbar plexus block with a posterior approach, combining nerve stimulation and catheter insertion. This report presents our technical results with a modified psoas compartment approach. A nerve stimulation-guided procedure was tested prospectively regarding the feasibility and success rate of the method for catheter placement, the extent of sensory and motor blockade obtained, and side effects and complications.
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Methods
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During a 2-yr period (October 1997 to September 1999), lumbar plexus catheters were placed by using our slightly modified landmarks in consecutive informed patients undergoing hip joint (total replacement or fracture) and proximal femoral shaft (fractures) surgery. The patients were placed in the lateral position with the affected side up. The puncture site was located 3 cm below the intercrest line and 3 cm lateral to the interspinous line 1 to 2 cm medial to the original Chayen et al. (10) approach. A 110-mm ContiplexTM needle (B. Braun Melsungen AG, Melsungen, Germany) device was connected to an HNS11 StimuplexTM (B. Braun Melsungen AG); the frequency and duration of the stimulus were 1 Hz and 300 µs, respectively. The stimulation current of 0.5 mA was decreased to 0.3 mA to refine location. A polyethylene 20-gauge catheter was introduced 3 cm cephalad in the psoas compartment. Muscular twitches in the quadriceps femoris muscle were considered the accepted response to the neurostimulation, but activity in the adductor of the thigh muscle group was also accepted. After a 3-mL test dose (1% lidocaine with 1:200,000 epinephrine), 15 mL of 0.5% bupivacaine and 15 mL of 2% lidocaine were injected slowly through the catheter (3 to 5 min).
Anesthesia and residual motor block were evaluated 30 min later as follows:
- Sensory block using cold and pinprick tests in the femoral, obturator, lateral femoral cutaneous, ilioinguinal, hypogastric, and genitofemoral nerve distributions.
- Dermatome sensory block using cold and pinprick tests in the L1 to S1 cutaneous dermatomes to appraise the root block. The lumbar plexus was considered completely anesthetized if the L1 cutaneous dermatome area (corresponding to the ilioinguinal and the hypogastric—L1—and partially to the genitofemoral—L1 and L2—nerve territories) and the other lumbar cutaneous dermatomes corresponding to the three nerve supplies (enumerated previously) were blocked.
- Motor block using the modified Bromage scale specially adapted to the femoral and obturator nerves (score of 1 to 4, with 1 corresponding to full extension of the knee for the femoral nerve or adduction of the thigh for the obturator nerve, and 4 for total inability of the respective movement).
Side effects or complications relative to block placement were noted until the induction of general anesthesia (at least 30 min). In the 56 initial patients, 5 mL of iohexol 240 mg/mL was added to the 30 mL of anesthetic mixture. The distribution of radiopaque injection around the plexus was studied by taking a lower-abdominal radiograph, including the pelvis.
General anesthesia was induced to provide analgesia corresponding to the sacral plexus nerve supply, particularly at the gluteal level. SPSS 8.0 software (SPSS Inc., Chicago, IL) was used for computation and statistical analysis of the data.
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Results
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Psoas block and catheter insertion were performed in 132 ASA status I, II, and III patients (62 men and 70 women), aged 38 to 72 yr (median, 63 yr). The median weight was 80 kg (range, 47–112 kg), and the median height was 166 cm (range, 154–187 cm). The median location depth of the lumbar plexus was 9.5 cm (range, 8.0–10.5 cm). The median surgical duration was 135 min (range, 95 to 195 min). The effectiveness (sensory and motor block) after the first bolus and incidents are summarized in Table 1. During the same period, failure to locate the plexus was observed in four obese patients (body mass index >30 kg/m2) even after increasing the stimulation intensity to 1 mA. These patients could not be included in the study. When an S1 anesthesia occurred (13 patients), it was never complete with the cold and the pinprick tests. The same result was encountered in five patients presenting an L5 anesthesia with the same tests. No hemodynamic instability was noted during the 30-min observation after the local anesthetic injection.
Two cases of asymmetric presumed epidural distribution were noted. The upper anesthetic level was T11 and T10 on the ipsilateral to injection side and L1 and L2 on the contralateral side. The anesthetized area was homogeneous down to the L4 dermatome bilaterally.
When radiopaque dye was injected, two types of radiographs were obtained. In the first one (42 patients; 75%), the radiopaque dye reached the internal edge of the psoas compartment around the lumbar plexus, infiltrating the psoas compartment predominately in its medio-internal part up to L1 (Fig. 1). The obtained radiographs were comparable to those already published (10–12). In the 14 other patients (25%), the second sort of dye spread appeared wider, shorter, and more distal and lateral (Fig. 2) and could be compared with that obtained without nerve stimulation by Brands and Callanan (13), probably corresponding to the junction of the distal part of the psoas compartment and the proximal part of the fascia iliaca or to the intrapsoas muscle injection. The femoral and lateral femoral cutaneous nerves’ anesthesia were observed without a significant difference between the two types of radiographs, whereas the occurrence of blockade of the obturator nerve and the accessory ones (ilioinguinal, hypogastric, and genitofemoral) was observed significantly more often in the Type 1 group of patients (87%–71%, 64%–43%, 62%–38%, and 57%–38%, respectively). Consequently, a complete lumbar plexus block was noted in 64% of first group’s patients, compared with only 14% in the second group. However, a block extension to the first sacral root (dermatome anesthesia) was observed only in the second group’s patients (43%).
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Figure 1. Radiograph showing the distribution of radiopaque dye (30 mL of the anesthetic mixture added to 5 mL of iohexol 240 mg/mL) within the right psoas compartment through the catheter in a 58-yr-old female patient weighing 88 kg with ultimate coxarthrosis. Note that the anesthetic solution reached the psoas compartment medially around the lumbar plexus up to the first nervous root level.
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Figure 2. Radiograph showing the second kind of distribution of radiopaque dye (30 mL of the anesthetic mixture added to 5 mL of iohexol 240 mg/mL) within the right psoas compartment through the catheter in a 48-yr-old male patient weighing 79 kg with a posttraumatic coxarthrosis.
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Discussion
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Several techniques using the loss-of-resistance method for a posterior approach to the lumbar plexus have been described for single injection (10,12–16). The lower ones (10,12,13,16) have been preferred because of the smaller risk of puncturing an organ (kidney, ureter, etc.) or a vessel. Chayen et al. (10) and Winnie et al. (16) were the first to point out that the posterior approach was more appropriate for plexus block than the anterior one (17), because blockade of the main lumbar trunks stemmed from the plexus.
We modified the classical Chayen et al. (10) approach as follows. We accessed the psoas compartment more medially, performing the block closer to the emergence of the nerve roots into the compartment to try to adapt, at the lumbar level, the notion of paravertebral anesthesia described by Richardson and Lönnquist (18) at the thoracic one and to attempt to achieve a more radicular anesthesia than that produced by the Chayen et al. (10) and the Winnie et al. (16) techniques. We did this, first, to increase the likeliness of the obturator nerve block; second, to optimize catheter insertion with an introduction angle of 20° to 30° and to deliver the postoperative infusion as near as possible to the proximal plexus elements (19); and third, to minimize the occurrence of local complications.
The radiographic data show infiltration of the psoas compartment, particularly on its median edge, explaining the frequent obturator nerve blockade incidence (Table 1), even if anatomical variations must be considered (19). There was also infiltration at the superior level related to the infiltration of the three accessory nerves (ilioinguinal, hypogastric, and genitofemoral) that the nerve supply is issued mainly from the first lumbar nervous root and also explaining the L1 dermatome anesthesia.
We conclude that for lumbar plexus block for hip or proximal thigh surgery, the described posterior neurostimulation approach allows a frequent incidence of complete plexus blockade to be obtained, including the obturator nerve, together with a small incidence of minor side effects and without major complications. It seems to be an intermediate solution (20) between classic central block techniques, inducing non-negligible sympathetic and bladder function blockade, and more distal techniques, corresponding only to nervous blockade (8). For these reasons, this approach could be considered as a valuable alternative compared with the central neuraxial block for lower-limb proximal surgery.
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References
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Accepted for publication July 10, 2002.
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Abstract
Introduction
