Anesth Analg 2004;98:623-628
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000100662.87610.16
PEDIATRIC ANESTHESIA
Continuous Psoas Compartment Blocks After Major Orthopedic Surgery in Children: A Prospective Computed Tomographic Scan and Clinical Studies
C. Dadure, MD*,
O. Raux, MD*,
P. Gaudard, MD*,
M. Sagintaah, MD
,
R. Troncin, MD*,
A. Rochette, MD*, and
X. Capdevila, MD PhD*
Departments of *Anesthesia and Critical Care Medicine and
Pediatric Radiology, Lapeyronie University Hospital, Montpellier, France
Address correspondence and reprint requests to Christophe Dadure, MD, Département d’Anesthésie Réanimation A, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295 Montpellier, France. Address e-mail to c-dadure{at}chu-montpellier.fr
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Abstract
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Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV®; Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient’s weight (0.2 mg · kg-1 · h-1). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature.
IMPLICATIONS: Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.
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Introduction
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Femoral shaft and hip surgeries can lead to severe postoperative pain (1). Adverse effects attributed to opioids and continuous epidural blocks limit their use in children (2,3). The "three-in-one" block described by Winnie et al. in 1973 (4) and McNicol in 1985 for children (5), and psoas compartment block reported in 1974 for adults (6) and in 1993 for children (7) are alternative methods for providing anesthesia and postoperative analgesia. Three-in-one blocks are safe and straightforward, but cases of unsuccessful sensory blockade of the obturator and lateral femoral cutaneous nerves have been observed (8,9). With these techniques, moreover, the catheter is situated near the surgical site.
Psoas compartment blocks reliably block all branches of the lumbar plexus (LP) in adults (8,10). Continuous psoas compartment block (CPCB) providing excellent analgesia similar to that obtained in adults has been reported in children (11). No prospective study has previously evaluated LP location in children according to age or assessed CPCB placement procedures using landmarks other than those originally described by Winnie et al. (6). In adults, Capdevila et al. (8) have used landmarks more medial than those proposed by Winnie et al.
The purpose of the present prospective study was to evaluate the feasibility and efficacy of CPCB after major femoral shaft or hip surgery, using landmarks defined by a preliminary computed tomographic (CT) scan study in different age groups of children.
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Methods
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CT Scan Study
After ethical committee approval, parental informed consent was obtained for inclusion of 20 patients from 1 to 15 yr of age. The lumbosacral region of all these patients exhibited a radiographic aspect that was considered to be normal.
Axial transverse CT sections of the lumbosacral region (i.e., slices of 40 LP) centered on the L3, L4, L5, and S1 vertebrae were used to determine: 1) the distance between a first line passing through the spinous process of L4–5 to a second line, parallel to the previous one, passing through the posterior superior iliac spine (PSIS); 2) the distance from the former line to a line passing through the LP located in the psoas major muscle; and 3) the depth of the LP (its distance from the skin). When the LP was not clearly identifiable by CT scan, the pediatric radiologists assumed that its location corresponded to the junction of the anterior two-thirds and posterior third of the psoas major muscle (both LPs were actually located in eight of the patients).
Clinical Study
After approval by the ethical committee and informed consent of all parents, we included in the study 15 consecutive children who had ASA physical status I or II and who were scheduled to undergo major hip or femoral shaft surgery.
The children were premedicated using 0.4 mg/kg midazolam and 20 µg/kg atropine. Intraoperative general anesthesia was induced in all children using sevoflurane and 1 µg/kg IV fentanyl. Children underwent endotracheal intubation and mechanical ventilation was applied for the duration of surgery. Anesthesia was maintained with 50% nitrous oxide in oxygen and a 2% inspired fraction of sevoflurane. CPCBs were performed before the surgical procedure using a nerve stimulator for precise nerve location (Stimuplex®; Braun, Melsungen, Germany), connected to a new nontraumatic 18-gauge insulated needle 50- to 100-mm long depending on the patient’s age (Plexolong®; Pajunk, Melsungen, Germany). The landmarks found in the preliminary CT scan study were applied in the children according to age group.
Patients were turned to the lateral position with the operated side uppermost. The insulated needle was inserted three-quarters of the distance between the spinous process of L4 and a line parallel to the spinal column passing through the PSIS (Fig. 1). With a starting output of 2 mA (frequency, 1 Hz; duration, 50 µs), the needle was advanced perpendicularly to the skin until contact with the transverse process of L4 was obtained. Then the needle was pulled back 2 mm and advanced under the transverse process until femoris muscle twitches were elicited, or a maximal distance of 20 mm was reached. The position was judged adequate when quadriceps contraction (i.e., cephalad patellar movements) was elicited by impulses of 0.5–0.7 mA. The needle bevel was oriented caudally and laterally. The psoas compartment was distended with 0.1 mL/kg saline, and a 20-gauge multi-perforated catheter (Plexolong®; Pajunk) was threaded to a depth of 5 cm below the skin. After placement, 0.1 mL/kg contrast (Iopamidol® 200; Shering Pharmaceutical, Lys-Lez-Lannoy, France) was injected into the catheter, and an anteroposterior radiograph of the pelvic region was obtained within 5 min.
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Figure 1. Estimation of the point of puncture for insertion of the continuous psoas compartment block catheter (*) in a child using the preliminary computed tomographic scan study landmarks. PSIS = posterior superior iliac spine.
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The protocol called for exclusion of children with unreliable catheter location from analysis of pain score, but any case of unreliable catheter location was to be included among adverse events of the technique. In the others, 0.5 mL/kg of an equal-volume mixture of 0.5% ropivacaine and 1% lidocaine with 1:200000 epinephrine was injected via the catheter over a 5-min period. In the postoperative period, in awakened and tracheally extubated children, a continuous infusion of 0.2% ropivacaine, based on patient weight, was administered at 0.1 mL · kg-1 · h-1 using disposable multi-rate elastomeric pumps (Infusor® LV; Baxter, Paris, France) with a flow of 1, 2, or 3 mL/h for young children and a flow of 2, 3, or 5 mL/h for teenagers. Propacetamol (30 mg/kg four times daily) and niflumic acid (40 mg/kg twice daily) were administered IV over a 15-min period to all children. In the postoperative period, sensory blockade was evaluated by testing cold sensation (ether on a ball of cotton wool) at hour H1, H6, H12, H18, H24, H36, and H48. At the same follow-up times, motor blockade was evaluated for selected muscles of each nerve territory using a Bromage scale (12). Also at these times, pain was assessed using amounts of rescue analgesia and either a visual analog scale (VAS) ranging from 0 (no pain) to 10 (most imaginable pain) cm or, for very young children, the Children and Infants Postoperative Pain Score (CHIPPS) (13). If pain control was considered insufficient (VAS or CHIPPS score >3) during the postoperative study period, an IV injection of 0.2 mg/kg nalbuphine was administered as rescue analgesia. At the end of the study period (H48), parent satisfaction was recorded (unsatisfied, satisfied, very satisfied). Any adverse effects (pruritus, nausea, vomiting, dysesthesia, hematoma, urinary retention, local infection, or local anesthetic [LA] toxicity) were noted.
Statistical analysis was performed using SAS software version 8.02 (SAS Institute, Cary, NC). The quantitative anthropometric scores were expressed as median (extremes); motor blockade as median (extremes); sensory blockade as number of patients with a sensory block and pain score as median (25th–75th percentiles and extremes). Repeated measure analysis of variance was used for continuous variables. Comparisons between values at the times studied were made using the Mann-Whitney U-test for nonparametric data, and the 
2 test was used for categorical data. A significance threshold of P < 0.05 was retained.
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Results
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CT Scan Study
Twenty children were included in the CT scan study. Forty LPs were analyzed. Children were separated into 3 groups according to age (1–4, 5–8, or 11–15 yr). LP depth was correlated to the age of the patients (Fig. 2). A three-dimensional CT scan (Fig. 3) obtained after injection of contrast medium through the peripheral nerve catheter in one of the patients, aids in visualizing a typical catheter location, and the anatomical relationships between the LP and spinal column and between the LP and the L4 transverse process.
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Figure 2. Lumbar plexus depth according to age group. The box represents the 25th–75th percentiles; the dark line is the median. The extended bars represent the 10th–90th percentiles and the dark circles represent values outside this range.
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The median value of the ratio of the distance between the spinous process and LP and the distance from the spinous process to the line through the PSIS parallel to the spinal column was 0.715 in the 1-to-4 yr group of children, 0.76 in the 5-to-8 yr group, and 0.8 in the 11-to-15 yr group (Fig. 4). The median value for all the children of the ratio of the distance between the spinous process and LP and the distance from the spinous process to the line through the PSIS parallel to the spinal column was 0.76 (Fig. 5). This was situated at three-quarters of the distance between the spinous process of L4 and a line parallel to the spinal column passing through the PSIS. This ratio was used to determine the point of puncture for CPCB catheter placement in the subsequent consecutive series of 15 patients. Only 1 of the former 20 children had a ratio equal to 1 (i.e., LP was on the line through the PSIS parallel to the spinal column) (Fig. 4).
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Figure 4. Value of the ratio of the distance between the spinous process and lumbar plexus (LP) and the distance from the spinous process to the line through the posterior superior iliac spine parallel to the spinal column in 20 children (i.e., 40 LP; each histogram is an LP). The dotted line is the median value in the 1-to-4 yr group of children, the broken line is the median value in the 11-to-15 yr group, and the full line is the median value in the 5-to-8 yr group as well as the median value of all the children for the computed tomographic scan study.
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Figure 5. Computed tomographic scan determination of the distance between the spinous processes of L4 and L5 and lines through the lumbar plexus and through the posterior superior iliac spine.
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Clinical Study
Fifteen consecutive children, 8 boys and 7 girls, were included in this study. The median age was 8 (1–14) yr. Twelve patients were ASA physical status I and three were ASA class II. The median weight was 30 (range, 10–64) kg. The median duration of surgical procedure was 134 (range, 49–540) min. Three disposable pumps with a flow of 1 mL/h, 3 with 2 mL/h, 4 with 3 mL/h, and 5 with 5 mL/h were used over a 48-h period (from 36 to 48 h). No block failures were noted. All the nerve blocks were effective during surgery. All the catheters were correctly located as determined by use of contrast medium.
Postoperative analgesia was excellent. The VAS and CHIPPS values are shown in Figure 6. The median pain scores were 1 at H1 and 0 beginning H6. The use of rescue analgesia, sensory block efficacy, and motor block efficacy are shown in Table 1. Parent satisfaction was achieved for 93% of the children.
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Figure 6. Pain score during the study period. The box represents the 25th–75th percentiles; the dark line is the median. The extended bars represent the 10th–90th percentiles and the dark circles represent values outside this range.
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None of the children had hematoma or associated catheter infection. No dysesthesia or any other sign of LA toxicity was noted. No neurological symptom was noted after withdrawal of the disposable pumps. There was no accidental removal of the catheter during the study period. Four patients had nausea or vomiting and three patients reported pruritus.
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Discussion
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This study shows that CPCB with 0.2% ropivacaine provides effective analgesia with few adverse effects after major femoral shaft or hip surgery in children. The new landmarks described in this study were obtained from the present preliminary CT scan study.
These revised landmarks used in our study and the preliminary CT findings contrast somewhat with the conventionally used landmarks (6). The new landmarks permitted correct placement of the CPCB catheter in 15 consecutive children, facilitating and ensuring the safety of CPCB catheter insertion. In the literature on LP anatomy in adults (8,14,15), the point of puncture described by Winnie et al. (6) can be overly lateral, and recognizing this problem, the authors recommended proceeding with the needle in a slightly medial direction during the puncture, bringing the tip closer to the spine. However, a more medially oriented needle can result in bilateral anesthesia or spinal anesthesia, even if the physician uses a nerve stimulator for guidance (16). With these more medial landmarks, the puncture is performed perpendicularly to the skin in all planes. The depth of the LP, which was determined in the CT scan study, was in accordance with the clinically estimated depth reported by Dalens (7) in children.
There are few studies evaluating the effectiveness of continuous LP blocks for postoperative analgesia in children, either by femoral peripheral nerve block (17–19) or by CPCB (11). In adults, CPCBs achieve frequent success regarding sensory blockade of the femoral, obturator, and lateral femoral cutaneous nerves (8,10). For single-shot peripheral nerve blocks, Parkinson et al. (20) found that the anterior approach of Winnie et al. obtained less effective obturator nerve blockade than posterior approaches. After 3-in-1 block, the LA does not reach the obturator nerve at a concentration sufficient to achieve sensory block (21). In children, Sciard et al. (11) have confirmed the importance of lateral cutaneous and obturator nerve blockade after hip surgery for pain relief. In this population, the extent of sensory block is difficult to evaluate because of pelvic casts normally applied after hip surgery, but the present very low pain scores show the effectiveness of this analgesic technique. Surprisingly, we found a discrepancy between the observed low pain scores and the use of nalbuphine during the first postoperative night (H18). This discrepancy suggests inappropriate use of nalbuphine for its sedative effects (Table 1).
CPCB obviates use of bilateral blockade, which is unnecessary in unilateral surgery. This represents an important advantage over epidural analgesia or use of IV opioids (3). In our study, CPCB led to few adverse side effects. No major complication was reported. In adults, some authors have reported serious complications including unilateral epidural anesthesia (8) and retroperitoneal injection if the needle is inserted deeper (20). In children, the paucity of studies of CPCB does not permit conclusions on the risks of this technique. One may hypothesize that these risks are similar to the risks of CPCB in adults. Precise knowledge of the LP depth is useful to avoid deeper injection (20).
In conclusion, the present study demonstrates that CPCB with 0.2% ropivacaine is an effective technique for postoperative pain management in children after major orthopedic surgery. During the study period, there were few adverse events and no major complications. Nevertheless, because of the particular anatomical situations of the LP, this regional technique should be only performed by trained anesthesiologists, taking into consideration the depth of the LP estimated according to the patient’s age.
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Acknowledgments
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Financial support was obtained from the Association pour le Développement et la Recherche en Anesthésie Réanimation, CHU Lapeyronie, Montpellier, France.
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Accepted for publication September 24, 2003.
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Abstract
Introduction
