Combined sacral erector spinae and supra-inguinal fascia iliaca blocks in total hip arthroplasty pain

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Dear Editor, Severe postoperative pain may accompany total hip arthroplasty (THA) performed for end-stage osteoarthritis or after hip fracture. The PROSPECT guidelines recommend basic analgesics together with regional anesthesia techniques such as fascia iliaca block or local anesthetic infiltration for the pain management, especially if high postoperative pain is expected.[1] We hypothesized that a supra-inguinal fascia iliaca block (SIFIB) together with a complementary block as the novel sacral erector spinae (ESP) block could produce full postoperative analgesia after THA in an old frail patient who underwent surgery after a broken hip. An 83-year-old male patient (weight 54 kg, height 169 cm, BMI 19 kg.m-2) with multiple comorbidities (smoking habit, chronic obstructive pulmonary disease, chronic coronary artery disease, 75% bilateral carotid stenosis, chronic renal failure, vertebral angiomas, American Society of Anesthesiologists Physical Status III) underwent total hip arthroplasty for a femoral fracture. After the written informed consent of the patient, monitoring vital parameters, intravenous (IV) midazolam (2 mg) was provided; then, in aseptic conditions, we performed an ultrasound-guided SIFIB block using 0.2% ropivacaine 30 ml, followed by a unilateral sacral ESP (at the intermediate crest, S1 level) with 0.2% ropivacaine 40 ml, adding dexamethasone 4 mg in each block as an adjunct [Figure 1]. After that, the patient was introduced into the operation room and, aseptically, spinal anesthesia (at L3-4 level) was placed using plain 0.5% levobupivacaine 2 ml (10 mg). Intravenous midazolam was provided for sedation (0.04 mg/kg/h), with the patient spontaneously breathing. The surgery lasted 75 minutes without complications. At the end of the operation, the patient was monitored in the recovery room for 1 hour and before discharging to the ward, the patient received intravenous 1 g paracetamol. IV paracetamol was prescribed two times a day, and a rescue dose of IV tramadol 50 mg plus ondansetron 4 mg was prescribed if the NRS score for pain was >4. On the same afternoon of the surgery, 4 hours after the surgery, the patient regained complete control of the lower limbs with an NRS <3. The day after, the patient began rehab, and at 24–36–48 hours post surgery, the NRS score was <4. No rescue dose of analgesics and no opioids were administered.Figure 1: a Ultrasonography of supra-inguinal fascia iliaca block. The red arrows indicate the needle inside the fascia. The black arrow indicates the fascia iliaca and the initial spread of the local anesthetic. AIIS, anterior inferior iliac spine; IO, internal oblique muscle. b Ultrasonography of sacral intermediate crest at S1-2 level. The needle trajectory (black arrows) from cranial to caudal. Local anesthetic (LA) administration starts spanning beneath the multifidus muscle (MF) aponeurosis. The needle is advanced while the injection is performed (dynamic blockage)The SIFIB block was first described by Hebbard et al.[2] as an alternative technique to get a more proximal spread of the injectate with the potential of more efficacious analgesia after hip surgery. It results in the blockage of the femoral and the lateral femoral cutaneous nerves in most instances (up to 100%), while the coverage of the obturator nerve is controversial.[3] The sacral ESP was introduced for the block of posterior branches of sacral spinal nerves and, due to the potential cephalad and anterior spread of the anesthetic from the sacral to lumbar roots, demonstrated its usefulness even in the analgesia after orthopedic surgeries as in discectomy[4] and after hip fracture.[5] In this case, the two fascial blocks allowed the spinal puncture to be performed with the patient in greater comfort and without pain. The spinal anesthesia, even with a lower dose of anesthetic, was effective in providing surgical anesthesia and muscle relaxation. Furthermore, we highlighted the potential benefit of combining the sacral ESP with the SIFIB as part of an opioid-free analgesic approach in hip arthroplasty for a frail patient. In our approach, the sacral ESP worked overlapping with the SIFIB in a synergistic mode to get full coverage of the surgical area (anterior and also posterior aspects of the hip joint), providing optimal postoperative analgesia for 48 hours without the use of opioids and complications, allowing the patient to begin rehabilitation 24 hours after the surgery. Further studies are needed to ascertain the effectiveness and the limitations of these two fascial blocks, even if used in combination for the hip surgery. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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