|Year : 2018 | Volume
| Issue : 1 | Page : 54-60
Comparative study between combined spinal-epidural anesthesia versus femoral/sciatic nerve block under ultrasound and nerve stimulator guidance for both-bone leg fractures
Hamed Abd El-Aziz El-Badawy, Abd Al-Maksoad Aymen Yousef, Gamal Muhamad El-Mawy, El-Saied Hanan El-Kalawy
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||26-Apr-2017|
|Date of Acceptance||05-Feb-2018|
|Date of Web Publication||26-Jul-2018|
El-Saied Hanan El-Kalawy
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, El-Gharbia, Tanta, 44, Tot Ank Amon Street, 31111
Background General anesthesia has a lot of complications, so alternative procedures like combined spinal-epidural anesthesia (CSEA) are better but with their adverse effects on cardiovascular and pulmonary functions. New era tend toward ultrasound (US) guidance and nerve stimulator for nerve block to ensure better effects without any complications.
Aim The aim of this study was to compare CSEA versus femoral/sciatic nerve block (FSNB) by US guidance and nerve stimulator as anesthetic technique for patients with both-bone leg (BBL) fractures.
Patients and methods Ninety adult patients, ASA I–II, scheduled for fracture BBL were included in the study. Patients were randomized into two equal groups. Group I CSEA received intrathecal 5 mg of hyperbaric bupivacaine 0.5+15% μg fentanyl, and then 7 ml of epidural (0.375% of plain bupivacaine+fentanyl 2 μg/ml) was injected as a loading dose. Finally, an additional epidural of 4 ml of 2% lidocaine was given if the desired sensory level was not reached till after 20 min or the operation lasted more than 80 min. Group II underwent FSNB by using US guidance and nerve stimulator. We first blocked the sciatic nerve by injection of 15 ml of 0.25% bupivacaine and 10 ml of 1% lidocaine. Then femoral nerve block was done by injection of 20 ml of bupivacaine 0.25% and 10 ml of 1% lidocaine.
Results There was no significant difference between both groups in demographic data and failure rate. The onset of sensory and motor block was shorter in CSEA group, but the duration of sensory and motor block was prolonged in FSNB group. First dose of analgesia required was earlier in CSEA group. Heart rate and mean arterial blood pressure showed significant decrease in CSEA group at 5, 15, and 30 min intraoperatively. Visual analogue pain scale was higher and need for rescue analgesia was earlier in CSEA group.
Conclusion FSNB by US guidance nerve stimulation technique provides better block characteristics, longer duration of analgesic, better intraoperative hemodynamics, and decreased the need for postoperative rescue analgesia in comparison with CSEA in patients with BBL fractures.
Keywords: bupivacaine, combined spinal-epidural block, femoral/sciatic nerve block, both-bone leg fracture, levobupivacaine
|How to cite this article:|
El-Badawy HE, Yousef AMA, El-Mawy GM, El-Kalawy ESH. Comparative study between combined spinal-epidural anesthesia versus femoral/sciatic nerve block under ultrasound and nerve stimulator guidance for both-bone leg fractures. Tanta Med J 2018;46:54-60
|How to cite this URL:|
El-Badawy HE, Yousef AMA, El-Mawy GM, El-Kalawy ESH. Comparative study between combined spinal-epidural anesthesia versus femoral/sciatic nerve block under ultrasound and nerve stimulator guidance for both-bone leg fractures. Tanta Med J [serial online] 2018 [cited 2018 Dec 16];46:54-60. Available from: http://www.tdj.eg.net/text.asp?2018/46/1/54/237623
| Introduction|| |
Regional anesthesia (RA) is an alternative to general anesthesia in orthopedic surgery because it provides sufficient anesthesia, better postoperative analgesia, and higher patient satisfaction ,, as well as it reduces the risk of pulmonary aspiration, which is the most feared complication of general anesthesia .
Combined spinal-epidural anesthesia (CSEA) is a popular technique as it can reduce or eliminate some of the disadvantages of spinal anesthesia and epidural anesthesia while preserving their advantages .
Combined spinal-epidural (CSE) is inappropriate for patient with compromised cardiovascular or pulmonary function . So, alternative anesthetic techniques are needed such as femoral/sciatic nerve block (FSNB) for those high-risk patients undergoing lower limb surgeries .
It was impossible to verify the needle tip location relative to the nerves and how the local anesthetic was distributed during RA before the advent of ultrasound (US) . So, US guidance saves time and improves the quality of sensory block while avoiding associated complications .
Our study hypothesis is to compare CSEA versus FSNB using US and nerve stimulator guidance as anesthetic technique for patients with both-bone leg (BBL) fractures.
| Patients and methods|| |
After obtaining approval from institutional research ethical committee, an informed consent was obtained from all participants in this study. This study was carried on 90 patients with physical status ASA I–II admitted for internal fixation of open fracture of BBL in Tanta University Hospitals in the Orthopedic Department.
Patient refusal, uncooperative patients, unconscious patients, patients with head trauma, patients with history of relevant drug allergy to local anesthetics, patients with local infection at the site of the block, patients with coagulopathies and impaired platelet functions, patients with hemodynamic instability, those with previous neurological deficit in lower limb, patients with previous back surgery, patients with previous femoral artery grafts or injuries, patients with short stature less than 150 cm, patient on long-term use of opioids, and patient with chronic pain were excluded from the study.
Patients were randomized and allocated into two equal groups using sealed envelope: 45 patients received intrathecal 5 mg (1 ml) of hyperbaric bupivacaine 0.5% plus 15-μg fentanyl, and then 7 ml of epidural local anesthetic solution containing 0.375% of plain bupivacaine plus fentanyl 2 μg/ml was injected epidurally as a loading dose in group I (CSE group). Another 45 patients were injected with 15 ml of 0.25% bupivacaine and 10 ml of 1% lidocaine to block sciatic nerve, and then 20 ml of bupivacaine 0.25% and 10 ml of 1% lidocaine were injected to block femoral nerve under US guidance with nerve stimulation in group II (FSNB group).
All patients clearly understood the visual analogue pain scale (VAS) to ensure accurate expression of postoperative pain severity by marking on a line of 10-cm length graded from 0 to 10 and demonstrating how to detect pain severity: 0=no pain and 10=most severe pain.
Heart rate (HR), peripheral oxygen saturation, and noninvasive blood pressure were monitored in all patients. Patients received 1 mg of midazolam intravenously 5 min before the start. An intravenous preload of 100–200 ml of Ringer’s lactate solution was given.
In the CSEA group, needle-through-needle technique was done. CSEA was performed with the patient in sitting position. The epidural space was identified by using the midline approach at L3–L4 levels, then intradermal injection of 1% lidocaine was administered after waiting for 30 s, and then the epidural space was identified with 18-G Touhy needle using loss of resistance to air technique. Thereafter, the 27-G pencil-point spinal needle was advanced into the subarachnoid space through the epidural needle. After appearance of clear cerebral spinal fluid (CSF), the intrathecal local anesthetic of 5 mg (1 ml) of hyperbaric bupivacaine 0.5% plus 15 μg fentanyl was injected.
The spinal needle was withdrawn, and then an epidural catheter was inserted through the Touhy needle, leaving 4–5 cm of the catheter into the epidural space. Then, an epidural test dose (4 ml of 1% lidocaine in 1 : 400 000 epinephrine) was injected to exclude intravascular or intrathecal placement, followed by injection of 7 ml of epidural local anesthetic solution containing 0.375% of plain bupivacaine+fentanyl 2 mic/ml as a loading dose. Hypotension is a decrease in blood pressure of more than 20% from the baseline level, which was treated by ephedrine (6 mg) injected intravenously. Bradycardia is a decrease in the HR to less than 50 beats/min, which was treated with incremental doses of intravenous atropine (0.01 mg/kg). The level of sensory block is the level of the loss to pinprick sensation, which was recorded bilaterally at the mid-clavicle line every 2 min for 20 min. Surgery commenced after adequate sensory block was reached at T12.
In FSNB group, sciatic nerve is blocked first. The operator stands on the side that is to be blocked, facing the patient, with the US machine across the other side of the patient. The patient was put in the supine position, the hip was abducted and externally rotated, and the knee was flexed for the exposure of the calf and the foot.
With the patient in the proper position for blocking sciatic nerve by anterior approach, the Doppler curved probe (SSI-6000; SonoScape, China (Mainland)) was placed 10 cm distal to the inguinal crease, so as to identify the sciatic nerve. After standard skin preparation, subcutaneous anesthesia was done at the puncture site with 1 ml of lidocaine 1%. A 22 G, 150 mm insulated B-bevel needle (Stimuplex; B-Braun, Boulogne-Billancourt, France) connected to the nerve stimulator was inserted and directed posteriorly and laterally with a 10°–15° angle relative to the vertical plane. At a depth of 5 cm, the nerve stimulator was set to deliver a current of 5.0 mA. Within a depth of 10–15 cm, the sciatic nerve was identified via stimulation and muscular responses of one of its two components: plantar flexion or inversion of the foot for the tibial nerve and dorsiflexion or eversion of the foot for the common peroneal nerve. If no muscular response was obtained at a depth of 15 cm or if the needle ended on the lesser trochanter, the needle was retracted to the level of the skin and reintroduced slightly more medially. After identification, the current was then decreased until the muscular response of either the tibial nerve or the common peroneal nerve was elicited at 0.5–0.7 mA impulses delivered at a frequency of 1 Hz. At that time, the stimulator was switched off. Then, after negative blood aspiration, a 1-ml test dose of 15 ml of 0.25% bupivacaine and 10 ml of 1% lidocaine was injected to exclude intraneural injection; the local anesthetic was injected by increments over a 2-min period.
Then, femoral nerve was blocked. The operator stood on the side that is to be blocked, facing the patient, with the US machine across the other side of the patient. The patient was placed in the supine position, with the table flattened to maximize operator access to the inguinal area. The leg was placed in a neutral position, slightly abducted or laterally rotated up to 150°C, and then exposure of the thigh and patella was done.
With the patient in the proper position for femoral nerve block, the skin was sterilized by 2% povidone-iodine. We placed a linear probe (SonoScape) along the line of the inguinal crease. Initially, we searched for the most easily visible structures such as the femoral artery. The nerve was seen in cross-section as a hyperechoic speckled triangular or oval-shaped structure just lateral to the artery. Adjustments using alignment, tilt, and rotation were required to optimize the view of femoral nerve.
After standard skin preparation, subcutaneous anesthesia was done at the puncture site with lidocaine 1% 2 ml. A 15-cm short bevel 21-G insulated nerve block needle was inserted in plane, and then the needle was connected to a peripheral nerve stimulator. We entered the skin on the lateral side of the probe using a long needle (≤100 mm) piercing through the sartorius muscle, the fascia lata, and the fascia iliaca.
When the tip of the needle advanced slowly until it approached the femoral nerve under the US guidance, then the nerve stimulator was set to deliver a current of 5.0 mA, till it elicited a brisk ‘patellar snap’. Thereafter, the current was decreased until the muscular response was elicited at 0.5–0.7 mA impulses delivered at a frequency of 1 Hz. At that time, the stimulator was switched off. After a negative aspiration test result, 20 ml of bupivacaine 0.25% and 10 ml of 1% lidocaine was injected, with the nerve needle tip preferably inferiorly to the nerve, so that the local anesthetics elevated the nerve and separated it from the artery rather than pushed it away.
HR, mean arterial blood pressure, onset of sensory and motor block, and duration of sensory and motor block were measured. VAS had been done with activity. The need for rescue analgesia (morphine) 0.1 mg/kg was recorded. Patients received rescue analgesia, as well as the total number of rescue analgesia was recorded. Any undesirable adverse effect or complications were recorded. Failure of the technique in both groups was recorded, in cases where general anesthesia was required ([Figure 1]).
Student’s t-test was used for statistical analysis. Repeated measures analysis was used for variables with multiple readings. Numerical data were presented as mean and SD. Categorical data were presented as number and percentage, and the χ2-test was used for statistical analysis. When the χ2-test was not appropriate, the Mont Carlo exact test was applied. The level of significance was adopted at P value less than 0.05. SPSS version 21 (IBM, Chicago, Illinois, USA) was used.
Sample size analysis
The calculation of sample size depended on the level of postoperative pain score. Based on the results of previous studies like Cook et al.  in which the SD was 2, at least 40 patients were required in each group to detect the significant difference in the postoperative pain score of 1.64 between groups at α error of 0.05 and the study power of 95%. We factored a 10% dropout rate, and 45 patients were included in each study.
| Results|| |
Regarding the demographic data (age, sex, BMI, ASA status, and failure rate), there was no significant difference between both groups ([Table 1]).
The mean value of HR showed significant decrease at 5, 15, and 30 min in the intraoperative period in group I (P=0.001) ([Table 2]), whereas the mean value of mean arterial blood pressure showed significant decrease in group I at 5, 15, and 30 min after the procedure ([Table 3]).
|Table 2 Comparison of the mean value of heart rate in the studied groups|
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|Table 3 Comparison of the mean value of mean arterial blood pressure in both groups|
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The onset of sensory block was significantly shorter in group I. The mean value was 8.9±1.7 min in group I, whereas 17.84±5.36 min in group II. The duration of sensory block was significantly prolonged in group II. The mean value was 182.91±21.04 min in group I, whereas in group II, it was 200.76±24.98 min. The onset of motor block in group II was significantly prolonged in group I. The onset of motor block was 11.5±1.5 min in group I, whereas in group II, it was 27.09±4.39 min. The duration of motor block was significantly longer in group II. The mean value of duration of motor block was 100.07±14.57 min in group I, whereas in group II, it was 118.87±9.64 min (P<0.001) ([Table 4]).
Comparison between the two groups regarding VAS with activity showed statistically significant increase in group I at 3 and 4 h postoperatively (P=0.001) ([Table 5]).
|Table 5 Comparison of visual analogue score at activity in the studied groups|
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Total morphine consumption in group 1 was 316.2 mg with a mean value of 7.71±2.5218 mg, whereas in group 2, it was 175.1 mg, with a mean value of 4.38±3.0887 mg. Number of patients who received rescue analgesia in group 1 was 41 (100%), whereas in group 2, it was 27 (67.5%) ([Table 6]).
| Discussion|| |
RA is favorable than general anesthesia, with improved outcomes owing to avoidance of intubation and mechanical ventilation and markedly reduced blood loss ,.
This study revealed that combined FSNB by US/nerve stimulator technique produce longer duration of analgesia and less incidence of hypotension and bradycardia than CSEA in patients with BBL fractures.
RA techniques, including neuraxial and peripheral nerve block, lead to decrease in postoperative pain (subsequently reducing opioid consumption and associated adverse effects), nausea, and vomiting .
The ‘needle-through-needle’ CSEA technique combines the rapid, reliable onset of profound analgesia resulting from spinal injection with the flexibility and longer duration of epidural techniques .
However, the first impression of CSE technique was thought to be more complicated than epidural or spinal block alone, and administration of intrathecal drug and application of the epidural catheter appear to improve patient outcome .
The widely used RA for the peripheral nerve or plexus delivers a smaller volume to the targeted nerve without injury to it or its surrounding structures. So, the clarification of the desired nerve using nerve stimulator combined with US guidance produces higher efficacy and safety relief.Because of technical problems, sciatic nerve blocks had the lowest performance rate before using various navigator enhancements. The success rate increases to 88.9%. The use of combining sciatic and femoral nerve block had marvelous effect on patient satisfaction at 85%, shorter hospital stay, with utilization of fewer resources .
Cohen et al.  studied the combination of a preoperative femoral nerve block with a sciatic nerve block on patients undergoing anterior cruciate ligament reconstruction and showed a decreased postoperative analgesic consumption and VAS score. The study by Lee et al.  demonstrated the effect of the double block on surgical anesthesia and postoperative pain control for patients with hind foot and ankle disease and revealed that the addition of preoperative sciatic nerve block to a femoral nerve block resulted in decrease in the VAS postoperative pain and need for rescue analgesics.
Moreover, Tummala et al.  studied geriatric patients for hip joint surgeries under a CSEA to reduce the severity and incidence of hypotension and concluded that CSE technique is very effective and safe method, producing stable hemodynamic and prolonged analgesia when compared with spinal anesthesia for surgeries around the hip joint.
| Conclusion|| |
The use of FSNB by US guidance nerve stimulation technique provides better block characteristics, longer duration of analgesic, better intraoperative hemodynamics, and decreased need for postoperative rescue analgesia in comparison with CSEA in patients with fracture BBL.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]