| Frequently Asked Questions |
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| Category #10 - Lumbar paravertebral block (lumbar plexus/psoas) |
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| Lumbar Plexus Block for hip surgery |
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I have been performing lumbar plexus blocks for some time now in combination with sciatic nerve block for surgical anesthesia, for several lower leg surgical procedures including knee surgery. I finally have to admit that this block produces disappointingly quite high rate of partial failures needing intravenous opiates supplementation or continuous intravenous propofol. What is your opinion and personal clinical experience with this block? |
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Dear Colleague:
Thank you very much for this most interesting question.
To put it bluntly, very few people experienced with this block are really impressed by it. The lumbar paravertebral block or lumbar plexus block or psoas compartment block, is a relatively easy block to perform and its success rate is relatively high. Unfortunately, so is the complication rate and this is a relatively dangerous block. I concur with the views of Xavier Capdevila in his latest paper in the Regional Anesthesia and Pain Medicine journal (Reg Anesth Pain Med 2005; 30(2): 150 - 162), that the only indications for psoas compartment block is if you, for some reason, cannot perform a proper continuous femoral nerve block. This would include situations where a continuous femoral nerve catheter would be in the surgical field and bother the surgeon. In my practice, therefore, the hard indications for lumbar paravertebral or lumbar plexus block are high femur osteotomies and pelvic osteotomies especially in spastic children. We find that epidural block do not address the spasticity and that lumbar paravertebral block works very well for these children. A femoral block would adequately cover high femur osteotomies but obviously the femoral catheter would be in the surgical field and that would not be acceptable.
To do lumbar paravertebral blocks for lower limb surgery as recently described by Trip Buckenmaier in Regional Anesthesia and Pain Medicine (Reg Anesth Pain Med 2005; 30(2): 202 - 205) is, in my view, not an acceptable practice, because of all of the lumbar plexus, the saphenous nerve is the only nerve that goes to the lower limb, and this nerve can easily be blocked at much safer sites. In my personal opinion, the lumbar plexus block is over rated and should only be reserved for very rare occasions.
Being an experienced clinician, you obviously know that primary hip replacement surgery is relatively painless surgery and continuous peripheral nerve block is generally not indicated for this. There may be an argument for review hip replacement surgery but I personally still prefer a combined spinal epidural technique for this. All these arguments are discussed on the movie related to lumbar plexus block on the http://www.RAEducation.com and http://uianesthesia.com/rasci websites.
I trust this explanation adds some value to your practice.
Yours sincerely,
Andre P. Boezaart, MBChB, FCA(SA), MMed (Anaesth) Ph.D
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What is the direction of the needle when performing a lumbar paravertebral block?
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When performing a paravertebral block, we direct the catheter down the desired nerve, away from midline. The bevel of the needle therefore faces away from the midline.
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Do you consider a paravertebral block the same as a neuraxial block?
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We follow the ASRA guidelines for anti-coagulated patients when performing paravertebral blocks. While these guidelines are based on a paucity of scientific data, without that data, we have chosen to err on the side of conservatism.
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Why would you use a paravertebral block over an epidural block?
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Paravertebral block allows for unilateral analgesia without the hemodynamic and visceral side effects of epidural anesthesia.
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