Circum-Psoas Blocks Versus Combined Lumbar and Sacral Plexus Blocks in Hip Fracture Surgery

The acetabulum and the head of the femur combine to produce a traditional ball and socketjoint in the hip. Both the lumbar (L1‐L4) and sacral (L4‐S4) plexuses innervate the hipjoint, and its sensory innervation is from the femoral (FN), obturator, and sciaticnerves with contribution from superior gluteal nerve and nerve to quadratus femoris.Cutaneous innervation is by lateral femoral cutaneous (LFCN), subcostal iliohypogastricnerve, and the superior cluneal nerves which predominately arise from the dorsal rami ofL1.Hip fracture is a major worldwide public health problem in elderly patients aged 65 yearsand over with an incidence of more than 1.6 million worldwide each year. Furthermore, thetotal number is expected to exceed 6 million by 2050. Generally, early surgical repairwithin 48‐72 hours after admission is recommended according to the treatment guideline,however, elderly patients with hip fractures commonly have several comorbidities, whichmake these patients more liable to a high risk of morbidity and mortality after surgery.Pain, both before and during the first 24 hours of surgery is usually reported as severeby most patients therefore, one of the keys to a patient's recovery following hipfracture surgery, is effective postoperative pain management. Recently, the concept ofpain relief with multimodal analgesia and regional anesthesia plays a vital role inpostoperative analgesia minimizing opioid consumption and reducing the time to earlymobilization. The acetabulum and the head of the femur combine to produce a traditionalball and socket joint in the hip. The lumbar (L1‐L4) and sacral (L4‐S4) plexuses bothinnervate the hip joint, and its sensory innervation is from the femoral (FN), obturator,and sciatic nerves with contribution from superior gluteal nerve and nerve to quadratusfemoris. Cutaneous innervation is by lateral femoral cutaneous (LFCN), subcostaliliohypogastric nerve, and the superior cluneal nerves which predominately arise from thedorsal rami of L1.Hip fracture is a major worldwide public health problem in elderly patients aged 65 yearsand over with an incidence of more than 1.6 million worldwide each year. Furthermore, thetotal number is expected to exceed 6 million by 2050. Generally, early surgical repairwithin 48‐72 hours after admission is recommended according to the treatment guideline,however, elderly patients with hip fractures commonly have several comorbidities, whichmake these patients more liable to a high risk of morbidity and mortality after surgery.Pain, both before and during the first 24 hours of surgery is usually reported as severeby most patients therefore, one of the keys to a patient's recovery following hipfracture surgery, is effective postoperative pain management. Recently, the concept ofpain relief with multimodal analgesia and regional anesthesia plays a vital role inpostoperative analgesia minimizing opioid consumption and reducing the time to earlymobilization. Several regional anesthetic techniques have been recommended, includingintrathecal morphine, patient‐controlled epidural analgesia, and various peripheral nerveblocks techniques; however, to obtain complete sensory loss for hip fracture surgery,it's required to block the branches of both lumbar and sacral plexuses, although thereremains no single technique that reliably acquires this. Moreover, each of thesetechniques has specific limitations that prevent them from being the analgesic techniqueof choice for hip fracture surgery.The ultrasound‐guided lumbar plexus block results in the blockade of the FN, LFCN, andobturator nerve while the sacral plexus block results in the blockade of the sciaticnerve, superior and inferior gluteal nerves, posterior cutaneous nerve of the thigh, andthe inferior hypogastric plexus. Thus, the combination of lumbar plexus and sacral plexusblocks results in complete analgesia of the ipsilateral lower limb in the perioperativeperiod.Circum‐psoas blocks is a new sonar‐guided fascial block technique proposed by Huili etal., where the two main branches of the lumbar plexus (FN and LFCN) can be blocked bylocal anesthetic (LA) injection posterior to transversalis fascia (TF) and around theanterolateral edge of psoas muscle (PM) just cranial to iliac crest. Furthermore, cranialspread along TF may lead to a lower thoracic paravertebral block through the medialarcuate ligament. On the other hand, the obturator nerve and lumbosacral trunk could beblocked if the LA is injected at the level of L5/S1 into the retro‐psoas space and aroundthe posterior edge of PM.Our study will be designed to evaluate and compare the impact of combined lumbar andsacral plexus blocks and circum‐psoas blocks for sensory level and achievement ofpostoperative analgesia for patients undergoing hip fracture surgery under generalanesthesia.