Regional Nerve Block for Hip Surgery
Hip fracture is a common condition that is correlated with old age and tends to arise due to osteoporosis combined with instability and falling. Approximately 98 percent of hip fracture treatment interventions involve hip surgery.1 Therefore, many patients requiring hip surgery are elderly and have multiple comorbidities. This can pose an issue when it comes to anesthetic intervention: specifically, anesthesia during hip surgery has been associated with 35-60 percent frequency of post-operative delirium in elderly patients. This condition has detrimental effects on morbidity and mortality. Additionally, many patients experience operation-related pain for hip surgery in particular.2 Given these considerations, regional nerve block has been considered as a superior, non-systemic analgesic alternative to general anesthesia for hip surgery.
For hip surgery, the regional nerve block used is typically the femoral block. A method first introduced in 1957, femoral nerve block has continued to gain popularity with anesthesiologists as a non-systemic analgesic alternative.3 The nerve block is achieved by injecting local anesthetic proximal to the relevant femoral nerves. Locating the nerve can be achieved in a variety of ways: using a nerve stimulator, performing a blind method known as the fascia iliaca block (which requires more anesthesia), the paravascular “Three in One” block which provides analgesia to the femoral, obturator and lateral cutaneous nerves with a single injection, or using ultrasound. Depending on the accuracy of the nerve location method, different amounts or types of anesthesia may be employed.4
When compared to general anesthesia interventions, a regional nerve block demonstrates superior analgesic efficacy. A systematic review of pain in patients with hip fracture requiring surgery reported that femoral nerve block was associated with a decrease in pain and requested medication as compared to fentanyl.4 Several other studies have shown that a regional nerve block prevents pain more effectively than administration of opioids alone.5 Given the addictive quality of opioids and the context of the current opioid crisis, regional nerve block may present an opportunity to avoid such adverse effects in patients with a history of or increased vulnerability toward addiction.
Not only is a regional nerve block more efficacious at blocking pain, but it also has been associated with reduced likelihood of adverse perioperative events. Some of the most common complications associated with hip surgery, including vascular hematoma, nerve damage, infection and intravascular infection, were found to have low incidences when hip surgery was performed using femoral nerve block.4
Given the efficacy and safety of femoral nerve block, scientists and clinicians alike recommend its use for hip surgery. However, general anesthesia continues to be the most prevalent approach – for example, a survey conducted in England concluded that femoral nerve block is an underutilized anesthetic approach for femoral hip fracture, despite being highly effective and conferring multiple benefits when compared to alternative methods.6 The reason for this disparity is likely due to insufficient integration of regional nerve block as a preferred anesthetic approach for hip surgery, as opposed to insufficient evidence of its efficacy. Therefore, increased training and repetition of this approach by anesthesiologists has the potential the bridge the gap and improve hip surgery outcomes.
References
1 Maxwell, L. & White, S. (2013). Anaesthetic management of patients with hip fractures: an update. Cont Educ Anaesth Crit Care Pain. Retrieved May 26, 2022, from DOI: 10.1093/bjaceaccp/mkt006
2 Rudolph, J. L., & Marcantonio, E. R. (2011). Review articles: postoperative delirium: acute change with long-term implications. Anesthesia and analgesia, 112(5), 1202–1211. DOI: 10.1213/ANE.0b013e3182147f6d
3 Berry F. R. (1977). Analgesia in patients with fractured shaft of femur. Anaesthesia, 32(6), 576–577. DOI: 10.1111/j.1365-2044.1977.tb10009.x
4 Hartmann, F. V., Novaes, M. R., & de Carvalho, M. R. (2017). Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures – a systematic review. Brazilian journal of anesthesiology (Elsevier), 67(1), 67–71. DOI: 10.1016/j.bjane.2015.08.017
5 Parker, M. J., Griffiths, R., & Appadu, B. N. (2002). Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. The Cochrane database of systematic reviews, (1), CD001159. DOI: 10.1002/14651858.CD001159
6 Pennington, N., Gadd, R. J., Green, N., & Loughenbury, P. R. (2012). A national survey of acute hospitals in England on their current practice in the use of femoral nerve blocks when splinting femoral fractures. Injury, 43(6), 843–845. DOI: 10.1016/j.injury.2011.10.003