|Year : 2020 | Volume
| Issue : 2 | Page : 49-52
Adductor Canal block with 0.5% ropivacaine for postoperative pain relief in lower limb surgeries performed under spinal anesthesia
Department of Anaesthesia and Critical Care, Sms Medical College, Jaipur, Rajasthan, India
|Date of Submission||20-Feb-2020|
|Date of Decision||11-Mar-2020|
|Date of Acceptance||16-Mar-2020|
|Date of Web Publication||11-May-2020|
Dr. Manisha Agrawal
Senior Resident, Department of Anaesthesia and Critical Care, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Postoperative pain is an essential consequence of lower limb surgeries that can affect early ambulation, range of motion, and duration of stay in the hospital. This study aimed to evaluate the effect of the adductor canal block in the postoperative pain control and analgesic consumption in the lower limb surgeries done under spinal anesthesia. The adductor canal block is a compartment block of the saphenous nerve (branch of femoral nerve), which can provide adequate analgesia with the preservation of motor function. Patients and Methods: Sixty patients aged 18–70 years scheduled for lower limb surgeries under spinal anesthesia were included in this prospective, placebo-controlled randomized study. The patients were randomly divided into two equal groups of 30 each. At the end of the surgery, single-shot ultrasound-guided adductor canal blockade was given with 30 ml of 0.5% ropivacaine (Group A) or 30 ml of 0.9% saline (Group C). The pain was assessed for 24 h postoperatively by a visual analog scale (VAS). Postoperative analgesia consumption was also studied. Motor function was assessed with a straight leg raise test. Results: Analgesic consumption was lesser in the ropivacaine group as compared to the control group. VAS was favorable in the ropivacaine group. There was no prolonged loss of motor function in either group. Conclusions: The adductor canal block significantly reduces pain and analgesic consumption. It also does not affect motor function. Hence, it can be effectively used as an adjuvant to spinal anesthesia for lower limb surgeries.
Keywords: Adductor canal block, ropivacaine, spinal anesthesia
|How to cite this article:|
Agrawal M. Adductor Canal block with 0.5% ropivacaine for postoperative pain relief in lower limb surgeries performed under spinal anesthesia. Bali J Anaesthesiol 2020;4:49-52
|How to cite this URL:|
Agrawal M. Adductor Canal block with 0.5% ropivacaine for postoperative pain relief in lower limb surgeries performed under spinal anesthesia. Bali J Anaesthesiol [serial online] 2020 [cited 2022 Dec 8];4:49-52. Available from: https://www.bjoaonline.com/text.asp?2020/4/2/49/284172
| Introduction|| |
Postoperative pain is the most common complication of the lower limb surgery that can affect early ambulation, range of motion, and duration of stay in the hospital. However, systemic analgesics have many adverse effects such as nausea, vomiting, sedation, and drowsiness. Hence, multimodal analgesia techniques are being widely used, which include a combination of systemic and regional analgesia.
Among regional techniques, epidural anesthesia is most widely used but may have adverse effects such as hematoma formation, urinary retention, and motor blockade of the nonoperative leg. Therefore, to avoid these side effects, the peripheral nerve block technique is introduced. The femoral nerve block provides effective analgesia in the lower limb surgeries but is associated with quadriceps weakness and delayed ambulation, as the femoral nerve has both sensory and motor components., Hence, adductor canal block is being used since it results in blockade of the saphenous nerve which is purely sensory.,
With the development of the ultrasound technique, the adductor canal can be visualized easily in the middle third of the thigh. It extends from the apex of the femoral triangle to the opening in the adductor magnus and the adductor hiatus. It is a trough-like space, the roof being formed by sartorius and floor by the medial vastus and adductor magnus. This canal is traversed by the saphenous nerve, which is a branch of the femoral nerve. The blockade of this nerve provides analgesia with preservation of quadriceps muscle strength, hence facilitating the early ambulation.
| Patients and Methods|| |
This prospective, randomized, comparative study was conducted at Mahatma Gandhi University after getting approval from the ethical committee extending over a period from July 2016 to January 2018. Inclusion criteria include patients with American Society of Anesthesiologists physical Status I–III, aged 18–70 years, body mass index (BMI) 18–35 kg/m, and who were scheduled for the lower limb surgery. Exclusion criteria include known allergy with ropivacaine, BMI >35 kg/m, if spinal anesthesia had resolved before conducting the block, chronic analgesic use (defined as daily or almost daily use of analgesic for >3 months), contraindication for neuraxial anesthesia or nerve block (bleeding diathesis, preexisting lower extremity neuromuscular disorder, local infection, or sepsis), and refuse to provide consent.
A total of 60 patients were included and randomly divided into two equal groups using chit in the box method. Group C (n = 30) was given an ultrasound-guided adductor canal block using 30 ml 0.9% saline. Group R (n = 30) was given an ultrasound-guided adductor canal block using 30 ml 0.5% ropivacaine. There was no dropout.
After the surgery, the ultrasound-guided adductor canal block was performed under aseptic precautions immediately before the effect of spinal anesthesia wears off. Linear ultrasound transducer (10–12) Hz was placed at the mid-thigh level. The superficial femoral vessels were identified, deep to the sartorius muscle. Then, 22G needle was advanced (using the in-plane technique from lateral to medial) toward the adductor canal where 30 mL of 0.9% saline in Group C or 30 mL of 0.5% ropivacaine in Group R. Heart rate, blood pressure, respiratory rate, and peripheral oxygen saturation were noted.
After the procedure, the postoperative pain, muscle weakness, and total analgesic requirement were evaluated at frequent intervals until the demand for rescue analgesia. Pain was assessed with 10-point visual analog scale (VAS) at rest and at the time mobilization where 0 means no pain, while 10 means maximum pain. To assess the quadriceps muscle power, the patient was asked to perform a straight leg raise in the supine position.
The time to first rescue analgesia, the total dose of analgesic required at 0–24 h postoperatively, and the motor strength were compared between the study groups. Quantitative data were analyzed using Student's t-test, and qualitative data were analyzed using the Chi-square test using an online P value calculator. P <0.05 was considered statistically significant.
| Results|| |
A total of 60 patients who met the inclusion criteria were included in our study. All patients were randomly divided into two groups on the basis of chit in the box. In Group R, one of the cases had a block failure. The patients were demographically comparable with regard to age, weight, and height [Table 1] in both the groups. No significant difference was observed according to the success rate among the groups (P = 0.364). Only one case was failed in Group R [Table 2] and [Figure 1].
|Table 1: Variables of Physiological and Operative Severity Score for enumeration of mortality and morbidity (POSSOM) score with the logistic equations|
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The difference between both the groups on the basis of the VAS scores [Table 3] and [Figure 2] and the total number of analgesia dosage in 24 h [Table 4] and [Figure 3] was statistically significant (P < 0.001). The requirement of first rescue analgesia in Group R was after 8 h, which was statistically significant as compared to Group C [Table 5] and [Figure 4]. On the basis of the straight leg raise test, the patient of Group R had less quadriceps muscle weakness as compared to Group C. The difference is statistically significant [Table 6] and [Figure 5].
|Table 3: Surgical outcome in terms of 30.day mortality and morbidity (n=60)|
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|Table 5: Outcome of POSSOM stratified by risk groups for morbidity (30 day)|
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|Table 6: Area under the curve for predicting postoperative mortality and morbidity|
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| Discussion|| |
Postoperative pain in the lower limb surgeries can delay rehabilitation and ambulation. Hence, striking a balance of optimal pain control following surgery, decrease morbidity, early mobility, and overall decrease hospital stay. The prime goal after lower limb surgeries is enabling faster recovery and reduction of the hospital stay by providing adequate analgesia with motor preservation. This can be efficiently achieved by the ultrasound-guided adductor canal block, administered immediately after surgery before the effect of spinal anesthesia wears off.
The adductor canal is an aponeurotic tunnel present in the middle third of the thigh and bounded by three muscles, that is, sartorius (medially), vastus medialis (anterolaterally), and the adductor longus muscles (posteriorly). In this canal, the femoral artery, femoral vein, the posterior branch of the obturator nerve, nerve to vastus medialis, and the saphenous nerve (branch of the femoral nerve) are present.
Jenstrup et al. demonstrated the effectiveness of the adductor canal block on pain and ambulation after total knee arthroplasty surgeries compared with placebo, and they used high doses of local anesthetic (30 ml of 0.75% ropivacaine). These doses lead to quadriceps weakness, while in our study, we used a lower concentration of local anesthetic (0.5% ropivacaine 30 ml), which preserves quadriceps strength.
In a study conducted by Akkaya et al., the VAS score in the placebo group is more than saphenous nerve block group; similar results found in our study have concluded that patients of Group C perceived more pain than that of Group R. Lund et al. reported that the adductor canal block group significantly reduced the morphine consumption and pain compared with placebo. A similar result was found in our study where patients in Group R consume less analgesia as compared to Group C.
Jaeger et al. reported that patients in the adductor canal block group have significantly reduced pain as compared to the placebo group. A similar result was found in our study, Group R has a significant reduction in pain as compared with the Group C. A study by Kampitak et al. showed that the adductor canal block prolongs the time of first rescue analgesia as compared to local infiltration group. These findings were also in accordance with our results.
| Conclusions|| |
The adductor canal block significantly reduces morbidity, analgesic consumption without the prolonged adverse effect of motor blockage, and thus allows early ambulation after lower limb surgeries.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: A systematic review and meta-analysis of randomized trials. Br J Anaesth 2008;100:154-64.
Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, et al
. Continuous femoral nerve blocks: Varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011;115:774-81.
Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111:1552-4.
Muraskin SI, Conrad B, Zheng N, Morey TE, Enneking FK. Falls associated with lower-extremity-nerve blocks: A pilot investigation of mechanisms. Reg Anesth Pain Med 2007;32:67-72.
Jaeger P, Grevstad U, Henningsen MH, Gottschau B, Mathiesen O, Dahl JB. Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty: A randomised study. Acta Anaesthesiol Scand 2012;56:1013-9.
Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 2009;34:578-80.
Goffin P, Lecoq JP, Ninane V, Brichant JF, Sala-Blanch X, Gautier PE, et al
. Interfascial spread of injectate after adductor canal injection in fresh human cadavers. Anesth Analg 2016;123:501-3.
Jenstrup MT, Jæger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, et al
. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: A randomized study. Acta Anaesthesiol Scand 2012;56:357-64.
Akkaya T, Ersan O, Ozkan D, Sahiner Y, Akin M, Gümüş H, et al
. Saphenous nerve block is an effective regional technique for post-menisectomy pain. Knee Surg Sports Traumatol Arthrosc 2008;16:855-8.
Lund J, Jenstrup MT, Jaeger P, Sørensen AM, Dahl JB. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: Preliminary results. Acta Anaesthesiol Scand 2011;55:14-9.
Kampitak W, Tanavalee A, Ngarmukos S, Amarase C, Songthamwat B, Boonshua A. Comparison of adductor canal block versus local infiltration analgesia on postoperative pain and functional outcome after total knee arthroplasty: A randomized controlled trial. Malays Orthop J 2018;12:7-14.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]