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Correspondence |
Annecy, France
I thank Drs. Paterson and Kuehne for their comments on our article.1 Unfortunately, I radically disagree with their comments.
First, the comparison between analgesia techniques is a very common research subject in the anesthesia literature, even when these techniques appear to be different in terms of route of administration (for example iv morpine patient-controlled analgesia, epidural analgesia and femoral block for total knee arthroplasty).1 The recent articles on the use of single shot psoas compartment block and intrathecal morphine injection for pain relief after total hip arthroplasty (THA) prompted us to conduct our study.
Drs. Paterson and Kuehne explain themselves the anatomical reasons why the psoas block cannot provide similar pain relief than intrathecal morphine: the innervation of the hip does not depend only on the lumbar plexus, but also on the sacral plexus. In their description, they forget that the last thoracic root (T12) innervates the upper part of the incision. However, it is well known that postoperative pain after THA does not depend on cutaneous stimuli.
They combine a psoas block with a single shot sciatic block without considering the risks of Mansour’s block (rectal perforation, iliac vessel or ureter injury). Furthermore, they seem to forget another concern, the systemic toxicity of local anesthetics and/or the risk of massive intrathecal or intravascular injection (their combined sacral and lumbar blocks require 30 mL of 0.5% bupivacaine and 40 mL of prilocaine!).
The volume of ropivacaine 0.475% used in our study (25 mL) is comparable with the volumes recommended for psoas compartment block (0.4 mL•kg-1 of bupivacaine 0.5%)2 and, thus, cannot be considered low. In addition, there is no study comparing the duration of analgesia with both techniques.
To our knowledge, the only reference regarding continuous psoas compartment block for pain relief after THA is the descriptive study by Capdevila et al.3 Drs. Paterson and Kuehne do not produce any data to support their assertion that the combination of parasacral and psoas blocks is the ideal technique to provide postoperative analgesia after THA.
Concerning their last comment on the site of postoperative pain after THA, we believe that the only concern with our assessment is not its location but the fact that we did not differentiate between pain at rest and during motion.
Paterson and Kuehne say we are comparing apples and oranges. Nevertheless "primum non nocere" is our duty. Our results show that low dose intrathecal morphine provides better postoperative pain relief than psoas compartment block after THA. The only side effect was urinary retention requiring bladder catheterization. With psoas compartment blocks, disastrous complications have been described with an incidence of 8/1000.4 Anesthesiologists should always keep in mind the benefit/risk ratio of the techniques they use to provide relief.
References
1 Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled anlagesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88–92.
2 Stevens RD, Van Gessel E, Flory N, Fournier R, Gamulin Z. Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology 2000; 93: 115–21.[Medline]
3 Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg 2002; 94: 1606–13.
4 Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: the SOS regional anesthesia hotline service. Anesthesiology 2002; 97: 1274–80.[Medline]
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