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Volume:4 Issue:9 Number:2 ISSN#:2563-559X
OE Original

Quadratus Lumborum Block for Postoperative Pain Management in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-analysis

Authored By: OrthoEvidence

September 13, 2021

How to Cite

OrthoEvidence. Quadratus Lumborum Block for Postoperative Pain Management in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-analysis. OE Original. 2021;4(9):2. Available from: https://myorthoevidence.com/Blog/Show/147

Highlights


  • - In total, 7 randomized controlled trials (RCTs), all of which were published in or after 2020, were eligible.


  • - Three RCTs compared posterior quadratus lumborum block (QLB2) or transmuscular QLB (QLB3) vs. sham procedure. Three RCTs compared QLB3 with another type of block, including femoral nerve block, fascia iliaca block, and lumbar plexus block. One RCT compared QLB3 vs. local infiltration analgesia.


- Meta-analyses identified no significant differences in post-operative pain, opioid consumption, incidence of pruritus or urinary retention between QLB2/3 vs. all types of control (including sham procedure, nerve block other than QLB, and local infiltration analgesia).


  • - Our subgroup analysis found no significant differences in either postoperative pain or opioid consumption between QLB and sham procedure.


  • - The quality of evidence is low or very low. More RCTs are warranted.




First described by Blanco (2007), ultrasound-guided quadratus lumborum block (QLB) belongs to the fascial plane block where local anesthetic is injected next to the quadratus lumborum muscle (Elsharkawy et al., 2019). According to the needle tip position in relation to the quadratus lumborum muscle, there are mainly 4 approaches for QLB: I) lateral QLB (QLB1); II) posterior QLB (QLB2); III) anterior (QLB3, also known as transmuscular QLB, and IV) intramuscular QLB (El-Boghdadly et al., 2016; Nassar et al., 2021).


In this OE Original, we conduct a systematic review and meta-analysis to examine randomized controlled trials (RCTs) and determine the efficacy and safety of QLB for the postoperative pain management in patients undergoing total hip arthroplasty (THA).




Methods


Ovid MEDLINE, Ovid EMBASE, Cochrane Controlled Register of Trials (CENTRAL), and OrthoEvidence were searched from inception to August 24, 2021 with both indexed terms and free text terms with regard to QLB and THA. We also searched reference lists to identify additional eligible studies.


We included only RCTs with full texts published in English. Eligible studies should involve ultrasound-guided QLB as a treatment for postoperative pain management among adult patients who have undergone THA.


We adopted the Cochrane risk-of-bias tool and the GRADE approach to determine the risk of bias (RoB) and the quality of evidence for included RCTs, respectively. Two reviewers independently worked on the study screening and selection processes.





Results


1. Characteristics of included studies


In total, 101 records were retrieved, among which 7 RCTs were eligible and included (Abduallah et al., 2020; Aoyama et al., 2020; Brixel et al., 2021; He et al., 2020; Hu et al., 2021; Nassar et al., 2021; Polania Gutierrez et al., 2021).


The characteristics of the included studies are presented in Table 1. All of the RCTs were published in or after 2020. Sample sizes were relatively small, ranging from 30 to 100. All of the RCTs investigated QLB3 (i.e., the anterior or transmuscular QLB) except one study focusing on QLB2 (posterior QLB) (Brixel et al., 2021). Three RCTs employed a sham procedure in the control group (Abduallah et al., 2020; Brixel et al., 2021; He et al., 2020). Three RCTs compared QLB with another type of block, including femoral nerve block, fascia iliaca block, and lumbar plexus block (Aoyama et al., 2020; Nassar et al., 2021; Polania Gutierrez et al., 2021).


Table 1. Characteristics of included studies

Study ID

Country

No. of Subjects at Randomization

Age [years, mean (SD)]

Intervention

Control

Abduallah et al., 2020

Egypt

60

Intervention: 67.90 (4.8); Control: 66.43 (3.89)

Ultrasound-guided transmuscular quadratus lumborum block (QLB) at the end of THA (QLB3)

Sham procedure

Aoyama et al., 2020

Japan

30

Intervention: 70 (9); Control: 67 (11)

Ultrasound-guided anterior QLB before general anesthesia and immediately after THA (QLB3)

Femoral nerve block

Brixel et al., 2021

France

100

Intervention: 68 (range: 59-72); Control: 65 (59-72)

Ultrasound-guided posterior QLB before general anesthesia (QLB2)

Sham procedure

He et al., 2020

China

88

Intervention: 66 (7); Control: 67 (8)

Ultrasound-guided transmuscular QLB before THA (QLB3)

Sham procedure

Hu et al., 2021

China

80

Intervention: 58.78 (12.16); Control: 55.73 (13.45)

Ultrasound-guided transmuscular QLB before general anesthesia + local analgesia (QLB3)

Local analgesia only

Nassar et al., 2021

Egypt

38

Intervention: 54 (16); Control: 47 (17.6)

Ultrasound-guided transmuscular QLB before anesthesia (QLB3)

Fascia iliaca block

Polania Gutierrez et al., 2021

United States

50

Intervention: 68.6 (11.8); Control: 65.7 (9.8)

Ultrasound-guided transmuscular QLB before anesthesia (QLB3)

Lumbar plexus block




In terms of risk of bias assessment (Figure 1), all included studies showed a low risk of bias in random sequence generation, allocation concealment, blinding of outcome assessment, and selective reporting. Three studies did not mask participants (Aoyama et al., 2020; Hu et al., 2021; Nassar et al., 2021). Three RCTs (Abduallah et al., 2020; Brixel et al., 2021; Nassar et al., 2021) did not provide detailed information on criteria for anesthesiologist’s participation or expertise (Figure 1, other bias).




2. Meta-analysis results


2.1 Pain


2.1.1 Meta-analysis of all included studies




All 7 included RCTs reported postoperative pain outcomes measured by visual analog scale (VAS) or numeric rating scale (NRS). We quantitatively synthesized the pain outcomes on a normalized scale with a range between 0 and 10. A higher score indicates worse pain.


As shown in Figure 2, no significant differences were found between QLB2/3 and control (including sham procedure, nerve block other than QLB, and local infiltration analgesia) in pain scores at 2, 6, 12, 24, and 48 hours post THA.




2.1.2 Subgroup analysis


2.1.2.1 Subgroup: QLB2 or QLB3 in the intervention group


The effect estimates remained insignificant when excluding the only 1 study investigating QLB2 (Brixel et al., 2021) while the rest focusing on QLB3 for pain scores at 2 hours [mean difference (MD): -0.29; 95% confidence interval (CI): -1.15 to 0.56], 6 hours (MD: 0.24; 95% CI: -1.16 to 1.65), and 24 hours (MD: -0.50; 95% CI: -1.80 to 0.80) post THA (forest plot not shown).


Results from Brixel et al. (2021) also found no significant difference in pain scores between QLB2 vs. control (i.e., sham procedure) at 2 hours, 6 hours, and 24 hours post THA (Figure 2).


2.1.2.2 Subgroup: sham procedure, nerve block other than QLB (i.e., femoral nerve block, fascia iliaca block, lumbar plexus block), or local infiltration analgesia in the control group


We further conducted quantitative synthesis for pain outcomes (i.e., pain 24 hours post THA) based on the type of the control intervention, including sham procedure (Abduallah et al., 2020; Brixel et al., 2021; He et al., 2020) and nerve block other than QLB (Aoyama et al., 2020; Nassar et al., 2021; Polania Gutierrez et al., 2021). Effect estimates showed no statistical significance for neither control groups (vs. sham: MD: -1.24; 95% CI: -3.29 to 0.81; vs. nerve block: MD: 0.22; 95% CI: -0.69 to 1.13) (forest plot not shown).


Hu et al. (2021) was the only RCT comparing QLB3 vs. local infiltration analgesia, and showed that QLB3 significantly relieved pain at 6 hours (MD: -1.15; 95% CI: -1.47 to -0.83), 12 hours (MD: -0.75; 95% CI: -1.05 to -0.45), and 24 hours post surgery (MD: -0.40; 95% CI: -0.69 to -0.11) (Figure 2).


2.1.2.3 Subgroup: QLB3 vs. sham procedure


Two RCTs (Abduallah et al., 2020; He et al., 2020) compared QLB3 vs. sham procedure for pain outcomes at 24 hours post surgery. There was no statistical significance between these two comparators (MD: -1.59; 95% CI: -4.60 to 1.43) (forest plot not shown).




2.2 Opioid consumption


2.2.1 Meta-analysis of all included studies



Five RCTs reported opioid consumption (mg, mainly morphine) 24 hours post THA. As shown in Figure 3, there was no significant difference in opioid consumption between QLB2/3 and control (including sham procedure, nerve block other than QLB, and local infiltration analgesia) at 24 hours after surgery.





2.2.2 Subgroup analysis


2.2.2.1 Subgroup: QLB2 or QLB3 in the intervention group


The difference in opioid consumption at 24 hours after THA remained insignificant when including those which compared QLB3 vs. control (MD: -4.56 mg; 95% CI: -12.49 to 3.38) in the quantitative analysis (forest plot not shown).


Results from Brixel et al. (2021) which compared QLB2 with sham procedure showed no significant difference (MD: -1.66 mg; 95% CI: -5.56 to 2.24) (Figure 3).


2.2.2.2 Subgroup: sham procedure or nerve block other than QLB (i.e., femoral nerve block, fascia iliaca block, lumbar plexus block) in the control group


Among the 5 RCTs, 3 (Abduallah et al., 2020; Brixel et al., 2021; He et al., 2020) compared QLB with sham procedure. Analyses showed no difference between QLB and sham procedure in opioid consumption (MD: -7.56 mg; 95% CI: -17.56 to 2.45) (forest plot not shown).


Two RCTs (Nassar et al., 2021; Polania Gutierrez et al., 2021) compared QLB3 with other types of nerve block, including femoral nerve block, fascia iliaca block, lumbar plexus block. Nerve blocks in the control group significantly reduced opioid consumption at 24 hours post THA (MD: 2.18 mg; 95% CI: 0.42 to 3.94), compared to QLB3 (forest plot not shown).


2.2.2.3 Subgroups: QLB3 vs. sham procedure


Two RCTs (Abduallah et al., 2020; He et al., 2020) compared QLB3 vs. sham procedure for opioid consumption at 24 hours post surgery. There was no statistical significance between these two comparators (MD: -10.44 mg; 95% CI: -25.34 to 4.45) (forest plot not shown).





2.3 Adverse events


No significant differences were found between QLB vs. control in the incidence of pruritus or urinary retention (Figure 4).


Aoyama et al. (2020) and Polania Gutierrez et al. (2021) reported no severe complications for both QLB and control groups.






Summary and Interpretation


In this OE Original, we examined RCT evidence to determine the efficacy (i.e., postoperative pain, opioid consumption) and safety (i.e., incidence of pruritus or urinary retention) of QLB for the postoperative pain management in patients undergoing THA. To our knowledge, this is the first systematic review and meta-analysis to address this topic.


In total, 7 RCTs, all of which were published in or after 2020, were identified. Three RCTs compared QLB2 (posterior QLB; Brixel et al., 2021) or QLB3 (anterior or transmuscular QLB; Abduallah et al., 2020; ; He et al., 2020) vs. sham procedure. Three RCTs compared QLB3 with other types of nerve block, including femoral nerve block, fascia iliaca block, and lumbar plexus block (Aoyama et al., 2020; Nassar et al., 2021; Polania Gutierrez et al., 2021). Hu et al. (2021) compared QLB3 vs. local infiltration analgesia.


Our meta-analyses found no significant differences in post-operative pain, opioid consumption, incidence of pruritus or urinary retention between QLB2/3 vs. all types of control (including sham, another type of nerve block, and local infiltration analgesia) (Table 2). The quality of evidence varied from low to very low.





Table 2: Summary of meta-analysis and quality of evidence

Outcomes

Comparison

Point Estimate Favors

Statistical Significance

Quality of Evidence

Pain (2 hours)

QLB2/3 vs. all types of control*

QLB2/3

No

Low

Pain (2 hours)

QLB2 vs. sham

QLB2

No

Very Low

Pain (2 hours)

QLB3 vs. all types of control

QLB3

No

Low

Pain (6 hours)

QLB2/3 vs. all types of control

QLB2/3

No

Low

Pain (6 hours)

QLB2 vs. sham

QLB2

No

Very Low

Pain (6 hours)

QLB3 vs. all types of control

Control

No

Very Low

Pain (6 hours)

QLB3 vs. local infiltration analgesia

QLB3

No

Very Low

Pain (12 hours)

QLB2/3 vs. all types of control

QLB2/3

No

Low

Pain (12 hours)

QLB3 vs. local infiltration analgesia

QLB3

No

Very Low

Pain (24 hours)

QLB2/3 vs. all types of control

QLB2/3

No

Low

Pain (24 hours)

QLB2 vs. sham

QLB2

No

Very Low

Pain (24 hours)

QLB3 vs. all types of control

QLB3

No

Very Low

Pain (24 hours)

QLB2/3 vs. sham

QLB2/3

No

Low

Pain (24 hours)

QLB3 vs. nerve block**

Nerve block

No

Low

Pain (24 hours)

QLB3 vs. local infiltration analgesia

QLB3

Yes

(MD: -0.40; 95% CI: -0.69 to -0.11)

Very Low

Pain (24 hours)

QLB3 vs. sham

QLB3

No

Low

Pain (48 hours)

QLB2/3 vs. all types of control

QLB2/3

No

Very Low

Opioid consumption (mg, 24 hours)

QLB2/3 vs. all types of control

QLB2/3

No

Very Low

Opioid consumption (mg, 24 hours)

QLB2 vs. sham

QLB2

No

Very Low

Opioid consumption (mg, 24 hours)

QLB3 vs. all types of control

QLB3

No

Very Low

Opioid consumption (mg, 24 hours)

QLB2/3 vs. sham

QLB2/3

No

Low

Opioid consumption (mg, 24 hours)

QLB3 vs. nerve block

Nerve block

Yes

(MD: 2.18; 95% CI: 0.42 to 3.94)

Very Low

Opioid consumption (mg, 24 hours)

QLB3 vs. sham

QLB3

No

Low

Adverse events-pruritus

QLB3 vs. sham

QLB3

No

Low

Adverse events-urinary retention

QLB3 vs. all types of control

QLB3

No

Low

* All types of control included sham, nerve block, and local infiltration analgesia; ** Nerve block included femoral nerve block, fascia iliaca block, lumbar plexus block; QLB: quadratus lumborum block



We made a priori hypotheses that variations in different approaches of QLB (QLB2, QLB3) or different control interventions (sham, nerve block other than QLB, or local infiltration analgesia) might impact postoperative pain and opioid consumption and conducted subgroup analyses accordingly.


First, the subgroup analysis of RCTs only investigating QLB3 did not find any significant difference in pain (i.e., pain 2 hours, pain 6 hours, and pain 24 hours post THA) or opioid consumption (i.e., opioid consumption 24 hours after THA) between QLB3 and all types of control (Table 2). The quality of evidence was low or very low (Table 2).


Second, we found no significant differences in pain (i.e., pain 24 hours after THA) or opioid consumption (i.e., opioid consumption 24 hours after THA) between QLB2/3 vs. sham procedure or QLB3 vs. sham procedure (Table 2). The quality of evidence was low or very low (Table 2).


Third, other types of nerve block (including femoral nerve block, fascia iliaca block, and lumbar plexus block) significantly reduced opioid consumption at 24 hours post THA (MD: 2.18; 95% CI: 0.42 to 3.94; Very low quality of evidence), compared to QLB3 (Table 2). However, no statistically significant differences were found between these 2 groups in postoperative pain outcomes (i.e., pain 24 hours after THA) (Low quality of evidence, Table 2).


Fourth, only 1 RCTs compared QLB3 vs. local infiltration analgesia (Hu et al., 2021) and found that QLB3 resulted in significant pain reduction at 24 hours post surgery (MD: -0.40; 95% CI: -0.69 to -0.11; Very low quality of evidence).




Bottom Line


Current evidence suggests that QLB is a safe treatment for patients undergoing THA. However, almost all outcomes synthesized (i.e., pain, opioid consumption, adverse events) found no statistically significant differences between QLB (QLB2 and/or QLB3) and control (sham, nerve block other than QLB, and/or local analgesia). The certainty of evidence was low to very low. More RCTs are warranted.









References


Abduallah, M. A., et al. (2020). The effect of post-operative ultrasound-guided transmuscular quadratus lumborum block on post-operative analgesia after hip arthroplasty in elderly patients: a randomised controlled double-blind study. Indian journal of anaesthesia, 64(10), 887-893. doi:10.4103/ija.IJA_275_20

Aoyama, Y., et al. (2020). Continuous quadratus lumborum block and femoral nerve block for total hip arthroplasty: a randomized study. Journal of anesthesia, 34(3), 413-420. doi:10.1007/s00540-020-02769-9

Blanco, R. (2007). 271. Tap block under ultrasound guidance: the description of a “no pops” technique. Regional Anesthesia & Pain Medicine, 32(Suppl 1), 130. doi:10.1136/rapm-00115550-200709001-00249

Brixel, S. M., et al. (2021). Posterior Quadratus Lumborum Block in Total Hip Arthroplasty: A Randomized Controlled Trial. Anesthesiology, 722-733. doi:http://dx.doi.org/10.1097/ALN.0000000000003745

El-Boghdadly, K., et al. (2016). Quadratus Lumborum Block Nomenclature and Anatomical Considerations. Regional Anesthesia & Pain Medicine, 41(4), 548. doi:10.1097/AAP.0000000000000411

Elsharkawy, H., et al. (2019). Quadratus Lumborum Block: Anatomical Concepts, Mechanisms, and Techniques. Anesthesiology, 130(2), 322-335. doi:10.1097/aln.0000000000002524

He, J., et al. (2020). Ultrasound-Guided Transmuscular Quadratus Lumborum Block Reduces Postoperative Pain Intensity in Patients Undergoing Total Hip Arthroplasty: a Randomized, Double-Blind, Placebo-Controlled Trial. Pain research & management, 2020, 1035182. doi:10.1155/2020/1035182

Hu, J., et al. (2021). The impact of ultrasound-guided transmuscular quadratus lumborum block combined with local infiltration analgesia for arthroplasty on postoperative pain relief. Journal of clinical anesthesia, 73, 110372. doi:10.1016/j.jclinane.2021.110372

Nassar, H., et al. (2021). Transmuscular quadratus lumborum block versus suprainguinal fascia iliaca block for hip arthroplasty: a randomized, controlled pilot study. Local and regional anesthesia, 14, 67-74. doi:10.2147/LRA.S308964

Polania Gutierrez, J. J., et al. (2021). Quadratus lumborum block type 3 versus lumbar plexus block in hip replacement surgery: a randomized, prospective, non-inferiority study. Regional anesthesia and pain medicine, 46(2), 111-117. doi:10.1136/rapm-2020-101915


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