Journal of Anaesthesia and Pain, 2023, Volume: 4, No.

1: 5-9 P-ISSN : 2722-3167

https://jap.ub.ac.id E-ISSN : 2722-3205

Case Report

Combination of Femoral and Parasacral Sciatic Nerve Block as

Multimodal Pain Management in Post Hemiarthroplasty Surgery
Patient
Faundra Arieza Firdaus1, Ristiawan Muji Laksono2
1
Department of Anestesiology and Intensive Therapy, Hermina Hospital, Tangkuban Perahu, Malang, Indonesia
2
Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Brawijaya University, Malang, Indonesia

ABSTRACT

Background: The prevalence of femoral neck fractures is high in geriatric patients with a high
mortality rate. Many geriatric patients have comorbidities and find it difficult to tolerate general or
neuraxial anesthesia during hip hemiarthroplasty. A more safe technique in lower extremities using
peripheral nerve blocks is preferred. The combination of sciatic nerve blocks and psoas compartments
can supply adequate anesthesia for hip surgery thus reducing mortality. Femoral nerve blocks
decrease the incidence of complications than psoas compartment blocks.
Case: A 88-year-old female patient, 70 kg, with distal femoral subtrochanteric fracture accompanied
by dislocation, hypertension emergency, hyperplasia heart disease (HHD), and heart failure stage B Fc
II were undergoing hemiarthroplasty with regional anesthesia sciatic nerve block and femoral block.
After surgery, a block was performed using regional anesthesia sub-arachnoid block bupivacaine 0,5%
7mg + fentanyl 25 µg + Morphin 0,1 µg, post-operative pain with ultrasound, the patient received
0.375% naropin and 50 mg trilac total volume 20 cm3. Then femoral block was done with 0.375% and
Correspondence: 50 mg trilac total volume 20 cm3. Patients were observed for pain scale during hospitalization, time
Faundra Arieza Firdaus of mobilization, and length of stay. Post-operative hemodynamic was stable, the pain scale using VAS
MD, SpAn* assessment was 0-1 during hospitalization without additional opioid analgesia, active mobilization
Department of Anestesiology
and Intensive Therapy, Sebelas
began on the 2nd day, and the length of stay was 3 days.
Maret University, Dr. Moewardi Conclusion: The combination of a femoral and sciatic nerve block to the proximal part of the skin
General Hospital, Surakarta, incision can supply adequate pain compliance for hip hemiarthroplasty.
Indonesiae-mail:
[email protected]
Keywords: acute respiratory distress syndrome, COVID-19, IVIG

Received: December 2022, Revised: January 2022, Published: January 2023

How to cite this article: Firdaus, FA, RM Laksono. Combination of femoral and parasacral sciatic nerve block as multimodal pain management in
post hemiarthroplasty surgery patient. Journal of Anaesthesia and Pain. 2023:4(1):5-9.doi: 10.21776/ub.jap.2023.004.01.02

INTRODUCTION technique does not need special preparation, preoperative

Femoral neck fractures is having a high prevalence in optimization, and fasting. Additionally, this technique can
geriatric patients with an elevated mortality rate. The treatment approach better cardiorespiratory stability rather than central
needs a replacement of the cap of the femur (hip neuraxial blockade by using peripheral nerve blocks for surgical
hemiarthroplasty) to delay the rise in mortality rate. Many anesthesia. This technique avoids the side effects of meningitis,
geriatric patients have comorbidities and find it difficult to hypotension, postural headaches, bradycardia, hematomas, and
tolerate general or neuraxial anesthesia. A safer technique in neurological deficits. The growth of new techniques of
lower extremities using peripheral nerve blocks is preferred. The ultrasound and peripheral nerve stimulators has shifted the area
combination of sciatic nerve blocks and psoas compartments can of anesthesia for isolated limb surgery from general anesthesia
supply adequate anesthesia for hip surgery thus reducing (GA) and central neuraxial blockade to peripheral nerve blocks.
mortality. Femoral nerve blocks decrease the incidence of The most useful but commonly ignored technique for anesthesia
complications than psoas compartment blocks. However, the for lower limb surgery is the combination of sciatic and femoral
effectiveness of hip hemiarthroplasty is not yet known.1 nerve blocks (3:1). However, it is important to emphasize that the
The risk of mortality due to the administration of drug’s maximum dose should be carefully monitored because
general and central neuraxial anesthesia can be avoided by both blocks create double volume. 2
having regional block anesthesia as an option because this

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 The high consumption of opioids to relieve pain in hemodynamics was confirmed to be stable, the patient was then
femoral fractures leads to gastrointestinal problems, impaired positioned laterally left decubitus and the operation begins.
cognitive functions such as delirium, urinary problems, and
respiratory arrest. The theory of Henrik Kehlet in 1997 about
improved recovery after surgery (ERAS) was the first concept
that commonly used in the orthopedic area to aim for functional
recovery. 3
Peripheral nerve block (PNB) is an endorsed anesthesia
technique with the ERAS protocol used by patients undergoing
joint arthroplasty. GNP provides enough analgesia effect with
lower side effects, such as nausea, hypotension, and
neurological complications than analgesia in patients with
epidural or intravenous administration (PCA) with opioids. The
effectiveness of GNP in arthroplasty has been proved by many
studies that show PNB as a critical factor in the ERAS protocol.3

CASE
The 88-year-old female patient came in with complaints
after falling in the bathroom 3 days before coming to the
hospital. The patient explained about her pain in the right waist Figure 1. Intertrochanter fracture of columna os femur dextra
and immovable. From the physical examination, glasgow coma accompanied by partial displacement of fracture fragments to
scale (GCS) 456 was obtained with a free airway, there were the medial side according to type A2 2 (AO
missing teeth, and adequate spontaneous breathing with 98% Foundation/Orthopaedic Trauma Association classification).
SpO2 in room air. The patient’s weight is 70 kg. In the cardiac
examination, a shift in the apex of the heart was obtained in ICS The operation goes with stable hemodynamics. Blood
III mid-clavicula sinistra and no abnormalities were found in the pressure is obtained at 110-120/80-90 mmHg, the pulse is 80
pulmonary examination. The pulse frequency is 100-120 times/min, and SpO2 is 99%. The operation went 1 hour and 50
times/min, regular pulse, and blood pressure is 160/90 mmHg. minutes and the patient was given an injection of midazolam 1
On the examination of the pain scale, a visual analog scale (VAS) mg and ketorolac 30mg. Postoperatively, patient receive sciatic
pain value was 6-7. On examination of localist status, the right nerve block with ultrasound and parasacral approach. The patient
limb was asymmetrical, ROM (Range of Motion) decreased, pain received naropin drug 0.5% TV 20 cm3 and then performed a
in the hip joint dextra, there was edema, crepitation, passive femoral nerve block (Figure 2).
active motion pain, no agulation was found, and distal saturation
was 96%. The diagnosis established is a distal femoral
subtrochanteric fracture accompanied by dislocation, emergency
hypertension, hyperplasia heart disease (HHD), and Heart Failure
stage B Fc II. From the orthopedics department, patients have
been educated to perform surgery and collaborate with the
consul of cardiology and anesthesia. Patients get a 30 mg
ketorolac injection three times a day and a 50 mg ranitidine
injection. Before the surgical procedure, an x-ray radiological
examination of the Thorax and Pelvis was performed. The results
of the examination are shown in Figure 1 and Figure 2.
The patient is then consulted with the cardiology
department and determined that the surgery plan was approved
with high risk. Patients received captopril 3x25 mg, amlodipine
1x5mg, and spironolactone. From the Anesthesia department,
the patient received ERAS surgery and peripheral nerve block
(femoral nerve and sciatic nerve) procedures. Patients received
informed consent regarding surgical procedures and the
possibility of air embolism during surgery and postoperatively Figure 2. The block needle already ascends the femoral nerve on
after 24 hours. The patient was treated in the intensive care unit the femoral block
(ICU) for postoperative observation. The patient was asked to fast
6 hours before surgery and during fasting rehydrating with 500 After the first day of surgical procedures, the patient
cm3 HES (Hydroxyethyl starch solutions) infusion fluid within 6 complained of minimal pain and was already able to do bed rest.
hours before surgery. Premedication of ondansetron injection Complaints such as nausea and vomiting were not found, but
4mg, ranitidine 50mg, and paracetamol infusion 1 gr patients complained of difficulty defecating from the first day of
administered. admission. From the physical examination, GCS 456, respiratory
In the pre-induction period before surgery, GCS 456 was rate 18times/min, SpO2 100% with nasal cannula 2 lpm, blood
obtained with a blood pressure of 129/66 mmHg, a pulse of 114 pressure 106/80mmhg, pulse 90x/min, temperature 36.5 C, VAS
times/min, and SpO2 of 99% with a nasal cannula. The patient stationary 0, VAS bed rest 0-1, and VAS motion pain 1-2 (Figure
then gets an intravenous injection of ketamine 10mg and 3), urine production 0.7 cm3/kg weight. Patients get ketorolac
fentanyl 50µg. Then, a mixture of Bupivacaine 10mg, Fentanyl 50 injection therapy 3x30 mg, and kalnex 3x500 mg. Ranitidine 2x50
µg, and Morphine 0.1 µg in lumbar 4 was performed. Once the

Journal of Anaesthesia and Pain. 2023. Vol.4(1):5-9 6

mg, Ondansentron 3x4 mg, and Lactolosa Shirp 3x1Cth. From the are attributable to health and social protection costs. Currently,
cardiology department obtained injection in Lovenox 1x0.4 cm3 approximately 25% of hip fracture patients are admitted to
SC, ramipril 5mg 0-1-0, and Spironolactone 25mg 1-0-0. medical care centers, and up to 10-20% who are treated at home
end up being transferred to institutional care. 4.5
Osteoporosis and osteopenia are the most common
causes of hip fractures, requiring patients to be rushed to
treatment centers and receive trauma orthopedic treatment. The
UK National Hip Fracture Database reports that the average age
of someone with a hip fracture is 84 for men and 83 for women,
with a proportion of 76 % of hip fracture patients who are female.
Further, around 30% patients with this fracture die within 12
months and about 10% within one month. Therefore, hip fracture
can be classified as the problem with a high mortality rate. 6 The
mortality rate caused by fractures does not only come from the
fracture itself but also comes from related diseases. Therefore,
hip fracture is not a specific surgical problem at all. Effective and
safe treatment of hip fractures requires the coordination of
various medical sectors, including the skills of anesthesiologists,
surgeons, and rehabilitation, which includes a holistic approach
Figure 3. The patient showed VAS pain with a Visual analog score to patient mobilization and follow-up from hospital care to the
of 0 and VAS pain in motion at numbers 1-2 community. 4
The mortality rate of hip fractures among the elderly
range from 14% to 36% with a temporary and sometimes
permanent decrease in independence and quality of life. Current
guidelines suggest that surgery for a hip fracture should be
accomplished within 24 hours of damage, as previous surgeries
have been linked to better functional outcomes, shorter hospital
stays, shorter pain durations and non-union rates, postoperative
complications, and lower mortality. 7
Those who support for early management opined
that this approach reduces the length of stay in bed for patients,
thus decreasing the risk of related complications, namely
pressure sores, deep vein thrombosis, and urinary tract
infections. Oppositely, those who support the postponement of
surgery believe in providing an opportunity to optimize the
patient's medical status, thereby reducing the risk of
perioperative complications.7 The argumentation for supporting
early management or not is related to the accepted definition of
initial surgical management. It is unclear whether periods of 24,
48, or 72 hours or more are considered unacceptable delays in
hip fracture surgery. 8
Figure 4. Above: Patient knee condition in VAS 0-1. Below: Hip fractures is divided into two types. The first one
When the patient’s foot is raised; the VAS score was 0-1. is femoral neck fractures. The second category is
intertrochanteric fractures. If the fracture happened in femoral
DISCUSSION neck, it threatens the blood source to the proximal bone
A hip fracture is a fracture that occurs between the edge fragments. This fracture is traditionally managed with reduction
of the femoral head and 5 centimeters below the minor and internal fixation. The fixation is carried out with several
trochanter. Based on their relationship to the joint capsule of the screws or pins (for example, Knowles) or assemblies of
hip, fractures are generally divided into two main types. The first compression screw side plates (for example, Richards, Zimmer).
fracture is a fracture above the capsule insertion, called an The most common further complications are nonunion and
intracapsular, subcapsular, or femoral neck fracture. The second avascular necrosis of the femoral head. Medullary prostheses for
fracture is an extracapsular fracture. Extracapsular fractures are the replacement of the femur head and neck are chosen as an
further divided into trochanteric (intertrochanter and reverse alternative treatment to avoid the second surgical procedure
oblique) and subtrochanteric fractures. Fractures are divided into required by this final complication. Even though the
intracapsular and extracapsular based on their relationship to the hemiarthroplasty procedure allows for faster postoperative
vasculature of the femoral cap and the complexity of the mobilization, the time of surgery and blood loss are greater
underlying mechanism. 4 compared to the internal fixation procedure. Additionally, the
Between 70,000 and 75,000 hip fractures, mostly of mortality of postoperative procedure may be slightly raised in
the proximal femur, occur each year in the UK, with a total cost treated patients using hemiarthroplasty than in patients
of around £ 2 billion in treatment, including medical and social undertaking internal fixation. 9
care. This is mainly due to the aging of the population which has Better knowledge of regional anatomy and surgical
made hip fractures a major health problem. These costs are techniques is critical to delivering nerve block anesthesia
mainly attributable to hospitalization costs and other expenses effectively when lateral hip approaches are used, and the skin and
fascia (iliotibial tract) are incised on the lateral aspects of the

Journal of Anaesthesia and Pain. 2023. Vol.4(1):5-9 7

thigh, proximal and distal major trochanters. The next step is to to anchor the head of the prosthetic femur in the hip socket. This
split the gluteus muscle medius and minimus to open the incised procedure causes discomfort to the patient. However, this
hip capsule. This can open the hip joint. Need to mention that maneuver can be managed under light sedation and only takes
incomplete anesthesia of the joints, muscles, or skin can create a a few seconds. 1
painful surgery. 1 Adequate anesthesia for hip surgery can be achieved
The process of preparing anesthetic techniques with a combination of PSOAS compartment block with sciatic
before surgery should accommodate the requirements of the nerve block and skin infiltration.12 PSOAS compartment block
surgery, patient comfort, and the ability of the anesthesiologist. carries a more serious risk than femoral nerve block. The most
General anesthesia (GA) has been preferred in the surgical common complication of PSOAS compartment block is
management of trauma over the past decades, however, this dominated by epidural spread (around 40%). These
technique may disrupt compensatory sympathoadrenal reflexes complications can lead to significant hemodynamic instability in
and physiological balance in trauma patients. Additionally, GA in susceptible patients. In addition, the occurrence of a lumbar
patients undergoing emergency surgery does not yet have a hematoma can be a serious complication, especially if the patient
clear fasting status. Therefore, the safe and easy implementation operated on the hip receives perioperative anticoagulant
of GA cannot be guaranteed. Several factors such as the treatment. A case report of a patient undergoing
simplicity, safety and effectiveness of regional anesthesia along hemiarthroplasty of the hip revealed that it was performed under
with the stability of cardiovascular function and better early anterior plexus block (3 in 1) with IV ketamine as adjuvant. In
postoperative rehabilitation in regional anesthesia are the high-risk patients, hemiarthroplasty of the hip is performed using
reasons why this anesthetic technique is used more as a safe only LA infiltration for tissue dissection.2
procedure for this type of patient. From various regional The study from Akkaya et al. compared ultrasound-
anesthesia techniques, postoperative analgesia and better guided femoral and sciatic nerve blocks and spinal anesthesia for
hemodynamic stability can be achieved using continuous spinal total knee arthroplasty and Mehrotra and Mehourotra with 3 in
anesthesia and epidural compared to single-use spinal 1 compared continuous sciatic and femoral nerve blocks in hip
anesthesia. However, it should be noted that continued use of replacement surgery. Both studies found a safe, simple and
spinal and epidural needles with catheters can cause various side effective method of using peripheral nerve blocks.11.13 Patients at
effects such as bradycardia, hypotension, post-dural puncture high risk for spinal or epidural anesthesia due to cardiovascular
headache, spinal hematoma, and even meningitis. In comparison, instability and consumption of anticoagulant can safely undergo
lower extremity peripheral nerve block has minimal lower extremity surgery using combined femoral and sciatic
hemodynamic effect and does not result in reduced regional anesthesia. Baddoo also concluded that peripheral nerve block
blood flow to the lower extremities. In the past, peripheral nerve was an effective anesthetic technique to provide adequate
blocks were rarely selected as an anesthetic procedure in patients cardiovascular stability and postoperative analgesia for lower
undergoing lower extremity surgery due to the inexperience of limb amputations in patients with diabetes. The same result was
anesthesiologists in performing this procedure. Various studies found by Vijayamohan et al. in a study of total knee arthroplasty
are underway to assess the safety of combined femoral and performed under a combination of femoral and sciatic blocks. 14
sciatic blocks versus general and central neuraxial blocks for Tantra et al. also conducted a study using a combined femoral
lower extremity surgery. 2 and sciatic block in anticoagulated patients with severe valvular
In Guideline Procedure Specific postoperative pain disease and found the procedure to be simple.15
management (PROSPECT) regional anesthesia in PROSPECT recommends Fascia iliac block action
hemiarthroplasty surgery is highly recommended (Grade A). And (grade D), for Hermiarthoplasty action according to M sign, M
the administration of Paracetamol as a premedication and Non- khan and R Chandrasekar can be performed with Femoral and
Steroid anti-inflammatory (NSAID) is recommended (Grade A) as sciatic nerve blocks.16 Compared to a central neuraxial block
a multimodal anti-pain in hemiarthroplasty procedures. 16 which provides an analgesia duration of approximately 4 to 5
Multimodal analgesia become one of the most preferable hours, a combined femoral and sciatic block provides a longer
modality in knee surgery.17 postoperative analgesia duration of approximately 12 to 13
The hip joint receive vascularization from the sacral hours. This advantage has implications for the administration of
plexus (via its articular nerve branches to the quadratus femoris, fewer doses of nonsteroidal anti-inflammatory drugs and
the superior gluteal and sciatic nerves), the obturator nerve (from opioids, so that postoperative side effects such as nausea,
hip branches), and the femoral nerve (via its branches towards vomiting, and sedation can be minimized and adequate control
the rectus femoris). Moreover, all of these nerves can be occluded of pain can be performed so that patients can perform early
in the inguinal and parasacral regions. 10 The entire sacral plexus mobilization. The posterior Labat approach to the sciatic nerve
can be blocked by parasacral sciatic nerve block. Obstruction of block has a better success rate than other approaches such as the
the proximal obturator nerve can block its coxal branch. A anterior, posterior, and parasacral approaches. Tagariello also
femoral nerve block can block its branches to the rectus femoris. found similar results in a study of the sciatic nerve block
The above nerve block succeeded in anesthetizing the entire approach which reported that the posterior approach showed an
lower limb (including all hip muscles) except for certain areas of almost 99% success rate in over 15,000 patients.2
the skin and the iliopsoas muscle (innervated in the abdomen). 11 Regardless of the type of anesthesia received,
The LFC (lateral femoral cutaneous) nerve supplies an area of skin preoperative assessment of patient comorbidities and
distal to the incision that can easily be blocked with ultrasound. optimization of assessment is important to do prior to surgery.
However, the psoas compartment block and calcaneofibular In the study by Bansal et al., mean duration of sensory and motor
ligament (CFL) block cannot anesthetize the proximal skin area block, mean time to onset of sensory and motor block,
supplied by the subcostal and iliohypogastric nerves. This can be perioperative VAS score greater than 24 hours, postoperative
corrected by subcutaneous infiltration of local anesthesia. During analgesia, need for total dose of rescue analgesic, incidence of
surgery, the operator avoid dissecting the iliopsoas muscle; adverse events and complications had comparable values in the
however, they are stretched during distal traction on the femur two treatment groups. Patients were asked to provide an

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assessment on a visual analogue scale (VAS) to determine the In this case report, there is still a bias value for the
level of analgesia in the postoperative period. The evaluation is evaluation of VAS pain in the first 24 hours, due to the effect of
done with a line from 0 to 10 cm with the number “0” meaning opioids (morphine) in intrathecal which can last 24 hours post-
“no pain” and the number “10” meaning “severe pain”. 2 subarachnoid block. The combination of nerve blocks needs a
Intraoperative pain was assessed using a visual analogue scale large doses of local anesthesia, therefore it is important to
(VAS); 0 means no pain and 10 means severe pain. A VAS value consider the toxicity risk. If available, a reduced amount of toxic
of up to 3 is considered uncomfortable and a VAS value greater LA levorotatory enantiomer should be utilized. The current block
than 3 is considered painful. Patients who completed surgery still causes ipsilateral limb sympathectomy. Tight monitoring of
without requiring opioid administration (VAS ≤ 3 during surgery) hemodynamics and other perioperative risks (excessive bleeding,
were considered to have adequate anesthesia. Conversely, hemodynamic complications, deep vein thrombosis, or
patients who experience pain (VAS > 3) and who receive pulmonary embolism) is crucial. 8
additional opioids or general anesthesia at any time during
surgery are considered to be under anesthesia. 1 Bansal et al. CONCLUSION
found that VAS scores were worth 0 to 10 hours postoperatively, The combined femoral nerve block and sciatic nerve for
with a peak VAS score of 3 post-15 hours of surgery and multimodal pain are highly effective in postoperative hip
decreased to a VAS score of 2 post-24 hours of surgery. 2 hemiarthroplasty.

ACKNOWLEDGMENT
-
CONFLICT OF INTEREST
The author declare there is no conflict of interest.

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