The Role of Nerve Blocks in Hip Arthroscopy

The popularity of arthroscopic hip surgery has increased greatly over the last 10 years,
particularly for correcting Femoroacetabular Impingement (FAI). FAI is a structural
abnormality of the proximal femur, the acetabulum, or both. It is a leading cause of labral
tears in the hip joint and can cause cartilage damage, which may increase subsequent risk of
developing osteoarthritis. Though far less invasive than open hip surgery such as for a total
hip replacement, hip arthroscopy can cause significant postoperative pain for the patient.
Given how relatively new the procedure still is, methods of pain control are highly variable.
Peripheral nerve blocks, mainly femoral nerve and lumbar plexus blocks, have been used by
some surgeons to control postoperative pain. However, in addition to their sensory effects,
these blocks cause motor impairment that has been associated with a significantly higher risk
of falling.

In managing pain after any operation, opioid consumption is, of course, a significant
concern. Ideally, hip arthroscopy patients could receive a peripheral nerve block that
decreases pain and the need for opioids, but without the muscular weakness and increased fall
risk observed with femoral nerve and lumbar plexus blocks. This may be achievable with the
newer Quadratus Lumborum (QL) block.

The ultrasound-guided QL block is currently most commonly used for abdominal surgery.

However, several case studies of a single-injection QL block in hip replacement surgeries
have been successful in minimizing pain and opioid use while sparing motor function and
avoiding the muscle weakness that can lead to falls. In the approach utilized in these cases,
local anesthetic was injected at the anterolateral border of the QL muscle to achieve
analgesia ranging from the T6-T10 through L3 dermatomes. One group has anecdotally reported
great success in using these QL blocks for alleviating postoperative pain with hip
arthroscopy, but no studies to date have evaluated the effectiveness of QL blocks for
arthroscopic hip surgery.

This study is a randomized, controlled, double-blind trial. Patients undergoing hip
arthroscopy who agree to participate will be randomly selected to receive an
ultrasound-guided QL block with either local anesthetic (QL block group) or normal saline
(control group) preoperatively.

After surgery and during the first postoperative week, patients will record their numerical
pain score, the location of their pain, and their opioid consumption using our attached study
instrument. On this form, they will record their pain score at 0.5, 1, 1.5, 2, 4, 6, 12, 24,
and 48 hours and 7 days after surgery. The form specifies that if patients are unable to
record their pain score at any of these time points, particularly because they are
sleeping/recovering, they can simply skip that time point. For pain location, patients are
instructed to draw X's on a standard cartoon at the site of their pain. For opioid
consumption, patients simply record when and how many pills they take. This form will be
collected from patients at their 10-14 day postoperative visit. Data will also be collected
from the medical chart on time to discharge and any complications in the perioperative
period. Questionnaires will be used to assess pain, physical and social health, such as
Patient-Reported Outcomes Measurement Information System (PROMIS).

Inclusion Criteria:

- Patients scheduled to receive unilateral arthroscopy hip surgery at Columbia
University Medical Center with Dr. Lynch.

Exclusion Criteria:

- Patients scheduled to receive bilaterally or staged hip arthroscopy.

- Patients unwilling to participate in the research.

- History of chronic opioid use.

- Contraindication or allergy to study medications, such as QL block.