spinal anaesthesia (SA) is frequently used for hip surgeries and it  has some inevitable consequences such as innate hemodynamic changes ,post dural puncture head ache,back pain, voiding difficulties and a rare potential for hematoma or infection¹. The lumbar plexus arises from the first four lumbar ventral rami that join within the substance of the psoas major. The first lumbar nerve, frequently supplemented by a twig from the last thoracic, splits into an upper and lower branch; the upper and larger branch divides into the iliohypogastric and ilioinguinal nerves; the lower and smaller branch unites with a branch of the second lumbar to form the genitofemoral nerve. The remainder of the second nerve, and the third and fourth nerves, divide into ventral and dorsal divisions. The ventral division of the second unites with the ventral divisions of the third and fourth nerves to form the obturator nerve. The dorsal divisions of the second and third nerves divide into two branches, a smaller branch from each uniting to form the lateral femoral cutaneous nerve, and a larger branch from each joining with the dorsal division of the fourth nerve to form the femoral nerve. The accessory obturator, when it exists, is formed by the union of two small branches given off from the third and fourth nerves.²

 Epidural spread is the most common complication. The incidence of epidural spread varies greatly in the literature from less than 1% to 16%.^{3, 4, 5} The epidural spread is due to the local anaesthetic traveling proximally into paravertebral space rather than the needle being placed directly in to the epidural space. The more medial approach has the highest (Chayens approach⁶) incidence of epidural spread. Epidural spread of the local anaesthetic is not a severe complication, but an expected event with minor side effects.

 Total spinal anaesthesia is a feared complication of posterior lumbar plexus block. Two case reports of total spinal anaesthesia are available in the literature.^7,8 The probable mechanism for intrathecal spread is due to the placement of the needle in the dural sleeve of a nerve root. Spinal nerve roots are surrounded by dural sleeves that follow the nerve root some centimeters outside the intervertebral foramina before becoming continuous with epineurium. This complication can be avoided by a test dose.

Hence this study was conducted to study the postoperative analgesia and complications of lumbar plexus block and low spinal with conventional spinal anesthesia in hip surgeries.

The present Prospective interventional study will be conducted on 60 patients posted for elective hip surgeries in the department of anaesthesia at Basaveshwara teaching and general hospital attached to Mahadevappa Rampure Medical college Kalaburagi. Duration of study was from 1^st october 2019 to 31^st march 2021(18 months)

Sample size: 60 patients (each group 30)

 GROUP A-  LUMBAR PLEUXUS  BLOCK WITH  LOW  SPINAL  ANAESTHESIA

GROUP B­ – CONVENTIONAL SPINAL ANESTHESIA

Sampling procedure: simple random sampling technique

INCLUSION CRITERIA:

1. Patients undergoing elective HIP surgeries
2. Between the ages of 20-80 years, of either sex
3. ASA (American society of anaesthesiologists) grade I,II and III
4. BODY WEIGHT 50-90KG

EXCLUSION CRITERIA :

1. Patients with ASA (American society of anaesthesiologists) grade 
2. Patients who have known allergies to local anaesthetics drugs.
3. Patients with coagulation disorders or on anti coagulant drugs.

For all the patients fulfilling selection criteria, before enrolment, an informed written consent will be taken in the patient own vernacular language after explaining the nature of the study

All patients will be kept fasting 8 hours prior to surgery. Basic monitoring equipment(pulse oximeter, NIBP,ECG monitor) will be checked. Baseline vital parameters will be recorded. All patients will be made to lie supine

GROUP A--  LUMBAR PLEUXUS  BLOCK WITH  LOW  SPINAL  ANAESTHESIA

All patients received lumbar plexus  with insulated 22 gauge stimuplex needle (100 mm) attached to a peripheral nerve stimulator. For the lumbar plexus block, the patient was put in lateral decubitus. The midline (spinous processes), both iliac crests, and posterior‐superior iliac spine were identified and the lumbar plexus was blocked by the posterior approach. The lumbar plexus was identified by eliciting quadriceps muscle contraction at a current setting below 0.5 mA.  Identifying the nerve by contraction of gastrocnemius muscle (foot plantar flexion) and/or tibialis anterior muscle (foot dorsiflexion). 10ml 0.5% Bupivacaine and 15ml of plane 2% lignocaine  was used for lumbar plexus component.  Then low spinal anaesthesia is given with 1-2 ml 0.5%Bupivacaine (hyperbaric).Patient was then turned back to a supine position after performing the the block.

GROUP B- CONVENTIONAL SPINAL ANESTHESIA

In the group B, After skin preparation with antiseptic solution and sterile draping, Spinal anaesthesia given with 2  to 4 ml of hyperbaric 0.5% bupivacaine at L3-L4 level.

 WE COMPARED:

1. Intra- and post-operative hemodynamic study
2. Duration and intensity of postoperative analgesia
3. Time at which rescue analgesic required and dose during first 24 h required in the two groups
4. Side effects/complications(intraoperative, postoperative)- such as nausea , vomiting, pruritus, drowsiness and respiratory depression were noted

Duration of analgesia = onset of sensory blockade till the requirement of rescue analgesic.

Intensity of postoperative pain was assessed with visual analog scale (VAS) score. Patients were given analgesic when VAS ≥3 cm or on patient demand.

The anaesthesiologist who observed the patient in the post op period is blinded to the drug injected in the lumbar plexus block. patient is monitored at 1, 2,4 ,6,12,24 hrs postoperatively for heart rate, blood pressure ,saturation ,VAS score, no of nausea vomiting and complications if any.

Table no.1: comparison of age wise distribution of patients in both the groups

Table No.2:  Comparison of mean age of patients in both the groups

  There was statistically significant in age distribution between the two groups (P value is 0.015). The mean age was 60.83(±13.43) in group A  and  52.53(±12.23) in group B .

Table No 3.  : comparison of gender wise distribution in both the groups

=

Table No 4 : Comparison of ASA grade in both the groups

P value <0.05 is taken as significant

The mean time at first rescue analgesia in group A was 559.67(±45.5) minutes and in group B was 166.03(±13.51) minutes .There was very highly statistical significant difference between the two groups(P<0.000)

The mean 24Hr requirement of Tramadol in group A was 193.33(±58.33) milligram and in group B was 306.67(±25.37) in milligrams .There was very highly statistical significant difference between the groups(P<0.000)

Figure No 1: Comparison of Mean 24Hhr requirement of Tramadol in both the groups

Compare the postoperative analgesia and complications of lumbar plexus block and low spinal with conventional spinal anesthesia in hip surgeries  

Figure No 2 : Comparison of 24Hhr requirement of Fentanyl(mcg) in both the groups

The 24 Hr requirement of Fentanyl was 0(±0) in group A and  16(±36.54) mcg in group-B. There  was statistically significant between the two groups.

Figure No 3 : Comparison of Mean 24Hhr requirement of Fentanyl(mcg) in both the groups

Table No  5: Comparison of  Complications in both the groups

P value <0.05 taken as significant

Spinal anesthesia is a simple technique that has a high success rate. Disadvantages of SA may include urinary retention, hypotension, and the rare risk of spinal hematoma, meningitis, or spinal abscess. The peripheral nerve blocks require multiple injections, increased anesthetic onset time, and larger volumes of local anesthetic solutions compared with single injection SA. The advantages of peripheral nerve blocks include decreased rates of urinary retention and the possibility of prolonged postoperative analgesia. Despite these advantages, it remains that the peripheral nerve blocks may not cover all areas required to complete hip surgery.

Peripheral nerve blocks improve analgesia and reduce the analgesic requirement in many orthopaedic surgeries. Lumber plexus block as sole anaesthetic technique with sedation OR with low spinal anaesthesia is frequently advocated in selected patients for unilateral lower limb orthopaedic procedures e.g. surgeries on hip, proximal femur fracture, arthroscopic surgery of knee etc⁹. The results of the present study indicated that single shot lumbar plexus block with low spinal anesthesia by nerve stimulator technique, was effective in providing better hemodynamic stability, prolonged postoperative analgesia and reducing the pain scores and requirement of supplemental analgesics during first 24 hrs.

Demographic data comparing sex, ASA grade and complications shows no statistically significant difference among both the groups.

There was statistically significant in age distribution between the two groups (P value is 0.015). the mean age in years was 60.83(±13.43) in group A  and  52.53(±12.23) in group B .

Lumbar plexus block with low spinal anesthesia is a superior alternative technique to conventional spinal anesthesia in the intra operative and post operative management of hip surgeries. It provides better post operative analgesia , reduced opioid requirement which can avoid adverse effects of opioids when used in elderly patients.  The success rate is 100% with the use of a nerve stimulator and the incidence of complications can be reduced by careful titrated doses of local anaesthetic, coupled with good vigilance and monitoring.

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