The suprasacral parallel shift: an attractive alternative to subarachnoid anaesthesia in the very elderly patient with proximal femur fracture.

Behr AU, Vasques F

Background Subarachnoid anaesthesia in very elderly patients with relevant comorbidities may be not feasible. The suprasacral parallel shift (SSPS), an ultrasound(US)-guided technique proposed by Bendtsen1, realizes a block of the lumbosacral nerves that innervates the hip and the proximal femur.
Case series Between October and December 2015, 15 consecutive ASA 3 patients (11 female, median age 89.4 years) underwent SSPS before surgery for femur fracture (4 partial hip replacements, 8 proximal femur nails, 3 open reductions) at the University Hospital of Padua. Patients’ comorbidities included severe aortic stenosis and severe dilated cardiomyopathy. Using a convex US probe (Sonosite), we introduced a nerve block needle (22G-100mm, Sonoplex, Pajunk) in the space between the sacrum and the transverse process of L5 with a steep out-of-plane approach. The bony structures were always visible at US, while the lumbosacral ligament was not always identifiable. Nonetheless, ligament crossing was always associated with a clear pop sensation followed by low resistance to injection. Correct needle positioning was further confirmed by electric nerve stimulation and quadriceps contraction was evoked in 70% of the patients. As soon as 10 min after injection of 20-25 ml ropivacaine 0.5%2 we assessed an important NRS reduction and visibly reduced pain behaviour in all patients. As dementia was frequent in our patients, the precise definition of sensory-motor block was not always possible. In 13 patients we obtained a satisfactory anaesthetic block and we reduced procedure-related discomfort in 5 of them with light intraoperative propofol sedation. In one patient, we placed an i-gel LMA for deeper sedation, while in another case we added a femur nerve block because the lumbosacral block was just analgesic. All the 15 patients were pain free at the end of the procedure with a median fentanyl need of 113 mcg/patient.
Discussion SSPS was born as US-guided technique2, but we found ENS of some help, especially in patients with poor US images. To date, the main implementation of SSPS was on healthy volunteers1. This technique may be invaluable in very old patients, as it is less invasive and safer than subarachnoid anaesthesia, being affected by less haemodynamic instability and contraindications3. Furthermore, it may be even preferred to other nerve blocks (e.g. psoas, 3-in-1) as it requires less volume and only a single puncture to block the whole surgical territory.

References
1)	Bendtsen TF, Pedersen EM, Haroutounian S, et al. The suprasacral parallel shift vs. lumbar plexus blockade with ultrasound guidance in healthy volunteers – a randomised controlled trial. Anaesthesia 2014,69,1227–1240.
2)	Bendtsen TF, Soeballe K, Pedersen EM, et al. Ultrasound guided single injection lumbosacral plexus blockade for hip surgery anaesthesia. Available at: http://bja.oxfordjournals.org. Accessed on December, 10th 2015. 
3)	Patorno E, Neuman MD, Schneeweiss S, et al. Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study. BMJ 2014,27;348:g4022.

The suprasacral parallel shift (SSPS): an attractive alternative to subarachnoid anaesthesia in the very elderly patient with proximal femur fracture