Combination of Pericapsular Nerve Group (PENG) and Sacral Erector Spinae Plane (S-ESP) Blocks for Hip Fracture Pain and Surgery: A Case Series

A hip fracture is a serious injury with life-threatening complications, and its risk rises with increasing age. A hip fracture can be a very painful condition, and prompt surgical treatment is recommended to reduce pain and complications. Pain management is considered integral to the management of a broken hip. The choice between general and regional anesthesia in hip fracture surgery continues to be a topic of debate because risks are potentially associated with both approaches. Nerve blockades have proven to be effective in reducing acute pain after a hip fracture and in the perioperative period. For this reason, many regional techniques have been introduced, such as the lumbar plexus block, fascia iliac block, femoral nerve block, and recently, the pericapsular nerve group (PENG) block. Hip joint innervation is complex, not limited to the lumbar plexus but also depending on the sciatic nerve and branches of the sacral plexus (superior and inferior gluteal nerves and an articular branch from the quadratus femoris nerve). We hypothesized that a combination of two emerging regional anesthesia techniques, such as the PENG block and sacral erector spinae plane (S-ESP) block, could represent a good option to obtain pain control of the whole hip joint without opioid administration intraoperatively and postoperatively. Here, we report the cases of three frail patients with significant comorbidities who underwent hip fracture surgery (two cases of intramedullary nailing and one hemiarthroplasty), in which we preoperatively performed PENG and S-ESP blocks. We registered optimal intraoperative and postoperative pain control up to 48 hours after surgery without complications and without opioid administration, allowing the surgery to be performed with intravenous sedation or laryngeal mask general anesthesia. The surgeries were uneventful, and no complications were reported. This approach warrants further investigation in hip fracture surgery.