Fascia Iliaca Compartment Research Articles

Pericapsular Nerve Group Block and Iliopsoas Plane Block: A Scoping Review of Quadriceps Weakness after Two Proclaimed Motor-Sparing Hip Blocks.

Iliopsoas plane (IP) is a fascial plane deep to the iliopsoas complex that can serve as a potential space for the injection of local anesthetics to selectively block the articular branches of femoral nerve and accessory obturator nerve to the anterior hip capsule. Two highly similar ultrasound-guided interfascial plane blocks that target the IP, pericapsular nerve group (PENG) block and iliopsoas plane block (IPB), were both designed to achieve motor-sparing sensory block to the anterior hip capsule. However, the most recent evidence shows that PENG block can cause 25% or more of quadriceps weakness, while IPB remains the hip block that can preserve quadriceps strength. In this scoping review of quadriceps weakness after PENG block and IPB, we first performed a focused review on the complicated anatomy surrounding the anterior hip capsule. Then, we systematically searched for all currently available cadaveric and clinical studies utilizing PENG block and IPB, with a focus on quadriceps weakness and its potential mechanism from the perspectives of fascial plane spread along and outside of the IP. We conclude that quadriceps weakness after PENG block, which places its needle tip directly deep to iliopsoas tendon (IT), may be the result of iliopectineal bursal injection. The incidental bursal injection, which can be observed on ultrasound as a medial fascial plane spread, can cause bursal rupture/puncture and an anteromedial extra-IP spread to involve the femoral nerve proper within fascia iliaca compartment (FIC). In comparison, IPB places its needle tip lateral to IT and injects just one-fourth of the volume of PENG block. The current evidence, albeit still limited, supports IPB as the true motor-sparing hip block. To avoid quadriceps weakness after PENG block, a more laterally placed needle tip, away from the undersurface of IT, and a reduction in injection volume should be considered. Future studies should focus on comparing the analgesic effects and quadriceps function impairment between PENG block and IPB.

Understanding fascial anatomy and interfascial communication: implications in regional anesthesia.

With the extensive application of ultrasound in regional anesthesia, there has been rapid development of interfascial plane block techniques recently. Compared with neuraxial anesthesia or nerve plexus blocks, the interfascial plane blocks have many advantages, such as technical simplicity, fewer complications and comparable or better analgesia. The concept of fascial interconnectivity is fundamental in understanding the effects and complications of interfascial plane blocks. Many fascial planes are continuous and communicate with each other without a clear anatomical boundary. The prevertebral fascia of the neck, endothoracic fascia of the chest, transversalis fascia of the abdomen, and the fascia iliaca of the pelvic cavity form a natural fascial continuation. This anatomical feature suggests that the space beneath the cervical prevertebral fascia, the thoracic paravertebral space, the space between transversalis fascia and psoas muscles (psoas major and quadratus lumborum), and the fascia iliaca compartment are a confluent potential cavity. Additionally, the permeability of the fascia at different anatomical locations to local anesthetics is different, which can also influence the block effect and the incidence of complications. This article summarizes the anatomical characteristics and communication relationships of the major fascia which are related to regional anesthesia, and their relationships with block effects and complications.

Comparative Study to Evaluate the Effect of Ultrasound-Guided Pericapsular Nerve Group Block Versus Fascia Iliaca Compartment Block on the Postoperative Analgesic Effect in Patients Undergoing Surgeries for Hip Fracture under Spinal Anesthesia.

Background:Fractures in and around the hip are a major concern in young as well as the elderly. Ultrasound-guided (USG) peripheral nerve blocks help in early surgical fixation of these fractures by providing perioperative pain relief as well as early mobilization resulting in reduced morbidity and mortality.Aims:This study aims to compare the efficacy of USG pericapsular nerve group (PENG) block versus fascia iliaca compartment (FIC) block.Setting and Design:Prospective, randomized, double-blind, controlled study.Materials and Methods:Twenty-four patients above 18 years of age with hip fracture belonging to the American Society of Anaesthesiologists physical status Classes I and II scheduled for hip surgery were randomly allocated into two groups. Group 1(PENG block) received USG-guided PENG block and Group 2 (FIC block) received USG guided FIC block for postoperative pain relief. Postoperative pain relief (at rest) was evaluated by Numeric Rating Scale score from 20th min and at regular interval for 24 h. The total analgesic consumption in the first 24 h was also noted.Statistical Analysis Used:Data were analyzed by using nonparametric test and Chi-square test. Hemodynamic variables and pain scores were analyzed using analysis of variance for two groups and independent t-test was used for comparison between two groups.Results:Postoperative NRS score was higher in FIC block than PENG block which was statistically significant at 1 h (P = 0.035) and at 4 h (P = 0.001). The first requirement of analgesic was significantly late in PENG block group (8.17 ± 3.129) as compared to FIC block group (4.00 ± 1.477).Conclusions:PENG block provides better postoperative analgesia, with reduced requirement of rescue analgesics in 24 h as compared to FIC block in patients undergoing surgeries for hip fracture under spinal anesthesia.

Fibrous configuration of the fascia iliaca compartment: An epoxy sheet plastination and confocal microscopy study

Background and Objectives: The underlying anatomical mechanism of the ultrasound-guided fascia iliaca compartment (FIC) block for anaesthesia and analgesia in the lower limb has not been illuminated and numerous variations were attempted to achieve an optimal needle placement. This study aimed to define the fibrous configuration of the FIC. Methods: A total of 46 adult cadavers were studied using dissection, latex injection, epoxy sheet plastination and confocal microscopy. Results: (1) The fascia iliaca originated from the peripheral fascicular aponeurotic sheet of the iliopsoas. (2) The FIC was a funnel-shaped adipose space between the fascia iliaca and the epimysium of the iliopsoas, had a superior and an inferior opening and contained the femoral and lateral femoral cutaneous nerves but not obturator nerve. (3) The estimated volume of the FIC in the cadavers was about 23 mls, of which about one third was below the level of the anterior superior iliac spine. Conclusions: This study revealed that the fascia iliaca was aponeurotic and may be less permeable for the local anesthetics. Conclusions: The FIC contained only the femoral and lateral femoral cutaneous nerves and communicated with the extraperitoneal space and femoral triangle adipose space via its superior and inferior opening, respectively.

Fascia iliaca block, history, technique, and efficacy in clinical practice.

The facsia iliaca block (FIB) is a relatively new regional technique where local anesthetic is delivered within the fascia iliaca region. Indications for a FIB include surgical anesthesia to the lower extremity after knee, femoral shaft, hip surgery, management of cancer pain or pain secondary to inflammatory conditions of the lumbar plexus, as well as treatment of acute pain in the setting of trauma, fracture, or burns. The FIB may be performed using either a loss of resistance technique or an ultrasound (US)-guided technique; however, the use of US has become commonplace and resulted in improved femoral nerve and obturator nerve motor blocks. The main targets of the FIB are the predominant nerves contained in the fascia iliaca compartment (FIC), namely the femoral nerve and the lateral femoral cutaneous nerve. The FIB US guided technique is beneficial to patients and the possibility to perform FIB should be discussed and coordinated with surgical staff appropriately, considering its superiority to general or epidural anesthesia.

Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models

BackgroundUltrasound-guided regional anesthesia (UGRA) is increasingly used by emergency physicians to provide safe and effective pain relief for patients. However, one of the factors limiting its widespread use is the lack of realistic models available for learners to train on. There are currently no inexpensive nerve block models available that are injectable and that closely mimic nerves, fascial planes, muscles, and other landmarks. Our aim is to create inexpensive, injectable nerve block models that can be used as effective medical training tools for UGRA.MethodsBy using a lean cut of pork such as pork loin, yarn soaked in ultrasound gel to simulate peripheral nerves, and drinking straws filled with gel to represent vascular structures, we created various nerve block models. Meat glue applied between sections of meat appears hyperechoic under ultrasound, thereby mimicking fascial planes and has the added benefit of helping to secure the components of the model together. Using these elements, we were able to create realistic peripheral nerve, fascia iliaca compartment, serratus anterior plane, and interscalene brachial plexus models.ResultsOne of the necessary skills in performing UGRA involves placing the needle tip along a fascial plane and visualizing hydrodissection of this plane with the local anesthetic. When meat glue (transglutaminase) is applied between layers of meat such as pork loin, the meat binds together and creates a hyperechoic line that mimics a fascial plane. When meat glue is applied to two apposing fascial layers naturally occurring on the meat, the fascial plane can be injected, and fluid can be seen hydrodissecting in this space. We created several nerve block models using meat glue and other components to mimic normal landmarks.ConclusionsWe have developed inexpensive and easily reproducible models that create the realistic appearance of tissues, nerves, and fascial planes under ultrasound. They can also accurately simulate hydrodissection of fluid in fascial planes. We hope these nerve block models will allow for the education in UGRA to be more widespread and accessible to learners from all specialties.

The modern state of analgesia after total hip replacement

Total hip replacement is an important orthopedic surgery allowing to increase high-activity profile and longevity of the elderly patients suffered from arthritis and proximal hip fracture. For the good outcome of the surgery we have to use enhanced recovery strategy which in turn needs performing adequate postoperative analgesia. Using painkillers only (per os, i.v., i.m., s.c.) after THR is not enough to reach this aim (well pain relief at rest and during movement) due to low analgesic potency of the non-opioid drugs and adverse reactions related to opioids, so, the regional analgesia methods are widely spread. Considered before as a gold standard epidural analgesia method is not quite suitable for the aged patients as so as the sympathetic and motor blocks hinder an enhanced recovery after THR. In recent decades the interest in peripheral regional analgesia methods has been gradually increasing. Fascia iliaca and psoas compartment blocks, local wound infiltration analgesia are getting the modern regional THR postoperative analgesia armamentarium. Each of them has some benefits and pitfalls and only face-to-face comparisons within the scope of clinical trials will give us the basic for the constituting the local and national post-THR analgesia guidelines.

Block them when it hurts.

Dear editor We read the article by Gadsden and Warlick with great interest.1 Good, patient-tailored pain relief is critical in all patients, but as stated by the authors, it is often suboptimal in trauma patients. Because of this, a trial was performed in collaboration with emergency medical service (EMS)-nurses in the South East Brabant Region, Eindhoven, the Netherlands.2 Patients with a proximal femur fracture are often difficult to transfer from the accident scene. Well-trained EMS-nurses performed a fascia iliaca compartment (FIC) block at the scene. Pain scores reduced by more than 50%. Transfer dynamic pain scores were reduced to 3–4 (out of 10), with very high patient satisfaction scores. This study showed that FIC block is easy to learn and very effective. This form of regional anesthesia can be safely used at the accident site to improve patient comfort.

Prehospital administered fascia iliaca compartment block by emergency medical service nurses, a feasibility study

IntroductionPatients with a proximal femur fracture are often difficult to evacuate from the accident scene. Prehospital pain management for this vulnerable group of patients may be challenging. Multiple co-morbidities, polypharmacy and increased age may limit the choice of suitable analgesics. The fascia iliaca compartment (FIC) block may be an alternative to intravenous analgesics. However this peripheral nerve block is mainly applied by physicians.In the Netherlands, prehospital emergency care is mostly provided by EMS-nurses. Therefore we examined whether well-trained EMS-nurses are able to successfully perform a FIC block in order to ensure timely and appropriate effective analgesia.The study was study was registered in the Netherlands Trial Register (NTR-nr 3824).MethodsTen EMS nurses were educated in the performance of a FIC-block. Indications, technique, side-effects and complications were discussed. Hereafter the trained EMS-nurses staffed ambulance teams were dispatched to patients with a suspicion for a proximal femur fracture. After confirmation of the diagnosis, the block was performed and 0.3 ml/kg lidocaine (10 mg/ml) with adrenaline 5 μg/ml was injected. The quality of pain relief, occurrence of complications and patient satisfaction were evaluated.ResultsIn 108 patients a block was performed. One hundred patients could be included. Every EMS nurse performed at least 10 FIC blocks. The block was effective in 96 patients. The initial median (NRS)-pain score decreased after block performance to a score of 6 (after 10 minutes), 4 (after 20 minutes) and 3 (after 30 minutes). At arrival at the Emergency Department the median pain score was 3. Dynamic NRS-pain scores when transferring the patient from the accident scene to the ambulance stretcher, during transportation to the hospital and when transferring the patient to a hospital bed were, 4, 3 and 3.5 respectively. Patient satisfaction was very high. No complications were noted.ConclusionAdditional educated EMS-nurses are able to successfully perform a FIC-block for providing acute pain relief to patients with a suspected proximal femur fracture.

Role of Preoperative Fascia Iliaca Compartment Block On The Side Of Femur Surgery

Background and Aims: Different kinds of adjutants are used with local anesthetics during intrathecal procedure for prolongation of action. However, they are not completely free from side effects. Fascia Iliaca Compartment Block (FICB) is useful for the same purpose. Method: After administering 20ml 0.5% injection Bupivacaine in FIC (Fascia Iliaca Compartment) on the fractured side before anesthesia as pre-operative medication, 50 elderly patients got relief of pain. Results: 50 patients of mean age and weight 68.38±8.08 years and 55.04±3.02 Kg respectively showed postoperative analgesia of average 15.82±2.34 hours with mean systolic blood pressure112.32±7.62 mm of Hg. Patients felt comforts with FICB. Conclusion: Preoperative, intra-operative and postoperative analgesia provided by FICB is of high quality to relieve pain on movement before surgery, to act as an adjuvant with spinal anesthesia during surgery and prolonged analgesia after surgery without adverse reaction.

Pre‐operative femoral nerve block vs fascia iliaca block for femoral neck fracture – 7

Regarding Newman et al.'s study 1, if ‘the right amount’ of local anaesthetic is injected into ‘the right place’ (the fascia iliaca compartment), it will spread to the femoral nerve and should produce an adequate femoral block, comparable with the femoral nerve block 2. Larger volumes may allow spread to the other nerves in the compartment (obturator and lateral femoral cutaneous) or even the lumber plexus. The fascia iliaca block is a ‘compartment block’, thus volume dependent, and therefore 20–30 ml local anaesthetic may not be adequate to allow spread and produce an adequate block. Capdevila et al.'s original comparative study used 30 ml 2 and many authors advocate up to 40 ml 3. There are also descriptions of multiple fascial layers in the inguinal area, and so using the blind ‘double-pop’ technique, one could deposit local anaesthetic between the wrong layers and not the fascia iliaca compartment as intended. Use of ultrasound has been shown to increase the success of this block compared with the landmark technique 4. It would be interesting, therefore, to know whether femoral nerve block is still superior to fascia iliaca block when performed using ultrasound with a larger volume.

Does obturator nerve block always occur in 3-1 block?

Objective: In the femoral q3-in-1 blockq, obturator nerve block is routinely unsuccessful. Anatomical studies are not available to explain why blockade of obturator nerve or lumbar plexus does not occur. The aim of this study was to examine the effectiveness of femoral q3-in-1 blockq obturator nerve block on a cadaver model. Materials and methods: Totally, 12 mature adult human cadavers were selected. Methylene blue dye (30 ml) was in-jected under the fascia iliaca in eight cadavers and into the femoral nerve sheath in four cadavers. Careful bilateral dissections were performed following dye injections. Results: It was seen that the dye did not spread to the medial part of the psoas major muscle and the obturator nerve was not stained with the dye in eight cadavers in whom dye was injected laterally into the femoral sheat. In four ca-davers in whom dye was injected into the femoral nerve sheat, metylene blue spread through fascial layers in the plane under the psoas muscle and stained the obturator nerve just before emerging medially from the fascia psoas. At this point, the obturator nerve pierced the psoas fascia and extended extrafascially in the medial and deep borders of the psoas muscle. In this area, the upper section of the obturator nerve was found also to be stained with the dye. Conclusion: We concluded that the cause of an unsuccessful obturator nerve block might be the fascial anatomy of this region. The lateral cutaneous femoral nerve and the femoral nerve easily can be blocked in the fascia iliaca com-partment, but the obturator nerve block fails because of its being extrafascial in this region.

Incisional Continuous Fascia Iliaca Block Provides More Effective Pain Relief and Fewer Side Effects than Opioids After Pelvic Osteotomy in Children

Intravenous opioid therapy is frequently used for postoperative pain management in children after orthopedic surgery but causes side effects such as respiratory depression, vomiting, sedation, and urinary retention. To investigate whether a continuous incisional fascia iliaca compartment (FIC) block provides more effective postoperative pain relief with fewer side effects than IV morphine, we performed a prospective, double-blind, randomized study to compare both techniques. Thirty children (ASA physical status I-II) aged 3 mo to 6 yr undergoing a pelvic osteotomy were included in the study. The children were randomized for either morphine IV and placebo (saline) via a FIC catheter (Group M) or placebo (saline) IV and ropivacaine via a FIC catheter (Group R). All patients received general anesthesia using inhaled sevoflurane and IV fentanyl. Perioperatively, a FIC catheter was placed by the surgeon. All patients received either a bolus dose of morphine IV (Group M) or ropivacaine 0.75% via the FIC catheter (Group R) at the end of surgery. Postoperatively, Group M received morphine IV 20 microg x kg(-1) x h(-1) and Group R ropivacaine 0.2% 0.1 mL x kg(-1) x h(-1) via the FIC catheter. In both groups, saline was administered along the other route. All children were assessed for pain, sedation, time until first oral intake, and adverse effects for 48 h postoperatively. During this period, all children had a urinary catheter. The study was completed by 28 children. In the anesthetic recovery room, children in Group M had significantly higher pain scores. These children were also significantly more sedated during the study period. The incidence of vomiting did not differ between the groups; however, children in Group R had first oral intake significantly earlier than Group M. A local retrospective study revealed an incidence of urinary retention of 4.7% in the ropivacaine-treated patients and 39% in the morphine-treated patients. Continuous incisional FIC block provides excellent postoperative pain relief, less sedation, and better return of appetite than morphine IV after pelvic osteotomy in children.

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block

In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture. The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n=20) and the IVA group (intravenous analgesia with alfentanil, n=20). Group IVA patients received a bolus dose of i.v. alfentanil 10 microg/kg, followed by a continuous infusion of alfentanil 0.25 microg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared. VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1-4) vs. 3.5 (2-6), P=0.001], and the mean (+/- SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 +/- 2.7 min vs. 10.8 +/- 5.6 min; P=0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)(P=0.008). An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.

High plasma ropivacaine concentrations after fascia iliaca compartment block in children

The pharmacokinetic profile of local anaesthetics is influenced by the mode of administration. We sought to compare the pharmacokinetics of two doses of ropivacaine after fascia iliaca compartment (FIC) block in children. In this prospective, double-blind study, children received an FIC block as a part of their anaesthetic management during elective orthopaedic surgery on the thigh. They were randomized to receive ropivacaine 0.7 ml x kg(-1) using either a 0.375% or 0.5% solution. Venous blood samples were drawn up to 6 h after injection. Plasma concentrations of ropivacaine were measured by gas-liquid chromatography. Six children (10.2 (range 5-15) yr, 35.6 (sd 10) kg were included. FIC block provided satisfactory peroperative pain relief. No signs of toxicity were observed, but high maximal plasma concentrations (C(max) 4.33-5.6 microg ml(-1)), were observed for three of four patients in the ropivacaine 0.5% group. The two patients in the 0.375% group showed values within the safe range (C(max) 0.66 and 0.98 microg ml(-1) respectively). Even though no toxic effects were observed, these results led us to discontinue the study. The administration of ropivacaine 3.5 mg x kg(-1) can be associated with sustained high plasma concentrations of ropivacaine, outside the tolerable range. In view of these results, we recommend the use of lower ropivacaine dosage during FIC block in children.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: A case report and description of a catheter technique

The pain following total knee arthroplasty can be associated with significant morbidity, especially in the elderly. Regional anesthetic techniques attenuate or eliminate postoperative pain, which may reduce this morbidity. A 74-year-old patient with history of an epidural abscess underwent elective bilateral total knee arthroplasty for degenerative joint disease. Bilateral lumbar plexus catheters were placed via the fascia iliaca compartments. Lidocaine was infused postoperative through both catheters, and serum lidocaine levels were followed. The patient received significant postoperative pain relief based on physical and subjective examination. There were no complications or untoward effects related to the technique. Lumbar plexus blockade with continuous local anesthetic infusion via the fascia iliaca compartment is an effective means of providing postoperative analgesia after total knee arthroplasty when epidural analgesia is contraindicated.