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Anatomy and principles of the fascia iliaca block

Dr Ganesh Kumar23rd November 2016

Courtesy Dr Fred Sage

Objectives

• Why do peripheral nerves blocks work?

• Why choose FIB over FNB?

• How does it work?

• How to do it?

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• The hip joint has a complex and still poorly understood innervation

• Hilton’s Law (1860): “the nerve supplying the muscles extending directly across and acting at a given joint also innervate the joint.”

Hilton's law revisited Hebert-Blouin Clin anat 2014 May;27(4):548-55.

Sensory innervation of the hip

Hip Superior Gluteal nn(TFL), Inferior Gluteal nn(Gluteus Maximus), N to Piriformis(Piriformis), N to obturator Internus and superior gemellus(same mm), N to quadratus femoris and inferior gemellus(Same mm), obturator nn(Add Magnus), Sciatic tibial nn(SemiTendinosis), Femoral nn(rectus Femoris), T12-L2 Spinal nn's(psoas maj/min),

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There are 2 groups of sensory nerves to hip from the ant and post compartments originating respectively from the lumbar and sacral plexuses

The sensory innervation of the hip joint - An anatomical study. K. Birnbaum Surg Radiol Anat (I997) 19:371-375

Sacral plexus

Posterior sensory innervations:

Nerve to quadratus femoris with contribution from sciatic nerve : superior and inferior section of hip joint

Superior gluteal nerve: posterolateral part of joint.

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Lumbar plexus

Anterior sensory innervations:

Femoral nerve (nerve to rectus femoris): anterolateral hip joint

Obturator nerve: anterior medial

Neuraxial

Lumbosacral plexus

Peripheral nerves: All 4 major nerves not a realistic option

Femoral nerve blocks used since 1970s to relieve fractured hip pain

Options for analgesia

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Also 2010 Cochrane review Parker et al

Femoral nerve blocks versus standard care

Comparison of the Three-in-One and Fascia lliaca compartment Blocks in Adults: Clinical and Radiographic Analysis

Capdevila X Anest Analg 1998;86:1039-44

An Evaluation of the Cutaneous Distribution After Obturator Nerve Block

Bouaziz H, Anesth Analg 2002;94:445–9

Obturator nerve and hip analgesia

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Ultrasound Guided Fascia Iliaca Block: A Comparison With the Loss of Resistance Technique

Dolan et al RAPM 2008; 33: 526-531

Does Fascia Iliaca Block Result in Obturator Block?

Robert S. Weller, MD, RAPM 2009; 34: 524

Obturator nerve and hip analgesia

In conclusion

re anatomical evidence of peripheral nerve blockade for hip analgesia

The femoral nerve is the main contributor in the ant compartment.

The obturator nerve has a smaller role

Blockade of the obturator nerve with a 3in1 technique or FICB is highly unlikely

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Why do a FIB over a FNB

Femoral nerve block is:

• A targeted injection

• Single nerve injection

It is limited by:

• Technical skills required

• High complication risk

Why do a FIB over a FNB

A FICB can be considered as a low risk FNBAdvantages:

• Safe

• Easy

• Quick to do

• More extensive (LCNT)

• Catheters Risks: l Requires meticulous technique to be reliable

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} A comparison of pre-operative nerve stimulator-guided femoral

nerve block and fascia iliaca compartment block in patients with a

femoral neck fracture : B. Newman, L. McCarthy, P. W. Thomas, P. May, M. Layzell and K. Horn: Anaesthesia 2013, 68, 899–903

110 patients

FNB by PNS v. FIB by landmarks

30 mls of 0.5 % levobupivicaine

Ø Reduction in VAS score 3.8 ( FNB ) v. 2.7 ( FIB ) p 0.047

Ø Reduction in morphine consumption FNB > FIB p 0.041

Ø Foss NB anesthesiology 2007 106 773-8

Ø High failure rate of FIB lmk technique

FNB v. FIB: FIB does not always do well REVIEW

- Pre-operative fascia iliaca block for fractured neck of femur and its effect on pre-operative analgesia consumption M. Chereshneva, Anaesthesia, 2011, 66, pages 405–406

Why do a FIB over a FNB

Logistics and organisational factors

• Reliable and comprehensive service is work intensive

• Staff training affected by high staff turnover and limited expertise (trainees)

• FICB is a relatively simple and cheap technique

• AAGBI 2013 position statement on FIB and non-physician practitioners

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AAGBI 2013 position statement

Regional anaesthesia UK (RA-UK) defines regional anaesthesia techniques as those that place local anaesthetic “around the major plexuses or identifiable peripheral nerve trunks”, and asserts that only appropriately trained physicians should perform these techniques (2010).

AAGBI 2013 position statement

Ideally, appropriately trained physicians should perform fascia iliaca blocks but, in many circumstances, they are not immediately available to administer the blocks.

Other registered health professionals who have received appropriate training and are following agreed clinical governance procedures may perform these blocks.

This extended role of non-medically qualified personnel should be closely monitored by the hospital’s Department of Anaesthesia, and such practices should be subject to regular audit and review.

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} ‘fascia iliaca compartment block is quicker to teach, easier to learn, and is cheaper and quicker to perform’

} ‘A much wider range of personnel could be trained to administer the block using this technique with many more patients benefiting’

Conclusion

Fascia iliaca compartment block

First described by Dalens in children in 1989

Compartment block in space posterior to fascia iliaca and covering iliacus muscle

Anesth Analg 1989;69:705-713

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Fascia iliaca compartment block

Allows block of femoral nerve and lateral cutaneous nerve of thigh.

Single shot injection or continuous infusion via catheter.

Femoral nerve anatomy

Pelvic route:

Emerges from lateral aspect of PSOAS muscle.

Runs in pelvis over iliacus & under fascia iliaca.

Enters the leg passing under inguinal ligament.

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Femoral nerve anatomy

Femoral nerve in upper thigh

Lateral to the femoral vessels and separated by fascia iliaca (iliopectineal arch)

Nerve is posterior to fascia iliaca and anterior to iliopsoas muscle.

Femoral nerve anatomy

Rapidly divides into a number of anterior and posterior branches after entering the thigh.

Branches to the knee and leg are posterior and include nerves to quadriceps: patellar twitch. Articular branch to hip via nerve to rectus femoris (Gray)

Anterior branches are proximal sensory. Also include nerve to Sartorius muscle

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Fascia iliaca anatomy

Anatomical relations:

In the pelvis: iliac crest lateral, linea terminalis medial.

Inguinal ligament lateral to femoral vessels and iliiopectineal fascia medial and posterior.

Merges with fascia lata in the thigh.

} Landmark Ultrasound

} Single shot Catheter

} Boluses Infusion

How to do your FIB ?

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Fascia iliaca block landmark technique

Fascia iliaca block landmark technique

Copyright C Egeler

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The Procedure

Identify landmarks

ASIS

Pubic tubercle

divide the line in thirds

Junction of middle and

lateral thirds

ASIS

artery

nerve

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FIB landmarks

Landmark FIB ward based

Epidural needle in parasagittal plane

Clicks on passing through fascia lata and fascia iliaca

Injection of 30 mls 0.25% Levobupivacaine

Epidural catheter advanced 10 cm

Landmark technique

Issues:Correct identification of injection point. Main risk too low and into sartorius.

Accurate positioning below FI: thin layer.

Sustaining training and level of competence.

High failure rate

Above ligament landmark technique

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. Stevens M et al Anaesth Intensive care 2007 Dec;35(6):949-52

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Fascia iliaca block: ultrasound guided

Aim: • Increase success rate

• Improve accuracy

• Reduce complications

• Availability of US scanners

• Development of block areas

Fascia iliaca block: ultrasound guided

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US guided nerve block

In plane/ out of plane

OOP: easier threading of catheter, familiar approach, shorter needle travel.

IP: needle visualisation and control, accurate positioning below fascia

iliaca.

Fascia iliaca block: In plane transverse view

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Lateral Medial

Femoral Nerve Block - USS

Lateral Medial

Femoral Nerve Block - USS

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Fascia iliaca block: In plane transverse view

Probe in transverse position just below inguinal ligament

Iliopsoas muscle in centre of screen

FA and nerve on margin of screen

Problems:

Injection not directed towards pelvis.

Potential difficulties in threading catheter.

Shariat et al Fascia lliaca Block for Analgesia After Hip Arthroplasty. A Randomized Double-blind, Placebo-controlled Trial. RAPM 2013;38: 201-205)

SUPRA INGUINAL FASCIA ILIACA BLOCK (IN PLANE PARASAGITTAL)

ULTRASOUND-GUIDED SUPRA-INGUINAL FASCIA ILIACA BLOCK: A CADAVERIC EVALUATION OF A NOVEL APPROACH. HEBBARD ET AL ANAESTHESIA, 2011, 66, PAGES 300–305

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A supra-inguinal ultrasound-guided technique that places local anaesthetic directly into the iliac fossa.

The probe is placed over the inguinal ligament, close to the anterior superior iliac spine, and orientated in the para-sagittal plane.

Ultrasound-guided supra-inguinal fascia iliaca block: a cadaveric evaluation of a novel approach. Hebbard et al Anaesthesia, 2011, 66, pages 300–305

Principles of the supra inguinal fascia iliaca block

Supra inguinal fascia iliaca block (In plane parasagittal)

Probe on ASIS in parasagittal plane.Move medially and caudally keeping ilium in picture.

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Iliopsoas muscle immediately above ilium.Fascia iliaca below internal oblique, inguinalligament and sartorius complex

Supra inguinal fascia iliaca block

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Fascia iliaca tips

Injection point just below inguinal ligament: risk of injecting within sartorius if too low.

Tilt probe aiming laterally as fascia iliaca is anisotropic.

Fluid diffuses cranially below inguinal ligament within pelvis.

Check presence of LA around femoral nerve in pelvis.

Obturator nerve not usually blocked.

In conclusion

FICB as a way of blocking the FN is effective, safe, easy to use, cheap and a non anaesthetic technique.

There is not enough data to say whether the obturator nerve is a major contributor to fract nof pain.

FICB can be used in different settings effectively to initiate hip analgesia without recourse to opiates

The landmark approach as described by Dalens is effective if done well

The new USG technique of parasagittal suprainguinal injection should increase efficacy and success rate

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Questions?