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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?