Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve

• Published in: Journal of clinical anesthesia Vol. 27; no. 8; pp. 652 - 657
• Main Authors: Swenson, Jeffrey D., MD, Davis, Jennifer J., MD, Stream, Joshua O., MD, Crim, Julia R., MD, Burks, Robert T., MD, Greis, Patrick E., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2015; Elsevier Limited
• Subjects: Adolescent; Adult; Anesthesia & Perioperative Care; Anesthetics, Local - administration & dosage; Anesthetics, Local - pharmacokinetics; Anterior Cruciate Ligament Reconstruction - methods; Fascia iliaca block; Female; Femoral Nerve; Humans; Knee; Ligaments; Magnetic Resonance Imaging - methods; Male; Medical research; Methods; Needles; Nerve Block - methods; NMR; Nuclear magnetic resonance; Obturator nerve; Obturator Nerve - metabolism; Pain Medicine; Pain, Postoperative - prevention & control; Patients; Prospective Studies; Three-in-one block; Tissue Distribution; Ultrasonography, Interventional - methods; Young Adult; United States > US; Fascia iliaca block; Three-in-one block; Obturator nerve
• DOI: 10.1016/j.jclinane.2015.07.001
• ISSN: 0952-8180

Abstract Study objective The femoral, lateral femoral cutaneous, and obturator nerves (ONs) can reportedly be blocked using a single-injection deep to the fascia iliaca (FI) at the level of the inguinal ligament. Two commonly used methods (the FI compartment and 3-in-1 blocks) have produced inconsistent results with respect to local anesthetic distribution and effect on the ON. To date, no study of either method has been performed using advanced imaging techniques to document both needle placement and local anesthetic distribution. We report the outcome of a series of 3-in-1 and FI blocks performed using ultrasound to guide needle position and magnetic resonance imaging (MRI) to define local anesthetic distribution. Design Patients were prospectively studied, and images were interpreted using a randomized and blinded protocol. Setting The study was performed in the perioperative area of an academic orthopedic specialty hospital. Patients Ten patients (ASA 1-2) having anterior cruciate ligament reconstruction received either 3-in-1 or FI compartment blocks for postoperative analgesia using the surface landmarks described for these techniques. Interventions Ultrasound was used to position the injecting needle immediately deep to the FI. Local anesthetic distribution was studied using MRI. Measurements Patients were examined for motor and/or sensory function of the femoral, obturator, and lateral femoral cutaneous nerves. Magnetic resonance imaging was used to document the limits of injectate distribution. Main results Magnetic resonance imaging showed distribution of injectate over the surface of the iliacus and psoas muscles to the level of the retroperitoneum. No patient showed medial extension of injectate to the ON. At the level of the inguinal ligament, injectate extended laterally toward the anterior superior iliac spine and medially to the femoral vein. All patients had significant weakness with extension of the knee and sensory loss over the anterior, lateral, and medial thigh. No patient demonstrated decreased hip adductor strength. Conclusions Ultrasound and MRI show consistent superior extension of local anesthetic to the level of the retroperitoneum for both techniques. There was reliable clinical effect on the femoral and lateral femoral cutaneous nerves. However, none of the injections produced evidence of ON block either at the level of the retroperitoneum or the inguinal ligament.