Anatomy and principles of the fascia iliaca block Dr Ganesh Kumar 23 rd 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? 1
Sensory innervation of the hip 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. 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), 2
The sensory innervation of the hip joint - An anatomical study. K. Birnbaum Surg Radiol Anat (I997) 19:371-375 There are 2 groups of sensory nerves to hip from the ant and post compartments originating respectively from the lumbar and sacral plexuses 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. 3
Lumbar plexus Anterior sensory innervations: Femoral nerve (nerve to rectus femoris): anterolateral hip joint Obturator nerve: anterior medial Options for analgesia Neuraxial Lumbosacral plexus Peripheral nerves: All 4 major nerves not a realistic option Femoral nerve blocks used since 1970s to relieve fractured hip pain 4
Femoral nerve blocks versus standard care Also 2010 Cochrane review Parker et al Obturator nerve and hip analgesia 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 5
Obturator nerve and hip analgesia 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 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 6
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 FNB Advantages: Safe Easy Quick to do More extensive (LCNT) Catheters Risks: l Requires meticulous technique to be reliable 7
FNB v. FIB: FIB does not always do well REVIEW } 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 - 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 8
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. 9
Conclusion } 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 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 10
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. 11
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 12
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. How to do your FIB? } Landmark Ultrasound } Single shot Catheter } Boluses Infusion 13
Fascia iliaca block landmark technique Fascia iliaca block landmark technique Copyright C Egeler 14
The Procedure Identify landmarks ASIS Pubic tubercle divide the line in thirds Junction of middle and lateral thirds ASIS nerve artery 15
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 16
Fascia iliaca block: ultrasound guided Fascia iliaca block: ultrasound guided Aim: Increase success rate Improve accuracy Reduce complications Availability of US scanners Development of block areas 17
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 18
Femoral Nerve Block - USS Lateral Medial Femoral Nerve Block - USS Lateral Medial 19
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 20
Principles of the supra inguinal fascia iliaca block 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 Supra inguinal fascia iliaca block (In plane parasagittal) Probe on ASIS in parasagittal plane. Move medially and caudally keeping ilium in picture. 21
Iliopsoas muscle immediately above ilium. Fascia iliaca below internal oblique, inguinal ligament and sartorius complex Supra inguinal fascia iliaca block 22
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 23
Questions? 24