1. Anterior approaches of the Lumbar Plexus
Matthias Desmet
az|groeninge

2. Anatomy of the Lumbar plexus
Lumbar plexus (L1-L4):
Ilio-hypogastric n.
Ilio-inguinal n.
Genitofemoral n.
Femoral n.
Lateral femoral cutaneous n.
Obturator n.

3. Innervation of the hip? Anterior Posterior Femoral N. Obturator N.
Lateral-Anterior
Obturator N.
Medial
Posterior
Sciatic N.
Superior
Superior Gluteal N.
Lateral
N. to Quadratus Femoris
Inferior
Birnbaum et al. Surg Rad Anat 1997

4. Aiming at the lumbar plexus…
Posterior approaches:
L4 approach by Capdevilla
L4-L5 approach by Winnie
L4-L5 approach by Chayen
L3 approach by Parkinson
Shamrock approach by Sauter
USG approach by Karmaker
Awad et al. RAPM 2005
Sauter et al. EJA 2015
Karmaker et al. RAPM 2015

5. Posterior Approaches of the Lumbar Plexus.
Landmark based or Ultrasound Guided
Technically challenging
Major Adverse Effects:
Epidural spread: 1-16%
Spinal Injection
Intravascular Injection
Infection
Hematoma incl. subcapsular renal hematoma
Awad et al. RAPM 2005
Sauter et al. EJA 2015
Karmaker et al. RAPM 2015

6. Anterior approach of the lumbar plexus
Winnie et al Anesth Analg 1973

8. CONCLUSION:
No involvement of the proximal and posterior portions of the obturator nerve was observed, nor was there any cephalad spread that could have resulted in a lumbar plexus blockade.
Marhofer P et al. Anesth Analg 2000

9. The fascia iliaca compartment block
1989
Dalens et al. Anesth Analg 1989

10. Despite considerable cephalad spread, there was no extension of injectate into the tissue plane reaching the ON in any patient.
Adductor strength of the femur at the hip was normal (5/5) in all patients.
Thus, none of the 10 patients manifested objective evidence for ON block.
Swenson et al. J Clin Anesth 2015

11. Hip Fractures?

12. Clinical utility of FICB?
Reduction in pain scores at rest and on mobilisation
Reduction in analgesic consumption
Decreased incidence of postoperative complications
Difficult to interpret the literature: different patient populations, different types of surgery different FICB approaches.

13. All but one study reported decreased rescue analgesia requirements.
All studies reported reductions in pain intensity with femoral nerve blocks.
All but one study reported decreased rescue analgesia requirements.
Two studies found a decreased risk of adverse events such as respiratory and cardiac complications.
Riddell et al. CJEM 2016

14. Newman et al. Anesthesia 2013
Levobupi 20-30ml depending on weight
Newman et al. Anesthesia 2013

15. This one of the most recent articles on FICB

20. Longitudinal supra-inguinal FICB?
Cadaver study.
MRI Study in volunteers.
Clinical trial assessing the clinical utility.

21. Cadaver study: Step up technique with different volumes of dye.
20-30 mL: inconsistent spread of dye, no involvement of ON.
40-50 mL: consistent spread of dye, involvement of ON.
Vermeylen et al. unpublished data

22. Cryogenic preservation technique:
Spread posterior of psoas muscle.

23. MRI study on volunteers
Bilateral FICB: classical versus longitudinal supra-inguinal approach.
MR imaging to assess spread of 40ml LA.
Data analysis ongoing
Vermeylen K, Desmet M et al. Unpublished data

24. Longitudinal supra-inguinal FICB
Transverse FICB

25. Longitudinal supra-inguinal FICB Transverse FICB

26. Longitudinal supra-inguinal FICB
Transverse FICB

27. Randomized controlled, double blinded trial.
88 patients, for anterior approach THA under GA.
Longitudinal Supra-Inguinal Fascia Compartment Block vs Control

28. Results: Morphine consumption.
45% morphine reduction at 48 hours
48 hours Morphine consumption:
12.66 (2.4) mg vs (2.8) mg

29. Results: Pain scores

30. Results: Sensory and Motor Evaluation
69% of patients had a block of all three nerves

31. Results: Safety? Total Ropivacaine Levels <4.3mg/L
Free Ropivacaine Levels <0.56mg/L
4.3 and 0.56mg/L -> in none of the patients these levels were reached

32. Conclusions:
Longitudinal supra-inguinal FICB is a promising approach of the LP.
Easy to perform with a high succes rate.
Safe in terms of LA toxicity.
More research needed.

33. A Big Thank You!!!