Download Lumbar Plexus Blocks-the anterior approaches

Anterior approaches of the
Lumbar Plexus
Matthias Desmet
az|groeninge
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.
Innervation of the hip?
Anterior
Posterior
Femoral N.
Sciatic N.
Lateral-Anterior
Superior
Superior Gluteal N.
Obturator N.
Lateral
Medial
N. to Quadratus Femoris
Inferior
Birnbaum et al. Surg Rad Anat 1997
Aiming at the lumbar plexus…
Posterior approaches:
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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
Posterior Approaches of the Lumbar Plexus.
• Landmark based or Ultrasound Guided
• Technically challenging
• Major Adverse Effects:
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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
Anterior approach of the lumbar plexus
Winnie et al Anesth Analg 1973
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
The fascia iliaca compartment block
1989
Dalens et al. Anesth Analg 1989
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
Hip Fractures?
Clinical utility of FICB?
• Reduction in pain scores at rest and
on mobilisation
• Reduction in analgesic consumption
• Decreased incidence of postoperative
complications
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
Newman et al. Anesthesia 2013
Longitudinal supra-inguinal FICB?
• Cadaver study.
• MRI Study in volunteers.
• Clinical trial assessing the clinical utility.
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
Cryogenic preservation
technique:
Spread posterior of psoas
muscle.
MRI study on volunteers
• 10 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
Transverse FICB
Longitudinal suprainguinal FICB
Longitudinal suprainguinal FICB
Transverse FICB
L4
Transverse FICB
Longitudinal suprainguinal FICB
• Randomized controlled, double blinded trial.
• 88 patients, for anterior approach THA under GA.
• Longitudinal Supra-Inguinal Fascia Compartment Block vs Control
Results: Morphine consumption.
45% morphine reduction at 48 hours
Results: Pain scores
Results: Sensory and Motor Evaluation
Results: Safety?
Total Ropivacaine Levels
<4.3mg/L
Free Ropivacaine Levels
<0.56mg/L
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.
A Big Thank You!!!