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BLOCK AT A GLANCE

Block of the nerves of the lumbar plexus under the fascia iliaca at the level of the inguinal ligament (femoral and lateral femoral cutaneous nerves).

  • Indications: Analgesia for hip and femur fractures, analgesia after hip and knee surgery, and procedures on the anterior thigh

  • Goal: Medial, lateral, and cranial spread of local anesthetic (LA) under the fascia iliaca

  • Local anesthetic volume: 20 to 40 mL

GENERAL CONSIDERATIONS

The fascia iliaca block, also called the fascia iliaca compartment block, is a well-established alternative to lumbar plexus or femoral nerve blocks to provide analgesia for hip procedures. Its effectiveness in the preoperative pain management of hip fracture patients has been well-documented, prompting several societies and institutions to recommend its use as part of the routine multimodal analgesic protocols for this indication.

The analgesic efficacy of this technique assumes that injection of the LA beneath the fascia iliaca spreads underneath the fascia and reaches the femoral, lateral femoral cutaneous, and (eventually) the obturator nerve proximally, although an obturator nerve block is not consistent. This block has been performed for decades using landmarks and loss-of-resistance technique; however, with the introduction of ultrasound (US), it became apparent that many of these “blind” injections do not occur in the proper plane. The fascia iliaca block has evolved from the infrainguinal “classic” approach to a suprainguinal technique with the aim to spread the LA injection cranially, more consistently reaching the lumbar plexus, and resulting in analgesic efficacy superior to the infrainguinal approach.

Limitations

Although the spread of LA toward the femoral nerve can be confirmed by US, the extent of the LA proximal toward the lumbar plexus cannot be monitored or ensured. Because the spread cannot be entirely controlled, this technique is primarily used for analgesia, not anesthesia.

Specific Risks

Overall complications involving the fascia iliaca compartment block are low. Being considered a fascial plane technique, intravascular injections or neurologic injury are uncommon as the injection site is remote from the major neurovascular structures. The most commonly reported complications include hematomas at the injection point and local anesthetic systemic toxicity (LAST). The plasma levels after an injection of 30 mL of 0.25% levobupivacaine are below the toxic threshold, even in elderly patients, who are the most common beneficiaries of the technique. However, pneumoperitoneum and bladder puncture have been reported.

ANATOMY

The fascia iliaca covers the iliacus muscle throughout its descent from the pelvic crest into the upper thigh and merges medially with the fascia overlying the psoas muscle. The femoral nerve (L2-L4) and the lateral femoral cutaneous nerve (L2-L3) emerge from the lateral border of the psoas major muscle and travel under the fascia iliaca over the ventral surface of the iliacus muscle in their intrapelvic and inguinal course (Figure 22-1). As ...

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