Focus on Fascia Iliaca Block for Total Hip Replacement
Dhiraj Jagasia, M.D.
NYU Langone Medical Center
NYU Department of Anesthesiology
New York, New York
The fascia iliaca compartment block (FICB) can be used for analgesia after total hip replacement, as an alternative to a femoral nerve block (FNB), a lumbar plexus (psoas compartment) block, and epidural analgesia. All these techniques, as part of a multimodal analgesic regimen (acetaminophen, NSAIDs, possibly gabapentin or pregabalin), allow reducing the postoperative opioid requirements and the associated side effects.
Dalens initially described the FICB in children in 1990. An injection under the fascia iliaca will reach both the femoral nerve and the lateral femoral cutaneous nerve without any risk of intraneural injection, even in anesthetized patients. Subsequent studies demonstrated a slightly higher rate of blockade of the lateral femoral cutaneous block with the FICB than the FNB. In both cases, the obturator nerve is blocked only inconstantly, unless very high volumes are used. Complications are rare with the FICB and the FNB, especially when ultrasound guidance is used.
The psoas compartment block is very proximal and will reliably reach the obturator nerve in addition to the femoral and lateral femoral cutaneous nerve. However, it is a deep block with a much higher risk of severe complications (peritoneal breach, renal injury, retroperitoneal hematoma, epidural or intrathecal injection.) All these blocks of the lumbar plexus will not block the areas innervated by the sacral plexus, and patients can still complain of posterior pain.
Epidural analgesia is effective, but interferes with postoperative thromboprophylaxis. Moreover, it blocks both lower extremities, will typically require a urinary catheter, and necessitates frequent rate adjustments to avoid hypotension and insufficient analgesia. This explains why it has fallen somewhat out of favor.
Ultrasound image showing relevant anatomy
From Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, McGraw-Hill, 2012.
To perform the fascia iliaca block, a linear array mid-frequency ultrasound probe is placed in a transverse orientation over the inguinal ligament, between the anterior superior iliac spine and the femoral artery. The femoral nerve, artery, and vein are appreciated medially, while the iliopsoas and sartorius muscles are visualized laterally. The probe is then turned 90 degrees (longitudinally) with the left now being cranial. By moving the probe cranially, the edge of the ilium can be seen as a bright white (hyperechoic) line towards the bottom of the ultrasound image. The muscle that is overlying this and descending into the pelvis along with the ilium is the iliacus muscle, covered by its fascia. As the probe is moved further cranially, the fibers of the femoral nerve were seen as bright white bands, while the fascia iliaca can be seen extending from the right of the image overlying the iliacus muscle. This can serve as the point of local anesthetic injection. Typically, for postoperative analgesia, 30mL of 0.2% ropivacaine or of 0.25% bupivacaine will be injected under the fascia iliaca. The spread can be seen in real time.
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