Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession

Vol 4 | Issue 2 | July-December 2023 | Page 27-28 | Sandeep Diwan, Georg Feigl, Shivaprakash S

DOI: https://doi.org/10.13107/ijra.2023.v04i02.080


Authors: Sandeep Diwan [1], Georg Feigl [2], Shivaprakash S [3]

[1] Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.
[2] Department of Anatomy and Clinical Morphology, Witten / Herdecke University, Witten, Germany.
[3] Department of Anatomy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka State, India..

Address of Correspondence
Dr. Sandeep Diwan,
Department of Anaesthesia, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India.
E-mail: sdiwan14@gmail.com


To the Editor,

Anatomic block efficacy of lumbar plexus elements is based upon the involvement of the obturator nerve. However, despite the anatomic location of the obturator nerve and improbable translocation of local anesthetic beyond the confinement of the fascia iliacus plane [1], investigators struggle to study extensively, exhaustively, and try to explicitly describe the means and mechanism to block the obturator nerve [2].
Our anatomical dissections reveal three important dissimilar fascial planes (figure 1a). The quadratus lumborum, the fascia iliaca, and the circum-psoas planes are isolated from each other with tight fascial attachments [Figure 1b], impeding the dissemination of local anaesthetic agents unless inadvertently perforating the fascia. Further exploration revealed the femoral, lateral femoral cutaneous, obturator nerves and the lumbosacral trunk emerge from the lateral and medial of the psoas muscle respectively, and exits the psoas fascia (figure 1a,1b, and 1c) to take their respective course. The obturator nerve might further arise in a separate muscular fold (Figure 1c).
However, if the obturator nerve needs to be blocked, two we recommend two alternatives; We presume that with injections deep to the psoas sheath, the plausibility of involvement of all the nerves of the lumbar plexus (lateral femoral cutaneous nerve, femoral nerve, and ON) exists, as reported in a case series [3] and the obturator nerve needs to be blocked separately after a supra-inguinal fascia iliaca block.


References


1. Bendtsen TF, Pedersen EM, Moriggl B, et al. Anatomical considerations for obturator nerve block with fascia iliaca compartment block. Reg Anesth Pain Med. 2021; 46:806-12.
2. Swenson JD, Davis JJ, Stream JO, Crim JR, Burks RT, Greis PE. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. J Clin Anesth. 2015; 27:652-7.
3. Diwan S, Nair A, Gawai N, Shah D, Sancheti P. Circumpsoas block – an anterior myofascial plane block for lumbar plexus elements: case report. Braz J Anesthesiol. 2021: S0104-0014(21)00180-9.


How to Cite this Article:   Diwan S, Feigl G, S Shivaprakash | Supra-inguinal Fascia Iliaca Block and the Obturator Nerve Obsession | International Journal of Regional Anaesthesia | July-December 2023; 4(2): 27-28 | DOI: https://doi.org/10.13107/ijra.2023.v04i02.080


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