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. 2024 Aug 28;32(3):227-232.
doi: 10.4103/jmu.jmu_70_23. eCollection 2024 Jul-Sep.

Dissimilar Planes and Approaches with Common Neural Targets - A Cadaveric Evaluation of Three Different Ultrasound-guided Fascial Plane Blocks for Lumbar Plexus Nerves

Sandeep Diwan  1 , Georg Feigl  2 , S Shivaprakash  3 , Archana Areti  4
Affiliations

Dissimilar Planes and Approaches with Common Neural Targets - A Cadaveric Evaluation of Three Different Ultrasound-guided Fascial Plane Blocks for Lumbar Plexus Nerves

Sandeep Diwan et al. J Med Ultrasound. .

Abstract

Background: The lumbar plexus (LP) is a group of nerves located at the fourth lumbar vertebra level, between the anterior two-thirds and posterior one-thirds of the psoas muscle. In this study, the researchers aimed to investigate the spread of latex in injections of LP, suprainguinal fascia iliaca, and circum-psoas planes to assess the different regional techniques for blocking LP nerves (LPNs).

Methods: The study involved performing ultrasound-guided injections of three different colored latexes in six cadavers. The researchers observed and compared the spread of latex in each plane by taking cross sections at the levels of L4, anterior superior iliac spine (ASIS), and sacral foramina (SF). The spread of latex and LPN staining was documented and analyzed through photography.

Results: The results showed that the latex spread within the psoas muscle and fascia iliaca plane (FIP) during LP injections, whereas suprainguinal fascia iliaca injections showed latex dissemination in the FIP at both ASIS and SF levels. On the other hand, circum-psoas injections spread beneath the iliopsoas fascia at both levels and medially toward the external iliac vessels. Despite this spread, there was no communication between the three planes, and there was no mixing of latex from the different injections at any level.

Conclusion: There are distinct fascial planes, for the three approaches, with no communication between them. While latex diffused from LP plane to FIP, no mixing of dye was observed and also the reverse could not be achieved. These findings suggest that different regional techniques for blocking LPNs have their unique planes of action.

Keywords: Fascial planes block; lumbar plexus nerves block; peripheral nerve block; regional nerve block; ultrasound-guided block.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
The sonoanatomy of the injection plane for the Lumbar plexus block. PMa: Psoas Major muscle, LVB: Lumbar vertebral body, QLM: Quadratus lumborum muscle, I-TP: Inter transverse process view
Figure 2
Figure 2
The sonoanatomy of the injection plane of the suprainguinal facia iliac block. IO: Internal oblique
Figure 3
Figure 3
The sonoanatomy of the injection plane in the circus poses block
Figure 4
Figure 4
Image showing cadaver section at L4 level on the left side following lumbar plexus injection. L4 VB: L4 vertebral body, L4 TP: L4 transverse process alias costal process, LP: Lumbar plexus, LP-I: Lumbar plexus injection, PM A 2/3: Psoas major anterior 2/3, PM P 1/3: Psoas major posterior 1/3
Figure 5
Figure 5
(a) Cross section at level of L4 right sided LP-I (green) and SIFI-I (blue) spread illustrates diffusion in the LP-P and the SIFI-P respectively. Note the thin band of green latex spread medial the LP in the LP-P. Green latex is in close vicinity of the lumbar plexus. (Identified is the blue latex lateral to the psoas muscle which is injected in the SIFI-P). (b) Cross section at level of ASIS right sided CP-I (yellow) and LP-I (green) spread illustrates diffusion in the CP-P. Diffusion occurs beneath the ilio-psoas fascia, medial and reaching the external iliac vessels. It engulfs the GFN, skirts superficial to FN and reaches the site of LFCN. LP: Lumbar plexus, LP-I: Lumbar plexus injection, PM: Psoas major, SIFI: Supra-inguinal fascia iliaca, LP-I: Lumbar plexus injection, CP-I: Circum-psoas injection, FN: Femoral nerve, LST: Lumbosacral trunk
Figure 6
Figure 6
(a) Cross section at level of L4 right sided LP-I (green) and SIFI-I (blue) spread illustrates diffusion in the LP-P and the SIFI-P respectively. Note the posterior to anterior medial to lateral spread inside the psoas muscle. Green latex is in close vicinity and lateral to the LP. (Thick band of blue latex SIFI injection at ASIS spreads cephalad till the L4, is anterior and lateral to the PM. (b) Cross section at level of ASIS right sided CP-I (yellow) and LP-I (green) spread illustrates diffusion in the CP-P. Diffusion occurs beneath the ilio-psoas fascia, medial and reaching the external iliac vessels, it skirts superficial to femoral nerve and reaches the site of lateral femoral cutaneous nerve. LP: Lumbar plexus, LNR: Lumbar nerve root, LP-I: Lumbar plexus injection, PM A 2/3: Psoas major anterior two-thirds, PM P 1/3: Psoas major posterior two-thirds, LA: Lumbar artery, SIFI: Supra-inguinal fascia iliaca, CP-I: Circum-psoas injection, FN: Femoral nerve
Figure 7
Figure 7
Image showing the dye spread following SIFI plane injections. SIFI: Supra-inguinal fascia iliaca, FN: Femoral nerve, LFCN: Lateral femoral cutaneous nerve
Figure 8
Figure 8
Image showing the dye spread following a circum-psoas injection. CP-I: Circum-psoas injection, FN: Femoral nerve, PM: Psoas major, EIV: External iliac vessels, LFCN: Lateral femoral cutaneous nerve, DCIA: Deep circumflex iliac artery
See this image and copyright information in PMC

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