Psoas Compartment Block: Ultrasound-Guided Technique

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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Stephen Mannion, MRCPI, FCARSCI Stephen Mannion, MRCPI, FCARSCI

Consultant Anaesthetist
Department of Anaesthesia
South Infirmary-Victoria University Hospital
Cork, Ireland
| Dominic Harmon, MB, MSc, MD, FCARCSI Dominic Harmon, MB, MSc, MD, FCARCSI

Professor, Anaesthesia and Pain Medicine
Department of Anaesthesia and Pain Management
Mid-Western Regional Hospital University of Limerick
Limerick, Ireland
| Henry P. Frizelle, MB, MD, FFARCSI Henry P. Frizelle, MB, MD, FFARCSI

Consultant Anaesthetist
Department of Anaesthesia and Intensive Care
Mater Misericordiae University Hospital
Dublin, Ireland
| Acknowledgements Acknowledgements

VIDEO EDITOR
Jeremy D. Kukafka, MD
Faculty
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Infraclavicular Nerve Block: Ultrasound-Guided Technique
Intercostal Nerve Block: Ultrasound-Guided Technique
Intraoperative Transesophageal Echocardiography
Psoas Compartment Block: Ultrasound-Guided Technique
Supraclavicular Nerve Block: Ultrasound-Guided Technique


MEDICAL WRITER
Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

MEDICAL AND VIDEO EDITOR AND SUBJECT MATTER EXPERT
Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

VIDEO COORDINATOR
Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

PRE-PROCEDURE
INDICATIONS
  • Surgery of the lower limb (must be combined with sciatic nerve block)
    • May be used in patients when neuraxial blockade is contraindicated
    • Provides unilateral lower extremity block and can avoid sympathectomy associated with neuraxial blockade
    • Particularly effective in hip and knee surgery
  • Postoperative analgesia for the lower limb
  • Palliative management of pain related to malignant disease
CONTRAINDICATIONS

Absolute contraindications

  • Patient refusal
  • Allergy to local anesthetics
  • Infection at or near the needle insertion site

Relative contraindications

These may be overlooked in cases in which the benefits of analgesia via a psoas compartment block outweigh the risks associated with its placement and use.

  • Uncooperative patient
  • Coagulopathy or medical anticoagulation
  • Traumatic nerve injury in the lower extremity
  • Preexisting neurodeficits in the distribution of the block
  • Previous surgery in the back that may distort lumbar plexus anatomy
EQUIPMENT
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, typically:
    • 2% lidocaine
    • 1.5% mepivacaine
    • 0.5% bupivacaine
    • 0.5-0.75% ropivacaine
  • Sterile gloves and mask
  • Sterile fenestrated drape or sterile towels for draping
  • Sterile prep solution
  • One 20- or 30-mL syringe; alternatively, two 20-mL syringes filled with local anesthetic and attached to a 3-way stopcock and via extension tubing to a nerve stimulator needle
  • A 5-mL sterile syringe and small gauge (25- or 30-gauge) needle for local anesthetic infiltration of the skin
  • IV extension tubing
  • Peripheral nerve stimulator and ECG electrode
  • 10-cm, 25-gauge short-bevel insulated nerve-stimulating needle
  • Ultrasound (US) machine and transducer
  • Sterile ultrasound gel
ANATOMY

The lumbar plexus is formed from five lumbar nerve roots on each side, emerging from the L1-2 interspace through the L5-S1 interspace. The L2-4 nerve roots exit the intervertebral foramina and become embedded in the psoas major muscle, which is attached to the lateral surfaces and transverse processes of the lumbar vertebrae. Within the body of the muscle, these nerve roots split into anterior and posterior divisions, which then reunite to form individual peripheral nerves of the lumbar plexus. The most important of these are the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve. In addition, the lumbar plexus gives rise to the genitofemoral nerve. The femoral and lateral femoral cutaneous nerves run in a fascial sleeve that divides the psoas into an anterior part, which includes two thirds of the muscle mass, and a posterior part consisting of the remaining third of the muscle mass. The obturator nerve can lie within this plane but is actually outside the fascial sleeve and contained in the substance of the psoas muscle itself in about 40%-50% of cases.


The femoral nerve supplies motor fibers to the quadriceps muscle, skin of the anteromedial thigh, and medial aspect of the leg below the knee and foot. See Femoral Nerve Block for more details. The lateral femoral cutaneous nerve is a purely cutaneous nerve, supplying the lateral aspect of the hip and thigh, down to the knee. The obturator nerve supplies motor branches to the adductors of the hip and supplies cutaneous innervation in a highly variable distribution on the medial thigh and around the knee joint. The genitofemoral nerve supplies the cremaster muscle and cutaneous innervation of the scrotal skin in males and supplies cutaneous innervation to the mons pubis and labia majora in females. A small femoral branch of the genitofemoral nerve also supplies innervation to the skin anterior to the upper part of the femoral triangle.


Other important structures include the kidney, which lies just anterior and lateral to the psoas muscle, the renal artery and vein; the inferior vena cava, which lies anterior and slightly medial on the right side; and the abdominal aorta, which is anterior and medial on the left.


Surface landmarks for psoas compartment include the iliac crest and spinous processes in the midline of the back. Ultrasound visualization of the psoas muscle in adults requires a low-frequency transducer (5-8 MHz) to reach a depth of 5-8 cm. Higher frequency transducers may be used in children.


PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Continue to monitor all vital signs, carefully observing for signs and symptoms of local anesthetic toxicity.
  • Spread of the local anesthetic to the epidural space can cause epidural blockade and lead to significant hypotension, and can occur in up to 40% of patients. Patients should therefore be monitored after the procedure as for epidural block.
  • Patients may have these procedures as same-day admits or in day surgery; counsel patients about appropriate expected duration of block and adjunct pain medication to ensure optimization of pain control.
  • Patients should be cautioned to stand and walk only with assistance until the block is completely gone to avoid falls; when prolonged block is expected, crutches should be advised until the block wears off.
COMPLICATIONS
  • Infection
  • Hematoma
  • Vascular puncture
  • Local anesthetic toxicity, either due to direct intravascular injection or delayed absorption of local anesthetic
  • Nerve injury due to intraneural injection
  • Epidural or spinal block due to spread of anesthetic along dural sleeves
  • Hypotension due to epidural or spinal spread; lumbar plexus block can lead to unilateral sympathectomy, but this rarely causes significant hypotension
  • Unintended trauma to adjacent structures, such as kidney, renal arteries and veins, inferior vena cava, and aorta
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