The fascia iliaca is the muscle fascia of the iliacus muscle and is continuous with the fascia of the psoas major muscle. Laterally it is attached to the iliac crest

The femoral as well as the lateral femoral cutaneous nerves are located underneath the fascia iliaca

The idea of the fascia iliaca block is to inject a large volume of local anaesthetic midways between the femoral and lateral femoral cutaneous nerves in order to obtain lateral and medial spread that will cover both nerves

Postoperative analgesia after:

– hip surgery

– anterior thigh surgery

– knee surgery

Only when a femoral nerve block and/or a lateral femoral cutaneous nerve block is not feasible

Place the patient supine

Place the high-frequency linear probe in the femoral crease, lateral to the femoral artery

Identify the femoral artery, the iliopsoas muscle, the fascia iliaca, and the sartorius muscle by sliding lateral (see next page)

Insert the needle from the lateral end of the probe with in-plane technique and pierce the fascia iliaca (usually with a palpable “pop”

Inject local anaesthetic with visible spread between the muscle and the fascia iliaca without resistance and no pain

The needle penetrates the external and internal abdominal obliques and the posterior tail of the transversus abdominis in order to place the needle tip on the anterior side of the aponeurotic posterior extension of the tranverse abdominis that connects to the quadratus lumborum

When local anaesthetic is injected in this position it spreads across the aponeurosis to cover the anterior side of the quadratus lumborum where it blocks the subcostal and iliohypogastric nerves before the lateral cutaneous branches branch off

On the picture on the right the needle (red) is inserted with the needle tip on the deep side of the transverse abdominis muscle (cyan arrows), after piercing the external (white asterix) and internal (yellow asterixs) abdominal oblique muscles

The local anaesthetic (yellow arrow) is deposited between the transverse abdominis muscle and the transversalis fascia (magenta line) which is loosely attached to the muscle

The local anaesthetic spreads across the aponeurosis and covers the deep side of the quadratus lumborum muscle (red asterix), where the subcostal and iliohypogastric nerves run across before the lateral cutaneous branches branch off

The subcostal (SC) and iliohypogastric (IH) nerves originate from the spinal nerve roots of T12 and L1 respectively

They run across the anterior surface of the quadratus lumborum (QL) muscle

They continue laterally and pierce the posterior aponeurotic extension of the transverse abdominis muscle and enter the TAP (transverse abdominis plane = the neurovascular fascial plane between the transverse abdominis and internal abdominal oblique muscles)

The lateral cutaneous branches of the two nerves branch off typically before entering the TAP, and these lateral branches are not covered by a classical TAP block

The lateral cutaneous branches of the two nerves innervate the iliac crest and the skin of the upper thigh between the iliac crest and the greater trochanter

Place the patient supine

Select a high-frequency linear probe or a curved array probe and place it in the axial plane just proximal to the iliac crest

Identify the three layers of abdominal muscles and slide the probe posterior until you can visualize the posterior aponeurotic extension of the transverse abdominis muscle connecting to the quadratus lumborum muscle (see next page)

Insert the needle from the anterior end of the probe with in-plane technique and advance the needle tip to the fascial plane between the transverse abdominis muscle and the transversalis fascia just anterior to the transverse abdominis aponeurosis

Inject 10 mL of local anaesthetic in this location and it will spread across the aponeurosis and anaesthetize the subcostal and iliohypogastric nerves before the lateral cutaneous branches branch off

– Bone graft harvesting from the iliac crest

– Surgical anaesthesia of the region between the iliac crest and the greater
trochanter

Alternative technique: The transmuscular quadratus lumborum block

Dingeman RS, Barus LM, Chung HK, Clendenin DJ, Lee CS, Tracy S, Johnson VM, Dennett KV, Zurakowski D, Chen C: Ultrasonography-guided bilateral rectus sheath block vs. local anesthetic infiltration after pediatric umbilical hernia repair: a prospective randomized clinical trial. JAMA Surg. 148(8): 707-13 (2013)

The needle is advanced to the fascial plane between the muscle fascia of the rectus abdominis and the posterior layer of the rectus sheath (see picture)