From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon (BF, J-LC, AB, YH, FB, ES), EA 3920 and SFR-FED 4234 INSERM (AB, LT, ES), Department of Anatomy, University Hospital of Besancon, University of Franche Comte, Besancon (LT) and Albert Schweitzer Hospital, Colmar, France (DJ).
Eur J Anaesthesiol. 2014 Jan;31(1):23-9. doi: 10.1097/01.EJA.0000435016.83813.aa.
The femoral nerve lies in the ilio-fascial space in a groove formed by the iliac and psoas muscles (GIPM) posteriorly, and overlaid by the iliac fascia. Recommendations for needle insertion for femoral blockade using ultrasound imaging are to insert the needle tip behind the iliac fascia at the lateral side of the femoral nerve, but this part of the nerve is poorly visualised in some patients. A more accurate location of the lateral part of the femoral nerve might be achieved by identifying the GIPM and its lateral segment.
The objectives of this study are to determine the frequency of ultrasound visibility of the lateral part of the femoral nerve and GIPM, and to note the motor response to electrostimulation of the nerve and the spread of local anaesthetic when positioning the needle tip at the lateral segment of the GIPM.
A prospective observational (case series) study.
Department of Anaesthesiology of a University Hospital.
Inpatients undergoing hip or knee surgery scheduled to have femoral nerve blockade were eligible to participate.
The ultrasound probe was positioned in the inguinal region, and direct ultrasound identification of the femoral nerve, lying on the GIPM behind the iliac fascia, was obtained. A stimulating needle, inserted in-plane and advanced lateral to medial was directed towards the femoral nerve until it made contact with the target structure defined as the lateral segment of the GIPM.
Ultrasound identification of the lateral part of the femoral nerve and GIPM.
An image compatible with the lateral part of the femoral nerve was observed in 91 out of 100 patients. In the remaining nine patients, when the lateral part of the femoral nerve was not seen, GIPM could be visualised in five (55%) patients. The iliac fascia and GIPM were clearly visualised in 68 and 85 patients respectively. In 85 cases when the needle tip was placed at the lateral segment of GIPM, a quadriceps femoris muscle motor response was obtained, and the distribution of the anaesthetic solution was observed behind the iliac fascia in all patients. In two patients, only the iliac fascia was identified, and in the two patients, none of these structures was correctly visualised.
The GIPM was seen in the majority undergoing ultrasound-guided femoral nerve blockade, even when the lateral part of the femoral nerve was not visualised. Using the lateral segment of GIPM as a target for needle tip location in an in-plane lateral to medial approach of the femoral nerve deserves further investigation.
股神经位于髂腰肌筋膜间隙（iliio-fascial space）内，由髂肌和腰大肌（psoas muscles）形成的沟（groove）构成，被髂筋膜（iliac fascia）覆盖。使用超声成像进行股神经阻滞时，推荐将针尖插入髂筋膜外侧的股神经旁，但是在一些患者中，这部分神经的可视性较差。通过识别髂腰肌筋膜间隙及其外侧段，可能更准确地定位股神经的外侧部分。
本研究的目的是确定股神经外侧部分和髂腰肌筋膜间隙的超声可见性频率，并记录在将针尖定位在髂腰肌筋膜间隙外侧段时，电刺激神经引起的运动反应和局部麻醉剂的扩散。
前瞻性观察（病例系列）研究。
大学医院麻醉科。
计划接受股神经阻滞的髋部或膝关节手术的住院患者有资格参加。
将超声探头放置在腹股沟区域，并直接在超声下识别位于髂筋膜后方的股神经，位于髂腰肌筋膜间隙内。插入平面内并向外侧到内侧推进的刺激针，直接指向股神经，直到与目标结构接触，定义为髂腰肌筋膜间隙的外侧段。
股神经外侧部分和髂腰肌筋膜间隙的超声识别。
在 100 名患者中，有 91 名患者观察到符合股神经外侧部分的图像。在其余 9 名患者中，当未观察到股神经外侧部分时，5 名（55%）患者可观察到髂腰肌筋膜间隙。分别有 68 名和 85 名患者清晰地观察到髂筋膜和髂腰肌筋膜间隙。在 85 例将针尖置于髂腰肌筋膜间隙外侧段时，获得股四头肌肌肉运动反应，并且在所有患者中均观察到麻醉剂溶液分布在髂筋膜后方。在 2 名患者中，仅识别出髂筋膜，在这 2 名患者中，均未正确观察到这些结构。
即使未观察到股神经外侧部分，在接受超声引导股神经阻滞的大多数患者中也能观察到髂腰肌筋膜间隙。使用髂腰肌筋膜间隙外侧段作为平面内从外侧到内侧进针的针尖定位目标，值得进一步研究。
