Lumbar Plexus Posterior Approach: A Catheter Placement Description Using Electrical Nerve Stimulation

Abstract

The authors describe a modified technique of posterior approach to the lumbar plexus in the psoas compartment which allows nerve stimulation for the location of the plexus and catheter placement for extended-duration surgery and postoperative patient-controlled regional analgesia. A frequent incidence of total lumbar plexus block was observed.

Lower-extremity peripheral nerve blockade: Essentials of our current understanding

“…Continuous techniques have been described to provide analgesia after a variety of operations including THA, TKA, open reduction and internal fixation of acetabular fractures, open reduction and internal fixation of femur fractures, and anterior cruciate ligament reconstruction. 2,17,18,31,32 Interest in this block developed as practitioners sought alternatives to neuraxial techniques that could provide consistent analgesia after hip, femur, and knee surgery. One theoretical advantage of psoas compartment block over other continuous approaches to the lumbar plexus is the decreased likelihood of catheter dislodgement because of the large muscle mass that must be traversed to reach the lumbar plexus.…”

“…They failed to place a catheter in only 3% of their patients and reported a high success rate (100% femoral, 93% obturator, 91% lateral femoral cutaneous) bolusing through a nonstimulating catheter. 32 Femoral Nerve Block. Indications for singleinjection femoral nerve block include anesthesia for knee arthroscopy in combination with intra-articular local anesthesia and analgesia for femoral shaft fractures, anterior cruciate ligament reconstruction (ACL), and TKA as a part of multimodal regimens.…”

A plantar flexion response to nerve stimulation indicates needle misplacement in the epidural/spinal space during psoas compartment block

“…Therefore, the possibility of central injection must always be considered when attempting lumbar plexus block. To avoid accidental central blocks, strict precautions are necessary, such as approach in the sagittal plane, and 3-5 cm lateral to the interspinous line [6,7]. However, these precautionary measures may not always be feasible.…”

“…In fact, such a deviation cannot be excluded. This misplacement may be more likely with the more medial approach described by Pandin et al [6], used in the present surgeries, than by the approach described by Chayen et al [7]. In the method of Pandin et al, the puncture site is located 3 cm lateral to the interspinous line, 1 to 2 cm medial to the approach described by Chayen et al In addition, in our case 2, the needle may have been advanced too far after contact with the transverse process of the lumbar vertebra (3 cm); 2 cm is advocated to prevent misplacement [3].…”

“…midazolam, the patient was placed in the right lateral decubitus position. The insertion site was identifi ed 3 cm below the intercrestal line and 3 cm lateral to the interspinous line, as described by Pandin et al [6]. After disinfection and local skin infi ltration, a 100-mm-long 22-gauge insulated needle (Stimuplex D; B. Braun, Melsungen, Germany) was inserted perpendicular to all planes, using a peripheral nerve stimulator.…”