This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (39) Citing Articles via Google Scholar Google Scholar Articles by Marhofer, P. Articles by Kapral, S. Search for Related Content PubMed PubMed Citation Articles by Marhofer, P. Articles by Kapral, S.

---

REGIONAL ANESTHESIA AND PAIN MANAGEMENT

Magnetic Resonance Imaging of the Distribution of Local Anesthetic During the Three-In-One Block

Peter Marhofer, MD^*, Christian Nael, MD, Christian Sitzwohl, MD^*, and Stephan Kapral, MD^*

Departments of *Anesthesiology and Intensive Care Medicine and Radiology, University of Vienna Medical School, Vienna, Austria

Address correspondence and reprint requests to Peter Marhofer, MD, Department of Anesthesiology and Intensive Care Medicine, University of Vienna Medical School, Waehringer Guertel 18-20, A-1090 Vienna, Austria. Address e-mail to peter.marhofer{at}univie.ac.at

The three-in-one technique of simultaneously blocking the femoral, the lateral femoral cutaneous (LFC), and the obturator nerves by a single injection of a local anesthetic was first described in 1973, and it was suggested that the underlying mechanism was one of cephalad spread resulting in a blockade of the lumbar plexus. Today, the technique is widely used in surgery and pain management of the lower limb. Many investigators have, however, reported suboptimal analgesia levels, particularly in the obturator nerve. The purpose of this prospective study was to trace the distribution of a local anesthetic during a three-in-one block by means of magnetic resonance imaging (MRI). Seven patients scheduled for surgery of the lower limb were analyzed with the aid of a primary MRI and then received three-in-one blocks using 30 mL of bupivacaine 0.5% under the guidance of a nerve stimulator. A secondary MRI was performed to determine the distribution pattern of the local anesthetic. It emerged that the local anesthetic blocks the femoral nerve directly, the LFC nerve through lateral spread, and the anterior branch of the obturator nerve by slightly spreading in a medial direction. No involvement of the proximal and posterior portions of the obturator nerve was observed, nor was there any cephalad spread that could have resulted in a lumbar plexus blockade. We therefore conclude that the basis of the three-in-one block is confined to lateral, medial, and caudal spread of the local anesthetic, which effectively blocks the femoral and LFC nerves, as well as the distal anterior branch of the obturator nerve.

Implications: We demonstrate by using magnetic resonance imaging that the mechanism of a three-in-one block is one of lateral, caudal, and slight medial spread of a local anesthetic with subsequent blockade of the femoral, the lateral femoral cutaneous, and the anterior branch of the obturator nerves. It does not involve cephalad spread of the local anesthetic with blockade of the lumbar plexus.

This article has been cited by other articles:

				J. Marino, J. Russo, M. Kenny, R. Herenstein, E. Livote, and J. E. Chelly Continuous Lumbar Plexus Block for Postoperative Pain Control After Total Hip Arthroplasty. A Randomized Controlled Trial J. Bone Joint Surg. Am., January 1, 2009; 91(1): 29 - 37. [Abstract] [Full Text] [PDF]

				M. J. Matava, W. D. Prickett, S. Khodamoradi, S. Abe, and J. Garbutt Femoral Nerve Blockade as a Preemptive Anesthetic in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study Am. J. Sports Med., January 1, 2009; 37(1): 78 - 86. [Abstract] [Full Text] [PDF]

				B. M. Ilfeld, V. J. Loland, J. C. Gerancher, A. N. Wadhwa, E. M. Renehan, D. I. Sessler, J. J. Shuster, D. W. Theriaque, R. C. Maldonado, E. R. Mariano, et al. The Effects of Varying Local Anesthetic Concentration and Volume on Continuous Popliteal Sciatic Nerve Blocks: A Dual-Center, Randomized, Controlled Study Anesth. Analg., August 1, 2008; 107(2): 701 - 707. [Abstract] [Full Text] [PDF]

				S. J. Fowler, J. Symons, S. Sabato, and P. S. Myles Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials Br. J. Anaesth., February 1, 2008; 100(2): 154 - 164. [Abstract] [Full Text] [PDF]

				N. Valade, J. Ripart, E. Nouvellon, P. Cuvillon, D. Prat-Pradal, J.-Y. Lefrant, and J.-E. de La Coussaye Does Sciatic Parasacral Injection Spread to the Obturator Nerve? An Anatomic Study Anesth. Analg., February 1, 2008; 106(2): 664 - 667. [Abstract] [Full Text] [PDF]

				S. M. Klein, H. Evans, K. C. Nielsen, M. S. Tucker, D. S. Warner, and S. M. Steele Peripheral Nerve Block Techniques for Ambulatory Surgery Anesth. Analg., December 1, 2005; 101(6): 1663 - 1676. [Abstract] [Full Text] [PDF]

				J. Kuhne, M. Y. Vanarase, H. G. Pandit, C. A. F. Dodd, D. W. Murray, M. T. Popat, and A. F. Davies Perioperative analgesia for knee arthroplasty Br. J. Anaesth., March 1, 2005; 94(3): 393 - 395. [Full Text] [PDF]

				D. Macalou, S. Trueck, P. Meuret, M. Heck, F. Vial, S. Ouologuem, X. Capdevila, J. -M. Virion, and H. Bouaziz Postoperative Analgesia After Total Knee Replacement: The Effect of an Obturator Nerve Block Added to the Femoral 3-in-1 Nerve Block Anesth. Analg., July 1, 2004; 99(1): 251 - 254. [Abstract] [Full Text] [PDF]

				B. Ben-David, K. Schmalenberger, and J. E. Chelly Analgesia After Total Knee Arthroplasty: Is Continuous Sciatic Blockade Needed in Addition to Continuous Femoral Blockade? Anesth. Analg., March 1, 2004; 98(3): 747 - 749. [Abstract] [Full Text] [PDF]

				B. Urbanek, A. Duma, O. Kimberger, G. Huber, P. Marhofer, M. Zimpfer, and S. Kapral Onset Time, Quality of Blockade, and Duration of Three-in-One Blocks with Levobupivacaine and Bupivacaine Anesth. Analg., September 1, 2003; 97(3): 888 - 892. [Abstract] [Full Text] [PDF]

				S. S. Liu and F. V. Salinas Continuous Plexus and Peripheral Nerve Blocks for Postoperative Analgesia Anesth. Analg., January 1, 2003; 96(1): 263 - 272. [Full Text] [PDF]

				X. Capdevila, P. Macaire, C. Dadure, O. Choquet, P. Biboulet, Y. Ryckwaert, and F. d'Athis Continuous Psoas Compartment Block for Postoperative Analgesia After Total Hip Arthroplasty: New Landmarks, Technical Guidelines, and Clinical Evaluation Anesth. Analg., June 1, 2002; 94(6): 1606 - 1613. [Abstract] [Full Text] [PDF]

				X. Capdevila, P. Biboulet, D. Morau, N. Bernard, J. Deschodt, S. Lopez, and F. d'Athis Continuous Three-in-One Block for Postoperative Pain After Lower Limb Orthopedic Surgery: Where Do the Catheters Go? Anesth. Analg., April 1, 2002; 94(4): 1001 - 1006. [Abstract] [Full Text] [PDF]

				H. Bouaziz, F. Vial, D. Jochum, D. Macalou, M. Heck, P. Meuret, M. Braun, and M.-C. Laxenaire An Evaluation of the Cutaneous Distribution After Obturator Nerve Block Anesth. Analg., February 1, 2002; 94(2): 445 - 449. [Abstract] [Full Text] [PDF]

				J. Elliot Regional anaesthesia in trauma Trauma, July 1, 2001; 3(3): 161 - 174. [Abstract] [PDF]

				F. K. Enneking and D. J. Wedel The Art and Science of Peripheral Nerve Blocks Anesth. Analg., January 1, 2000; 90(1): 1 - 1. [Full Text] [PDF]