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© 2000 International Anesthesia Research Society
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el, MD
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Abstract |
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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.
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Introduction |
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The technique of blocking the femoral, the lateral femoral cutaneous (LFC), and the obturator nerves by a single injection of a local anesthetic was first described by Winnie et al. in 1973 (1). The "three-in-one block," as it was called, has since become a preferred technique for regional anesthesia, used in many surgical procedures and pain management of the lower limb. Winnie et al. (1) suggested that the underlying anatomical mechanism was one of cephalad distribution of the local anesthetic resulting in blockade of the lumbar plexus. This hypothesis was later reaffirmed (2).
Many investigators have questioned the efficacy of the three-in-one block technique (3–8). The obturator nerve in particular has often failed to exhibit adequate blockade (5–8). However, some authors succeeded in optimizing the technique, as it had initially been described, to the point of achieving sufficient sensory analgesia in all three targeted nerves (9,10). Nevertheless, the existence of a genuine three-in-one block remains controversial (11,12).
Few reports describing nerve block mechanisms have used imaging techniques to analyze the distribution pattern of local anesthetics. A review of the literature shows that imaging studies specifically dealing with the three-in-one block are confined to two reports using conventional radiograph and computerized tomography (12,13). Magnetic resonance imaging (MRI) has been used with excellent results in a number of regional anesthetic techniques to visualize anatomical structures (14–17). However, only one report dealing with stellate ganglion blockade is available for MRI as a means to delineate the spread of solutions (18).
These open questions prompted us to conduct our MRI study in an effort to learn more about the distribution pattern of a local anesthetic during three-in-one nerve blocks and, hence, about the underlying mechanism of this controversial technique.
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Methods |
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Seven patients scheduled for trauma-related surgery of the lower limb were included in the study after institutional approval and having given their informed, written consent. All patients were ASA physical status II. Exclusion criteria were contraindications to local anesthetics, to puncture in the inguinal area, or to MRI. Patients unable to understand the study protocol because of a language barrier or other problems were also excluded.
MRI of the inguinal area was performed in three planes using a 1.5 Tesla scanner (Gyroscan ACS-NTTM, Philips, Best, The Netherlands). Patients were placed in a suitable position on the freely movable table of the scanner on a standard body coil. The projection of the crosshairs from the built-in light pointer, used to pinpoint the center position of the examination site, was marked on the patients’ skin to obtain corresponding slices for the primary and secondary scans.
A primary MR scan using (i) paracoronal, (ii) sagittal, and (iii) axial orientation was performed to obtain the baseline anatomical situation. The paracoronal plane was chosen in such a way that the iliopsoas muscle could be visualized along its entire length from the lumbar spine down to the inguinal area. The plane was defined using the three-dimensional planing aid of the scanner software, which simultaneously displays the orientation of a slice stack on three perpendicular guide views. In each plane, T1- and T2-weighted imaging was performed. For T1-weighted imaging, a spin echo sequence with repetition time 500 ms and echo time 20 ms was used. Twenty slices, 3-mm thick, were scanned. For T2-weighted imaging, a turbo spin echo sequence with repetition time 3000 ms and echo time 98 ms was used. An additional spectral fat suppression preimpulse (SPIR) was introduced into the T2-weighted sequence to reduce interference by bright signals emitted from fatty tissue in the examined area and to detect any accumulations of fluid (e.g., edema), before performing the three-in-one block. Again, 20 slices, 3-mm, thick were scanned.
For the subsequent three-in-one block, which was conducted for palliative preoperative pain management, we used the paravascular approach described by Winnie et al. (1) involving a nerve stimulator (AlphaplexTM, Sterimed, Püttingen, Germany). The local anesthetic consisted of 30 mL of bupivacaine 0.5%, administered after the injection of a skin wheal, insertion of a 7-cm Sprotte needle (24F), stimulation of the quadriceps femoral muscle at <0.3 mA, and aspiration through the Sprotte needle in two planes to prevent intravascular injection. The procedure was performed by two anesthesiologists. The variables monitored during its performance included heart rate, noninvasive blood pressure, and oxygen saturation. Monitoring was discontinued once the hemodynamic variables had remained stable for 15 min.
Secondary MRI was performed 15 min after the three-in-one block. The local anesthetic could be visualized by introducing SPIR into the T2-weighted sequences. The distribution pattern of the local anesthetic was then analyzed by comparing the T2-weighted, fluid-sensitive images obtained before and after the nerve block procedure. All images were investigated by the same radiologist.
Figure 1 illustrates how the spread of local anesthetic was analyzed on the basis of subdividing the inguinal area as follows: Sector 1, caudal to the inguinal ligament and lateral to the femoral artery; Sector 2, caudal to the inguinal ligament and medial to the femoral artery; Sector 3, covering the iliac fossa; and Sector 4, cranial to the iliac spine.
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Sixty minutes after injecting the local anesthetic, we used a pinprick test (9,10,19) to assess the quality of the sensory block in the central sensory area of each of the three nerves and compared the result with the same type of stimulation on the contralateral leg. Unlike previous studies, we additionally investigated the sensory region of the posterior branch of the obturator nerve in the popliteal fossa. The findings were rated on an ordinary percentage scale ranging from uncompromised sensation (100%) to complete absence of sensory response (0%). Blocks were considered successful if the sensation in the femoral, LFC, and obturator (anterior branch) nerves was down to 30% of the baseline value (9). Patients who failed to meet this criterion were retrospectively eliminated from the study.
Blockade of the posterior branch of the obturator nerve was not assessed in earlier studies. Thus, we considered the three-in-one block successful if there was evidence of the sensory block in the anterior branch of the obturator nerve alone.
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Results |
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Pertinent patient data and the results of sensory blockade 60 min after the injection are summarized in Table 1. There were no cases of anesthetic failure by our criteria or hemodynamic or respiratory impairment during the observation period.
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The femoral and LFC nerves could be identified based on anatomical reference structures, i.e., lateral to the femoral vein and medial to the superior anterior iliac spine, respectively. The obturator nerve could be identified in all patients on T1-weighted, sagittal images as hypointense (dark) relative to the pelvic fatty tissue lateral to the urinary bladder (Figure 2). Beyond the obturator foramen in a caudal direction, the anterior branch of the obturator nerve could be located between the adductor brevis and longus and its posterior branch behind the adductor brevis as anatomical reference points. The local anesthetic was visible on T2-weighted images as hyperintense (light) in relation to the muscle tissue (Figures 3B, 4B, 5B).
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The distribution of the local anesthetic after the three-in-one procedure was similar in all patients, regardless of their specific type of injury. Figures 3–5 show the distribution pattern of the local anesthetic in the secondary MRI compared with the baseline situation in primary MRI. In all patients, the local anesthetic had advanced to Sector 1 and to the medial portion of Sector 2. In contrast, it had advanced to Sector 3 in only three patients (43%), while no local anesthetic was ever detected in Sector 4.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This is the first study in which MRI was used to delineate the distribution of local anesthetic during three-in-one blocks. The images show that this three-in-one block technique involves spread of the local anesthetic in the caudal direction and, to a lesser degree, in the medial direction. The femoral nerve is influenced directly, and the LFC nerve is influenced by a lateral spread. The anterior branch of the obturator nerve is affected at its distal end via a slight medial spread. The local anesthetic does not, however, advance to the posterior branch of the obturator nerve.
The rationale behind the three-in-one approach has been controversial. Many authors have challenged the notion that the femoral, obturator, and LFC nerves could be simultaneously blocked by a single injection of a local anesthetic (3,5–7). The obturator nerve in particular has never been shown to be effectively blocked by this approach. In the past, most investigators have relied on clinical or electrophysiological methods to analyze analgesia levels. Cauhepe et al. (12) investigated the analgetic route of three-in-one blocks using standard pelvic radiography and computed tomography, and reported two unexpected distributions of local anesthetic. The first type consisted of an internal distribution of local anesthetic toward the psoas major muscle, and the second type was an external diffusion of local anesthetic in front of the iliac muscle. Based on clinical and radiographic findings obtained in adults, Capdevila et al. (13) reported the local anesthetic used in three-in-one blocks to spread under the iliac fascia, but rarely to the lumbar plexus.
Our investigation of the distribution pattern of a local anesthetic using MRI made it possible not only to visualize the major anatomical structures in the inguinal area, but also, by using SPIR in T2-weighted sequences, to trace the distribution of local anesthetic after three-in-one blocks. In particular, we were able to identify the obturator nerve on T1-weighted sequences as a dark (hypointense) structure lateral to the urinary bladder (Figure 2). Direct visualization of the obturator nerve was an important achievement because blockade of the obturator nerve by the three- in-one technique has been a matter of controversy. Some authors reported the sensory/motor blockade (9,10,20–22) of the obturator nerve to be adequate, but their findings conflict with other reports (6–8). In our study, the intrapelvic part of the obturator nerve was not affected by the local anesthetic (Figure 4b). This is in contrast to the results of Schwilick et al. (21) and Schwilick and Steinhoff (22), who by purely clinical methods observed elimination of the obturator reflex after three-in-one blocks during transurethral resection of lateral bladder tumors with regional or general anesthesia without muscle relaxation. In light of our new findings, however, the three-in-one block does not seem to be a suitable way to eliminate the obturator reflex in this situation.
Distal to the obturator foramen, the obturator nerve extends into two branches: an anterior branch between the adductor brevis and the adductor longus muscles, and a posterior branch between the adductor brevis and the adductor magnus muscles. Both branches end as sensory nerves at the medial thigh and the popliteal fossa, respectively (23). The local anesthetic acts on the anterior branch of the obturator by slightly spreading in medial direction (Figure 3b). This spread does not, however, extend to the posterior branch. Therefore, none of our patients exhibited sensory analgesia in the popliteal fossa. The local anesthetic also acts on the inguinal vessels located medially to the three-in-one puncture area (Figures 3b, 4b, and 5b). We therefore hypothesize that the iliopectineal fascia that separates the lacuna musculorum from the lacuna vasorum medially to the puncture area is a membrane permeable to local anesthetic.
It is well established that the three-in-one technique results in sufficient analgesia of the femoral and LFC nerves (1,4–6,8–10,20). Our MRI studies support this finding as seen in the lateral spread of the local anesthetic from the puncture area to the anterior superior iliac spine (Figure 5b). Most investigators favor the theory that the three-in-one block acts by cephalad spread of local anesthetic involving blockade of the lumbar plexus (1,2). Only a few have questioned this view (3,13). We observed the anesthetic to spread in a lateral, caudal, and to a small extent, in a medial direction. Cephalad spread was observed in only three (43%) of our patients and never reached the lumbar plexus. Therefore, the widely held opinion that the three-in-one block acts through retrograde filling of the femoral nerve sheath seems to be improbable.
To summarize, our MRI studies demonstrate that the mechanism of three-in-one blocks is one of lateral, caudal, and slight medial spread of the local anesthetic. It does not involve cephalad spread with blockade of the lumbar plexus, nor does the local anesthetic extend to the proximal part of the obturator nerve. Analgesia in the sensory region of the obturator nerve is a function of medial spread of the local anesthetic involving its anterior branch.
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References |
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Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the 3-in-1 block. Anesth Analg 1973;52:989–96.
[Free Full Text] - Lonsdale M. 3-in-1 block: confirmation of Winnie’s anatomical hypothesis. Anesth Analg 1988;67:601–2.
- Ritter JW. Femoral nerve "sheath" for inguinal paravascular lumbar plexus blocks is not found in human cadavers. J Clin Anesth 1995;7:470–3.[Web of Science][Medline]
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Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989;69:705–13.
[Abstract/Free Full Text] - Lang SA, Yip RW, Chang PC, Gerard MA. The femoral 3-in-1 block revised. J Clin Anesth 1993;5:292–6.[Web of Science][Medline]
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Madej TH, Ellis FR, Halsall PJ. Evaluation of "3-in-1" lumbar plexus block in patients having muscle biopsy. Br J Anaesth 1989;62:515–7.
[Abstract/Free Full Text] -
Parkinson SK, Mueller JB, Little WL, Bailey SL. Extent of blockade with various approaches to the lumbar plexus. Analg 1989;68:243–8.
[Abstract/Free Full Text] - Atanassoff PG, Weiss BM, Brull SJ, et al. Electromyography comparison of obturator nerve block to three-in-one block. Anesth Analg 1995;81:529–33.[Abstract]
- Marhofer P, Schrögendorfer K, Koinig H, et al. Ultrasonographic guidance improves sensory block and onset time for three-in-one blocks. Anesth Analg 1997;85:854–7.[Abstract]
- Marhofer P, Schrögendorfer K, Wallner T, et al. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998;23:584–8.[Web of Science][Medline]
- Winnie AP. The "3-in-1 block: " is it really 4-in-1 or 2-in-1. Reg Anesth 1992;17:176–9.[Web of Science][Medline]
- Cauhepe C, Oliver M, Colombani R, Railhac N. The "3-in-1" block. myth or reality? Ann Fr Anesth Reanim 1989;8:376–8.[Web of Science][Medline]
- Capdevila X, Biboulet P, Bouregba M, et al. Comparison of the three-in-one and fascia iliaca compartment blocks in adults: clinical and radiographic analysis. Anesth Analg 1998;86:1039–44.[Abstract]
- Wong GY, Brown DL, Miller GM, Cahill DR. Defining the cross-sectional anatomy important to interscalene brachial plexus block with magnetic resonance imaging. Reg Anesth Pain Med 1998;23:77–80.[Web of Science][Medline]
- Dangoisse MJ, Wilson DJ, Glynn CJ. MRI and clinical study of an easy and safe technique of suprascapular nerve blockade. Acta Anaesthesiol Belg 1994;45:49–54.[Medline]
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Brown DL, Cahill DR, Bridenbaugh LD. Supraclavicular nerve block: anatomic analysis of a method to prevent pneumothorax. Anesth Analg 1993;76:530–4.
[Abstract/Free Full Text] -
Klaastad O, Lilleas FG, Rotnes JS, et al. Magnetic resonance imaging demonstrates lack of precision in needle placement by the infraclavicular brachial plexus block described by Ray et al. Anesth Analg 1999;88:593–8.
[Abstract/Free Full Text] - Hogan QH, Erickson SJ, Haddox JD, Abram SE. The spread of solutions during stellate ganglion block. Reg Anesth 1992;17:78–83.[Web of Science][Medline]
- Tuttle AA, Katz JA, Bridenbaugh PO, et al. A double blind comparison of the abdominal wall relaxation produced by epidural 0.75% ropivacaine and 0.75 bupivacaine in gynecologic surgery. Reg Anesth 1995;20:115–20.
- Sprotte G. Pre- and postoperative analgesia by lumbar plexus anesthesia (3-in-1 block) in orthopedics and traumatology. Reg Anaesth 1981;4:39–41.
- Schwilick R, Weingartner K, Kissler GV, Reinhold P. Elimination of the obturator reflex as a specific indication for dilute solutions of etidocaine: a study of the suitability of a local anesthetic for reflex elimination in the 3-in-1 block technique. Reg Anaesth 1990;13:6–10.[Medline]
- Schwilick R, Steinhoff H. Elimination of the obturator reflex with prilocaine in transurethral resection of bladder tumors in combination with spinal and general anesthesia. Reg Anaesth 1987;10:65–9.[Medline]
- Wagner F. Beinnervenblockaden. In: Niesel HC. Regionalanaesthesie, lokalanaesthesie, regionale schmerztherapie. Stuttgart, NY: Georg Thieme Verlag, 1994: 417–521.
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