Successful use of Transversalis fascia plane block for iliac crest bone harvesting in a Polytrauma patient - A case report.

Iliac crest bone grafting is very common associated procedure in various bone fixation surgery. We report here successful use of Transversalis fascia plane (TFP) block for iliac crest bone harvesting in a Polytrauma patient with difficult airway. Copyright:

Transversalis fascia plane (TFP) block is a truncal block that targets the L1 nerve branches – ilioinguinal and iliohypogastric nerves, where they are between the fascia of the transversus abdominis muscle and the transversalis fascia.[1] This block is effective for pain relief following anterior iliac crest bone grafting (ICBG).[2] Many upper limb surgeries are done under regional nerve block require additional anesthesia for ICBG. We report here a successful use of this block in polytrauma patient.

Case Report

A 35 years old male with history of multiple trauma 2.5 months back was scheduled for open reduction and internal fixation of shaft of humerus with requirement of ICBG. He had a mandible bone wiring in situ for mandible fracture. His medical history was not significant. His routine investigations were within normal limits. Airway evaluation revealed a mouth opening of 1 finger. Keeping in view of difficult airway we planned to get the case done under combination of ultrasound - guided supraclavicular brachial block for open reduction and internal fixation of shaft of humerus and TFP block for ICBG.

Shaft of humerus surgery was started under the brachial block and 20 minutes prior to requirement of bone graft TFP block was given. The ultrasound probe was placed in a transverse orientation above the iliac crest; and the external oblique, internal oblique (IO), and transverse abdominis (TA) muscles were identified and traced posteriorly until first the TA muscle and then the IO muscle tapered into their common aponeurosis, adjacent to the quadratus lumborum muscle [Figure 1]. The tip of a 22-gauge 10 cm needle was positioned just deep to the TA muscle and its aponeurosis at the point where the TA tapered off. Bupivacaine 0.5% (20 mL) was injected into the plane between the TA and underlying transversalis fascia. Bone graft harvesting was started after 20 minutes. Twenty five micrograms of i.v. fentanyl was administered for sedation. Patient had no discomfort during the procedure with Visual analogue score (VAS) of 3 in the intraoperative period. Patient remained comfortable in postoperative period with VAS score of 2 for next 4 hours. At 4th postoperative period VAS score was 7 requiring administration of intravenous morphine 0.05 mg/kg BW.

Figure 1

Tip of needle between transversalis fascia and quadratus lumborum. EO-External oblique, IO- Internal oblique, TA-Transversus abdominis, QL- Quadratus lumborum, TF- Transversalis Fasia, RF- Retroperitoneal fat

Discussion

Herein we used TFP block for ICBG in a multiple trauma patient with mandible wiring being operated for fracture shaft of femur requiring bone graft. Since this patient had compromised airway giving general anesthesia in any form would have been risky. The iliac crest is primarily innervated by the L1 nerve root via the iliohypogastric and ilioinguinal nerves. We planned for TFP block which targets the ilioinguinal and iliohypogastric nerves along the posterior third of the iliac crest and proximal to the origin of its lateral cutaneous branch. Local anesthetic injected between the transversus abdominis muscle and its deep investing transversalis fascia will spread over the inner surface of the quadratus lumborum muscle and block the proximal portions of the T12 and L1 nerves. This will produce block of both the anterior and the lateral branches of these nerves.[3] Thus TFP targets these nerves anatomically between the lumbar plexus block and the TAP block. Transversus abdominis plane (TAP) block has also been used for pain relief in ICBG with success[4] but TFP seems more precise for the same. TAP block does not reliably block the L1 dermatome. It is more anteriorly placed and is limited to the anterior abdomen, as only L1, T12, and possibly T11 will be blocked. However TFB block blocks T12 and L1 supply laterally over the iliac crest as far as the greater trochanter enabling a simple and effective analgesic block over the iliac crest, upper lateral thigh, and lower abdomen.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.