Approaches to the Lumbar Plexus: Success, Risks,
and Outcome
Xavier Capdevila, M.D., Ph.D., Claudia Coimbra, M.D.,
and Olivier Choquet, M.D.
M any regional anesthesia options are available
for the management of postoperative pain
associated with major lower-limb surgery. Epidural
analgesia is commonly used, but lumbar plexus
nerve block may offer significant advantages in
terms of quality of postoperative analgesia, increase
in patient satisfaction, positive influence on surgical
outcome, and patient rehabilitation compared with
intravenous opioids, and it has a lower incidence of
side effects and complications.1,2 The use of periph-
eral nerve blocks has been recommended.3 Addi-
tionally, interest in continuous peripheral nerve
blocks (CPNB) is increasing because of benefits and
concerns over interactions of anticoagulants and
central neuraxial techniques. The aim of this review
is to provide an overview of the different ap-
proaches to the lumbar plexus, as well as their risks
and indications.
Functional Anatomy
The lumbar plexus (LP) is formed by the first three
and the greater part of the fourth lumbar ventral rami.
A contribution of the 12th thoracic nerve is common.
In the literature, the exact location of the LP remains
controversial. Some authors4 place the plexus be-
tween the psoas and quadratus lumborum muscles.
Recent studies on the plexus place the nerve branches
within the psoas muscle5-7 between its anterior and
posterior masses. The lateral femoral cutaneous nerve
supplies the skin of the lateral part of the thigh. The
femoral nerve provides sensory and motor innerva-
tion of the anterior thigh, the anterior part of the knee
From the Department of Anesthesiology and Intensive Care
Medicine, Lapeyronie University Hospital, Montpellier, France
(X.C.,C.C.); and Department of Anesthesiology and Intensive
Care Medicine, La Conception University Hospital, Marseille,
France (O.C.).
Accepted for publication December 17, 2004.
Reprint requests: Xavier Capdevila, M.D., Ph.D., Head of Depart-
ment, Department of Anesthesiology and Critical Care Medicine,
Lapeyronie University Hospital, Avenue du Doyen G Giraud,
Montpellier, France. E-mail: x-capdevila@chu-montpellier.fr
© 2005 by the American Society of Regional Anesthesia and
Pain Medicine.
1098-7339/05/3002-0007$30.00/0
doi:10.1016/j.rapm.2004.12.007
150 Regional Anesthesia and Pain Medicine, Vol 30, No 2 (March–April), 2005: pp 150 –162
and hip joints, and the medial aspect of the leg until
the first metatarsal (saphenous nerve). It is covered by
2 fascial layers, the fascia iliaca and fascia lata. The
fascia iliaca covers the psoas and iliacus muscles from
the iliac crest to the inguinal ligament and separates
the femoral nerve from the femoral vessels. The fascia
lata is attached to the inguinal ligament and the iliac
crest. The obturator nerve innervates the adductors
brevis and longus, the pectinueus and gracilis muscles
(anterior branch), and the adductor magnus muscle
(posterior branch). It sometimes gives sensory inner-
vation to the medial or posterior aspect of the knee.
Bouaziz et al.8 demonstrated that cutaneous distribu-
tion of the obturator nerve is highly variable and
frequently absent. After an isolated obturator nerve
block, 57% of their patients had no cutaneous distri-
bution of this nerve, 23% had an area of hypoesthesia
at the superior part of the popliteal fossa, and 20%
had a sensory deficit at the medial aspect of the thigh.
Farny et al.7 demonstrated variations in the localiza-
tion of the 3 main branches of the plexus within the
psoas muscle. The obturator nerve was the more vari-
able one. In 2 of their 4 cadavers, the nerve was in a
fold different from the fold that enclosed the femoral
and the lateral femoral cutaneous nerve. The iliohy-
pogastric, ilioinguinal, and genitofemoral nerves are
other branches from the lumbar plexus. For surgery
in a proximal area of the thigh, a block of the subcos-
tal nerve (from the 12th thoracic nerve) might be
necessary. The distance of the lumbar plexus to the
skin varies with body mass index (BMI)6,8 and gen-
der.6,7 In one study, the distances varied from 57 to
93 mm in women and from 61 to 101 mm in men.9
Different Approaches to the Lumbar
Plexus
Many approaches, both anterior and posterior, to
the lumbar plexus have been described (Tables 1-5)
and all have been used for both single-shot and
continuous techniques.
Anterior Approach
The paravascular technique, initially described as a
3-in-1 block by Winnie et al.,10 has proved to be more
 Approaches to the Lumbar Plexus • Capdevila et al. 151

Table 1. Studies on Single-Injection Paravascular Femoral Blocks

Number of Sensory
Author Local Anesthetic Patients Block Motor Block Pain Score (cm)

Parkinson11 lidocaine ⫹ tetracaine ⫹ 20 Fem 100% Fem 100% Not evaluated

epinephrine LFC 85% Obt 0%
Obt 0%
Madej71 lidocaine ⫹ epinephrine or 40 Fem 87.5% Not evaluated
(Muscle bupivacaine LFC 67.5%
biopsy)
Seeberger15 mepivacaine Not evaluated
20 mL Fem 92%
LFC 41%
Obt 62%
40 mL Fem 93%
LFC 44%
Obt 78%
Fournier64 bupivacaine ⫹ epinephrine 40 Not evaluated Not evaluated Median value: 7 at first analgesic
(THA) demand, but TFA 298 ⫾ 39
with FNB v 61 ⫾ 44 min
Capdevila18 lidocaine ⫹ bupivacaine ⫹ 100 Fem 90% Fem 76% 1.8
(Hip, femoral epinephrine LFC 62% Obt 32%
shaft or knee Obt 52%
3-in-1)
(Fascia Fem 88% Fem 80% 1.5
iliaca)
LFC 90% Obt 20%
Obt 38%
Wang47 (TKA) bupivacaine ⫹ epinephrine 30 Fem ⫹ Not evaluated 4.2 ⫾ 2.9

NOTE. Pain scores are mean ⫾ SD or median (range) 30 minutes after the local anesthetic injection.
Abbreviations: Fem, femoral nerve; LFC, lateral femoral cutaneous nerve; Obt, obturator nerve; TFA, time to first analgesic; THA,
total-hip arthroplasty; TKA, total-knee arthroplasty.

a 2-in-1 or solely a femoral block because the obtu-
rator nerve is almost always spared. Parkinson et al.11
showed by use of the technique of Winnie et al.10 that
the obturator nerve, tested by measuring adduction of
the thigh, was spared in 100% of the cases. The fem-
oral nerve was blocked in all patients, and the lateral
cutaneous nerve was blocked in 95% of cases. Lang
et al.12 and Atanassoff et al.13 have stated that the
only reliable indication of a successful block of the
obturator nerve is paralysis of thigh adductor mus-
cles, based on the variability of the cutaneous dis-
tribution of the obturator nerve. Bouaziz et al.8
have evaluated the cutaneous distribution of the
obturator nerve by performing a selective block.
They observed motor weakness of the adductor
muscles in all patients but great variation in sensory
loss. Marhofer et al.14 demonstrated the distribution
of local anesthetics after a single-injection 3-in-1
block guided by MRI. The anterior branch of the
obturator nerve may be affected at its distal end

Table 2. Studies on Single-Injection Posterior Lumbar Plexus Blocks

Number of
Author Local Anesthetic Patients Sensory Block Motor Block Pain Score (cm)

Parkinson11 lidocaine ⫹ tetracaine ⫹ 20 Fem 100% Fem 100% Not evaluated

epinephrine LFC 95% Obt 100%
Farny (Lower limb)
7 lidocaine ⫹ epinephrine 45 Complete analgesia in Not evaluated Not evaluated
88% of patients
DeVisme20 lidocaine ⫹ epinephrine 29 Successful anesthesia Not evaluated Not evaluated
(Femoral neck fractures) 30 mL in 93%
Fem 93% Not evaluated
LFC 44%
40 mL Obt 78%
Stevens26 (THA) bupivacaine ⫹ epinephrine 60 Not evaluated Not evaluated 1.3 ⫾ 2
Biboulet27 (THA) bupivacaine ⫹ clonidine 45 Fem 93% Not evaluated 1.9 ⫾ 1.7
LFC 93%
Obt 93%

NOTE. Pain scores are mean ⫾ SD or median (range) 30 minutes after the local anesthetic injection.
Abbreviations: Fem, femoral nerve; LFC, lateral femoral cutaneous nerve; Obt, obturator nerve; THA, total-hip arthroplasty; TKA,
total-knee arthtroplasty.
152 Regional Anesthesia and Pain Medicine Vol. 30 No. 2 March–April 2005

Table 3. Studies on Continuous Femoral Nerve Blocks

Number of
Author Patients Study Protocol Local Anesthetic Protocol Results

Edwards55 (TKA) 37 Continuous 3-in-1 block 0.25% bupivacaine 30 mL CFA had improved analgesia at 4
v IM narcotics 0.125% bupivacaine 6 mL/h and 24 h postop with
decreased morphine
consumption
Singelyn2 (TKA) 45 IV PCA morphine v 0.125% bupivacaine ⫹ CFA and CEA v IV PCA:
CFA v CEA sufentanil 0.1 ␮g/mL ⫹ improved analgesia, at 4 h
clonidine 1 ␮g/mL at postop and better knee flexion
10 mL/h from day 1 until discharge
CFA v CEA: lower analgesia at
4 h postop but less urinary
retention and technical
problems
Capdevila1 (TKA) 56 IV PCA morphine v 1% lidocaine ⫹ morphine CFA v IV PCA: improved
CFA v CEA 30 ␮g/mL ⫹ clonidine analgesia at 1 h and from 24 h
2 ␮g/mL at 0,1 mL/kg/h onward and knee flexion
CFA v CEA: comparable
analgesia (except from 6 h to
12 h), significantly less urinary
retention and hypotension
Singelyn66 (THA) 1338 IV PCA morphine v 0.125% bupivacaine ⫹ Comparable analgesia between
CFA v CEA sufentanil 0,1 ␮g/mL ⫹ the 3 CFA v IV PCA: less
clonidine 1 ␮g/mL at vomiting, nausea, pruritus, and
10 mL/h sedation
CFA v CEA: less urinary retention
and hypotension
Chelly72 (TKA) 92 IV PCA morphine v 0.2% ropivacaine at 12 mL/h CFA v IV PCA: improved
CFA v CEA analgesia and faster
rehabilitation
CFA v CEA: comparable
analgesia and knee flexion
Dauri57 (ACLR) 60 CFA v CEA v IAA 0.2% ropivacaine ⫹ CFA and CEA v IAA: improved
(intra-articular sufentanil 0.2 ␮g/mL at analgesia
analgesia) 5 mL/h CFA v CEA: comparable
analgesia but significantly less
urinary retention
Kaloul61 (TKA) 60 IV PCA morphine v 0.2% ropivacaine at 12 mL/h CFA and CPCB v IV PCA:
CFA v CPCB reduced morphine consumption
and improved analgesia at rest
CFA v CPCB: comparable
analgesia
Ben-David73 (TKA) 12 CFA v CFA ⫹ CSA 0.2% ropivacaine at 10/12 patients presented
7 mL/h inadequate pain postop (mean
VAS 7.3) significantly improved
by continuous infusion of the
sciatic nerve (mean VAS 2.4)

Abbreviations: ACLR, anterior cruciate ligament repair; CEA, continuous epidural analgesia; CFB, continuous femoral block; CSNB,
continuous sciatic nerve block; IAA, Intra-articular analgesia; THA, total-hip arthroplasty; TKA, total-knee arthroplasty.

when medial spread of local anesthetics occurs.
However, local anesthetics never seem to advance
medially enough to block the posterior branch of
the obturator nerve. In only a few cases, local an-
esthetic spread slightly in a cephalad direction, but
it never reached the lumbar plexus. Increasing the
volume of local anesthetic solutions does not seem
to provide better extension toward the lumbar
plexus area. Seeberger and Urwyler15 demonstrated
31% versus 41% successful 3-in-1 block in patients
who received 20 mL and 40 mL of 1% mepivacaine,
respectively. This difference is not significant, and,
therefore, it suggests that at clinically relevant vol-
umes between 20 and 40 mL, volume does not
influence the extent of block. So a 3-in-1 block with
the paravascular approach seems difficult to obtain,
and, as a consequence, this block is a multitruncular
block rather than a lumbar plexus block. Results are
quite similar for continuous 3-in-1 blocks. Capde-
vila et al.16 have demonstrated the trajectory of
catheters threaded according to the technique of
Winnie et al.10 with the aid of contrast media and
radiographs. Only 23% of catheters presented an
ideal position, with the tip near the lumbar plexus.
Thirty-seven percent of the catheters traveled lat-
erally under the iliacus muscle fascia, and 33%
coursed medially under the psoas muscle fascia.
Clinically, successful 3-in-1 block was observed in
 Approaches to the Lumbar Plexus • Capdevila et al. 153

Table 4. Studies on Continuous Fascia Iliaca Compartment Blocks

Number of
Author Patients Study Protocol Local Anesthetic Protocol Results

Ganapathy56 (TKA) 62 CFICB 0.2% bupivacaine v 0.1% 0.2% bupivacaine: success rate 100% (v 50%
v placebo at 10 mL/h with 0.1% bupivacaine), decreased morphine
consumption, and better knee ROM
Morau19 (ACLR 44 CFB v CFICB 0.2% ropivacaine at No difference in VAS and morphine consumption
femur surgery) 0.1 mL/kg/h

Abbreviations: ACLR, anterior cruciate ligament repair; CFB, continuous femoral block; CFICB, continuous fascia iliaca compartment
block; ROM, range of motion; THA, total-hip arthroplasty; TKA, total-knee arthroplasty; VAS, visual analog scale.

91% of patients, with the tip of the catheter near
the lumbar plexus, but this percentage decreased to
52% when the catheter took a medial direction and
to 27% when positioned laterally.
The fascia iliaca compartment block was initially
described in children by Dalens et al.17 Because the
injection site is distant from the femoral neurovas-
cular structures, no neurostimulator is needed. Au-
thors showed a block of the femoral nerve in 100%
of cases, whereas the lateral cutaneous nerve was
affected in 92% of cases and the obturator nerve in
88%. In addition to providing a better block, the
fascia iliaca compartment block requires no expen-
sive equipment. Capdevila et al.18 have tested this
new technique in adults (Table 1). They demon-
strated that fascia iliaca compartment block is more
effective than 3-in-1 block of the lateral femoral
cutaneous and femoral nerves in adults. In contrast
to the findings of Dalens et al.,17 sensory block of
the 3 nerves that supply the thigh was not usually
achieved in the adult population. The same group19
compared these two techniques for continuous
blocks (Table 4). They have concluded that both
techniques were equivalent in terms of VAS pain
scores and morphine consumption. Catheter place-
ment was faster in the fascia iliaca compartment
block. This approach in adults slightly optimizes the
anesthetic results of anterior lumbar plexus blocks.
Posterior Approach
Logically, a posterior approach to the lumbar
plexus should result in a complete block of the
principal nerves of the lumbar plexus.6,20,21 How-
ever, the reported failure rate for neurostimulation
for lumbar plexus localization is around 5% to
7%.20,22 Parkinson et al.11 have compared, in a
prospective study, the extent of block of 3 different
approaches to the lumbar plexus (Tables 1 and 2).
The inguinal paravascular technique (3-in-1) of
Winnie et al.10 was compared with 2 posterior tech-
niques: one described by Hanna et al.23 which ap-
proaches the lumbar plexus at the level of L3, and
the other by Chayen and Winnie,24 which involves
blockade at the L4-L5 level. Both posterior ap-
proaches were successful in blocking the femoral,
lateral femoral cutaneous, and obturator nerves.
Contrary to the initial claim of Winnie et al.,10 the
anterior approach resulted in femoral and lateral fem-
oral cutaneous nerve blocks only. Capdevila et al.6
modified the landmarks use by Winnie et al.10 and
reported, by use of CT, that their puncture site is
overly lateral. Another interesting result was that
the distance between the transverse process of L4
and lumbar plexus (18 mm) seems consistent re-
gardless of sex and weight. However, depth of the
lumbar plexus had a median value of 85 mm in

Table 5. Studies on Continuous Psoas Compartment Blocks

Author Patients Study Protocol Local Anesthetic Protocol Results

Chudinov68 (Femur) 40 CPCB v IV 0.25% bupivacine Improved analgesia in CPCB

meperidine 1-2 mg/kg with 8 h
intervals
Capdevila6 (THA 80 CPCB 0.2% ropivacaine Sensory block: Fem 95%, LFC
and revisions) 0.15 mL/kg/h 90%, and Obt 85%
VAS: 1 at rest, 1, 8-2, 5 during
physiotherapy
Kaloul61 (TKA) 60 IV PCA morphine 0.2% ropivacaine 12 mL/h CFB and CPCB v IV PCA: reduced
CFB v CPCB morphine consumption and
improved analgesia at rest
CFB v CPCB: comparable
analgesia

Abbreviations: ACLR, anterior cruciate ligament repair; CFB, continuous femoral block; CPCB, continuous psoas compartment block;
Fem, femoral nerve; LFC, lateral femoral cutaneous nerve; Obt, obturator nerve; THA, total-hip arthroplasty; TKA, total-knee arthroplasty.
154 Regional Anesthesia and Pain Medicine Vol. 30 No. 2 March–April 2005
men compared with 70 mm in women and was
correlated with BMI values.
Risks and Complications of Lumbar
Plexus Blocks
Unlike the femoral nerve block, which involves
very few risks, side effects related to psoas compart-
ment block are quite severe. Auroy et al.25 published
a retrospective study on complications of regional an-
esthesia in France. A total of 394 posterior lumbar
plexus blocks were performed. Among those patients,
1 cardiac arrest, 2 respiratory failures, 1 seizure, and 1
death occurred. In all complications related to poste-
rior lumbar plexus block in this study, a high derma-
tomal level and a bilateral mydriasis were observed,
which suggests intrathecal cephalad spread of the lo-
cal anesthetic. Macaire et al.22 made a retrospective
study that included 42 teams in the United States,
Canada, France, Belgium, and Switzerland. They re-
ported 4,319 posterior lumbar plexus blocks. Teams
declared 1% to 10% of epidural spread. Other com-
plications included 25 spinal anesthesia (with 11 total
spinal anesthesia and 1 death), 13 intravascular injec-
tions (with 3 seizures and 1 cardiac arrest), 4 delayed
toxic reactions, and 13 incorrect catheter paths.
Epidural diffusion is the most frequent problem
(Fig 1). The reported incidence of epidural diffusion
varies greatly in the literature from less than 1% to
16%.6,11,22,26-28 In one study, epidural diffusion was
more frequent when the approach was at the L3
level compared with the L5 level.11 Dalens et al.29
reported that epidural anesthesia occurred in 88%
of children who underwent a posterior lumbar
plexus block administered according to the tech-
nique of Chayen et al.24 In all the cases reported by
Dalens et al.,29 a stimulation of the lumbosacral
trunk was elicited, which probably indicated a too
medial position of the needle. Epidural catheter
localization is also possible.30
Spinal anesthesia is a feared complication of pos-
terior lumbar plexus block. In a retrospective study
by Macaire et al.,22 the test dose allowed the diag-
nosis of 11 of the 25 spinal injections observed. Two
case reports of total spinal anesthesia are available
in the literature. In the first report, the injection
was done after the observation of a myotonic re-
sponse of the adductor muscles.31 In the second
report,32 the continuous block was performed un-
der general anesthesia according to the Chayen
technique.24 In these 2 cases, patients were resus-
citated without sequelae. A case of subarachnoid
placement of a catheter, without initial CSF aspira-
tion, was also described.33 Intravascular injection
can rapidly lead to seizure,22,32,34,35 cardiac ar-
rest,22,34,35 and, eventually, death. An adequately
Unilateral epidural spread
Catheter tip
Fig 1. Continuous psoas compartment block with a cathe-
ter inserted 5 cm. Injection of 20 mL of bupivacaine. At 30
minutes, unilateral left thermoalgesia (L1 to T5) and motor
block of the left lower limb. Radiograph after 10 mL of
contrast media injection. Note a left unilateral epidural and
psoas compartment spread of the injected solution.
performed test dose helped to detect 7 out of 13
intravascular injections in one study.22 However,
false-negative results are possible,35 more so if the
patient is elderly or is being treated with ␤-adren-
ergic antagonist medications. The best way to pre-
vent toxicity is still a negative test dose and slow
fractionated injection. The persistence of a myo-
tonic response with neurostimulation after the in-
jection of 1 mL of normal saline or local anesthetic
should alert the anesthesiologist to a possible intra-
vascular injection. Deep sedation can mask initial
symptoms of systemic local anesthetics absorp-
tion.35 Delayed reactions can also happen.22 They
are mainly associated with absorption of large local-
anesthetic doses. Continuous infusion may also be
involved. It highlights the importance of patient
surveillance after block performance and during
catheter maintenance.
Posterior lumbar plexus block results in unilateral
sympathectomy. Fragile patients may develop he-
modynamic instability.20 Furthermore, a bilateral
sympathectomy is possible in the case of an epidural
diffusion. Every patient should be monitored dur-
ing and after the performance of a posterior lumbar
plexus block in the same manner as those who
receive an epidural block.
Posterior lumbar plexus blocks are best avoided
in anticoagulated patients. Renal subcapsular he-
matomas have been described after the perfor-
 Approaches to the Lumbar Plexus • Capdevila et al. 155

mance of lumbar paravertebral blocks at the L3

level.36 The inferior renal pole is close at this level.
An approach at the L4 level is safer.36 Two major
blood losses associated with psoas hematomas have
been reported.37
Neurologic damage is a major concern during and
after lumbar plexus blocks. Neurotoxicity of a local
anesthetic is caused by its neurotoxic potency, its
concentration, and the duration of its contact with
the nerve. The frequency of peripheral nerve neu-
rologic complications reported after single-shot pe-
ripheral nerve block is not well established. Auroy
et al.25 reported 4 neuropathies in more than
21,278 peripheral nerve blocks (0.04%). More re-
cently, the same authors38 reported 12 neuropa- Intraperitoneal
thies over 50,223 peripheral nerve blocks (0.02%). injection

Seven patients had sequelae after 7 months. The

incidence of neuropathies in this study was 0.03%
for the femoral block. Cuvillon et al.39 noted a
femoral nerve damage among 211 continuous fem-
oral nerve blocks (0.4%). Macaire et al.22 reported 2
neuropathies in a total of 4,319 blocks: 1 neuropa-
thy of the lateral femoral cutaneous nerve and 1
neuropathy of the femoral nerve. Both patients had
full recovery. One case report of plexopathy asso-
ciated with a psoas hematoma after a posterior lum-
bar plexus block was reported.40 However the re-
ported incidence of femoral nerve injury without
any peripheral nerve block is between 0.1% to
0.4%41 and ranges from 0.7% to 3% for all nerve
palsies.42
Continuous perineural catheter infection is an
issue that has received little attention to date. A
psoas abscess that complicated a continuous femo-
ral nerve block43 has been recently described.
Cuvillon et al.39 prospectively reported an incidence
of 57% of colonized femoral catheters, 1.5% with
bacteriemia, after 48 hours of continuous infusion
of bupivacaine or ropivacaine. A strict aseptic tech-
nique should be performed to decrease infection
risks.
Many incorrect localizations have been de-
scribed. Catheter tips have been located in the
abdominal cavity6,22 (Fig 2), the retroperitoneal
cavity,6 the subarachnoid space,22,32,44 the L4-L5
intervertebral disk6 and the paravertebral space.22
Recently stimulating catheters have been used in
an attempt to confirm perineural positioning of
the catheter and, therefore, increase the safety
and efficacy of analgesic infusion of local anes-
thetics.45,46
Indications for Lumbar Plexus Blocks
Major orthopedic surgery of the lower limb gen-
erates moderate to severe pain in the postoperative
Fig 2. Continuous psoas compartment block with a cath-
eter inserted 5 cm after nerve stimulation. Injection of 25
mL of ropivacaine. Neither sensory nor motor block at 45
minutes after injection. Radiograph after injection of 15
mL of contrast media. Note an intraperitoneal route of
the catheter.
period. Numerous authors have studied different
analgesic techniques to provide adequate pain relief
after major knee or hip surgeries because parenteral
opioids seem inefficient in relieving pain after such
surgeries.
Knee Surgery–Lumbar Plexus Block Compared
with Systemic, Neuraxial, or Intra-Articular
Anesthetic or Analgesic Alternatives
Major knee surgery, such as arthroplasty or cru-
ciate ligament repair, causes severe pain postoper-
atively and requires a rehabilitation program to be
started in the early postoperative period, which is
essential for a good functional prognosis. Several
comparative studies have evaluated the effective-
ness of different analgesic techniques for major
knee surgery.
Major Knee Surgery: Single-Shot Ap-
proaches. Anterior. Improved pain relief is
noted in patients who receive a lumbar plexus block
compared with patients who receive morphine ad-
ministration. In a recent study, Wang et al.47 (Table
1) evaluated the effect of single-injection femoral
nerve block on rehabilitation and length of hospital
stay after total-knee arthroplasty (TKA). Thirty pa-
tients were randomly selected to receive either 40 mL
of 0.25% bupivacaine with epinephrine or saline in
their femoral block, which was performed under
156 Regional Anesthesia and Pain Medicine Vol. 30 No. 2 March–April 2005
general anesthesia at the end of surgery. All
patients received intravenous morphine as patient-
controlled analgesia (PCA) in the postoperative pe-
riod. Results show significantly lower pain scores
and morphine requirements in the recovery room
for the bupivacaine group that lasted until the first
postoperative day. Although no difference in pain
scores was noted between the 2 groups after post-
operative day 1, patients who received bupivacaine
performed significantly better when walking
distances and during knee flexion until discharge.
Furthermore, hospital stay was shorter in the bu-
pivacaine group (3 v 4 days). This study shows
surprisingly that single-injection femoral block
improves rehabilitation after TKA, even when its
analgesic effects subside. Williams et al.48 have ret-
rospectively reviewed 1,200 consecutive cases of
outpatient knee surgery. The aim was to demon-
strate differences in pain associated with surgical
complexity and type of blocks used. As can be ex-
pected, patients who experienced complex inter-
ventions (ligament reconstruction, meniscal recon-
struction, and high tibial osteotomy) had a greater
risk of postoperative pain than patients who expe-
rienced less-invasive interventions. Results showed
that patients who received a femoral and sciatic
nerve block for major knee surgery presented less
pain in the ambulatory unit compared with patients
who received no block or who received a femoral
block alone. Also, less unplanned hospital admis-
sions were noted in patients who received either
femoral block alone or a combination of femoral
and sciatic nerve blocks. Although these findings
emphasize the importance of pain control in the
immediate postoperative period, one cannot reach a
conclusion on the equivalence of single injection
versus continuous femoral block. On the other
hand, Williams et al.48 suggested the greater impli-
cation of the sciatic nerve in major complex knee
surgery. A sciatic nerve block or a separate obtura-
tor nerve block seems necessary to optimize the
results obtained with a femoral block. Elmas and
Atanassoff.49 demonstrated the feasibility of lower-
limb surgery with the combination of a sciatic and
femoral block. Only 12% of patients required addi-
tional sedation during surgery. Misra et al.50 re-
ported complete analgesia that lasted about 17 hours
in patients who received combined femoral and sciatic
single-injection block before spinal anesthesia for
TKA. On the other hand, McNamee et al.51 reported
an improved analgesia obtained with addition of an
obturator nerve block to a combined sciatic and
femoral block after TKA. Further studies are neces-
sary to evaluate the percentage of patients who
really have benefited from such nerve block
associations.
More recently, the regional anesthesia tech-
niques have been compared with the intra-articular
administration of local anesthetics after anterior
cruciate ligament reconstruction (ACLR). Iskandar
et al.52 showed the better quality of analgesia from
femoral block compared with intra-articular injec-
tion after a single-injection bolus of 20 mL of 1%
ropivacaine. Femoral nerve block provides better
analgesia and allows a significant morphine-sparing
effect after ACLR.
Posterior. Luber et al.53 have reported complete
analgesia for about 13 hours after combined lumbar
plexus and sciatic block. As for the anesthetic effi-
ciency of the block for surgery, 22% of patients
required conversion to general anesthesia, despite
block of all the nerves responsible for innervation of
the knee joint. This observation reflects the fact that
regional anesthesia is not 100% successful for sur-
gery. Farny et al.21 also showed the efficacy of
combined lumbar-sciatic block (posterior approach)
for major knee surgery by administration of lido-
caine 680 mg with epinephrine and reported the
same percentage of patients who required sedation
intraoperatively, despite an apparently successful
block.
Major Knee Surgery: Continuous Ap-
proaches. Anterior. Continuous femoral nerve
block provides efficient analgesia after major knee
surgery (Table 3). Mansour and Bennetts54 inserted
a catheter into the femoral sheath and performed a
single-shot sciatic block for patients undergoing
major knee surgery (TKA and cruciate ligament
reconstruction). All patients reported adequate pain
relief for more than 85% of the 24-hour study
period. However, this study is simply observational,
and analgesia beyond 24 hours was not recorded.
Edwards and Wright55 demonstrated that continu-
ous low-dose infusion into the femoral nerve
sheath provided better analgesia than conventional
intramuscular injection of opioids after TKA. Ga-
napathy et al.56 have shown that a continuous fem-
oral paravascular block is efficient in providing pain
relief after TKA (Table 4). Although, only 40% of
catheters reached an ideal location, when 0.2%
bupivacaine was infused, all patients had a success-
ful block. Singelyn et al.2 evaluated the influence of
3 analgesic techniques on postoperative pain and
rehabilitation after TKA. Postoperative analgesia
was provided either by intravenous PCA with mor-
phine, continuous 3-in-1 block, or epidural analge-
sia in 45 patients. Pain scores at rest and during
mobilization were significantly lower in patients
who received regional anesthesia. Significantly bet-
ter knee flexion was observed in patients with con-
tinuous epidural or femoral blocks, compared with
the PCA group, until discharge. This difference was
 Approaches to the Lumbar Plexus
still present at 6 weeks postoperatively, although it
was no longer detected at 3 months. Duration of
hospital stay was also significantly longer in pa-
tients who administered PCA. No differences in
pain relief and rehabilitation were noted among
patients with femoral block or epidural analgesia.
However, urinary retention and catheter-related
problems were significantly more frequent in the
epidural group. Similarly, Capdevila et al.1 demon-
strated the influence of postoperative analgesic
techniques in surgical outcome and convalescence
duration after major knee surgery. Fifty-six adults
scheduled for major knee surgery were randomly
assigned to 1 of 3 groups: intravenous PCA with
morphine, continous femoral block, or continuous
epidural infusion. Pain scores at rest and during
continuous passive motion were significantly lower
in groups receiving continuous femoral or epidural
local-anesthetic infusion, compared with the PCA
group. The duration of stay in the rehabilitation
center was significantly shortened in patients who
received regional analgesia. Side effects such as
urinary retention, arterial hypotension, and dyses-
thesias were observed in the epidural group. The
authors concluded that continuous femoral nerve
block was the better choice for regional analgesia
after major knee surgery. Dauri et al.57 compared
continuous epidural, continuous femoral block, and
intra-articular administration of ropivacaine for
pain relief after ACLR. The assessment of analgesia
for the first 36 hours after surgery showed that
patients who received intra-articular local-anes-
thetic infusion reported significantly higher pain
scores compared with the other 2 groups. Adverse
effects were similar in all groups, except for urinary
retention, which was significantly more frequent in
the epidural group. The authors concluded that a
continuous femoral nerve block would be the tech-
nique of choice for postoperative pain relief after
major knee surgery.
However, some authors question the necessity of
continuous blocks. They argue that postoperative
pain is limited to the immediate postoperative pe-
riod and, therefore, could be adequately controlled
by use of single-injection blocks with long-acting
local anesthetics. Hirst et al.58 have compared single
injection versus continuous femoral nerve block
with 0.5% bupivacaine for analgesia after TKA. The
continuous-block group received an infusion of
0.125% bupivacaine at 6 mL/h after the surgery. A
control group received a “sham” femoral block. No
advantage to continuous femoral block was ob-
served beyond the recovery room period regarding
pain scores or morphine requirements. Single-
injection femoral nerve block lasted at least 18
hours. The authors found no benefit for continuous
• Capdevila et al. 157
procedures in postoperative analgesia after TKA.
However, no mention of postoperative rehabilita-
tion was included.
Another concern among anesthesiologists who
use these techniques is the risk of toxicity caused by
continuous infusion of large amounts of local anes-
thetics for prolonged periods. Thus, methods to
decrease the doses of local anesthetics injected
have been evaluated (Table 6). Singelyn and
Gouverneur59 compared continuous versus patient-
controlled techniques of local-anesthetic adminis-
tration through a femoral catheter. One group
received a continuous infusion of 0.125% bupiva-
caine with clonidine 1 ␮g/mL at a rate of 10 mL/h,
whereas another group received the same solution
at 5 mL/h with the possibility of PCA boluses of 2.5
mL every 30 minutes, and a third group received
only PCA boluses of 10 mL/h. Pain scores and sup-
plemental analgesia were similar among the 3
groups. However, PCA techniques reduce the con-
sumption of local anesthetic. Eledjam et al.60 have
reported similar conclusions when ropivacaine
rather than bupivacaine was used. However, in this
study, the femoral catheter was inserted by appli-
cation of a fascia iliaca compartment block tech-
nique, and a sciatic nerve single-shot block was also
performed before surgery. The regimens studied
here were a continuous infusion of 0.2% ropiva-
caine 10 mL/h, an infusion of 5 mL/h with patient-
controlled boluses of 5 mL every hour, and solely
PCA boluses of 10 mL every hour. All patients
experienced similar pain relief at rest and upon
mobilization. Supplemental analgesic use and pa-
tient satisfaction were also similar among the 3
groups. Significantly lower ropivacaine consump-
tion occurred in the bolus-alone group. We con-
clude that the PCA techniques should be recom-
mended for continuous femoral nerve blocks.
Posterior. Kaloul et al.61 compared, during a 48-
hour period, the efficacy of continuous anterior and
posterior lumbar plexus block with 0.2% ropivacaine
for analgesia after TKA performed under spinal anes-
thesia. Sixty patients were randomly assigned to 1 of
the 2 regional techniques or to receive intravenous
PCA with morphine alone. Results show that contin-
uous femoral block and psoas compartment block
reduced total morphine consumption by 48% and
50%, respectively, compared with the PCA group.
Pain scores at rest were also significantly lower in
patients who received local-anesthetic infusion 6 and
24 hours after surgery. After the first 24 hours, no
difference in pain scores was noted among the 3
groups, and morphine consumption was similar in
the 3 groups after 36 hours. Interestingly, pain scores
during physiotherapy do not differ among the 3
groups, despite the high volumes of local anesthetic
158 Regional Anesthesia and Pain Medicine Vol. 30 No. 2 March–April 2005

Table 6. Comparison of Different Infusion Techniques

Number of
Author Patients Local Anesthetic Solution Infusion Regimen Results

Singelyn59,67 (TKA 45 0.125% bupivacaine ⫹ Group 1: infusion at 10 mL/h
Femoral KT) clonidine 1␮g/mL Group 2: infusion 5 mL/h ⫹
PCA bolus 2, 5 mL every
30 min
Group 3: PCA bolus 10 mL
every 60 min
(THA Femoral KT) 45 0.125% bupivacaine ⫹ Group 1: infusion at 10 mL/h
sufentanil 0.1 ␮g/mL Group 2: PCA bolus 10 mL
⫹ clonidine 1␮g/mL every 60 min
Group 3: PCA bolus 5 mL
every 30 min
Eledjam60 (Fascia 140 0.2% ropivacaine Group 1: PCA bolus 10 mL
Iliaca KT) every 60 min
Group 2: infusion at 10 mL/h
Group 3: infusion 5 mL/h ⫹
PCA bolus 5 mL every 30
min
Pain scores and supplemental
analgesia were comparable.
Bupivacaine consumption was
less in groups 2 and 3, and
more so in group 3 v 2
Group 3: lowest local
anesthetic consumption and
best patient satisfaction
Pain scores and supplemental
analgesia were comparable.
Ropivacaine consumption was
lower in PCFA (group 1)

Abbreviations: ACLR, anterior cruciate ligament repair; KT, catheter; THA, total-hip arthroplasty; TKA, total-knee arthroplasty; PCA,
patient-controlled analgesia; PCFA, patient-controlled femoral analgesia.

used. Although sensory and motor block of the obtu-
rator nerve was more frequently achieved in the
psoas compartment– block group, morphine con-
sumption and pain scores did not differ between the 2
regional anesthesia–technique groups. Therefore, the
authors conclude that both continuous femoral and
psoas compartment block provided better analgesia
than PCA alone after TKA, but no analgesic benefit
was observed from the psoas compartment block over
the more simple femoral block. For these authors,
because posterior lumbar plexus block has been asso-
ciated with complications, femoral nerve block is the
technique of choice for pain control in patients un-
dergoing TKA.
Minor Knee Surgery: Single-Shot Ap-
proaches. As ambulatory surgery becomes more
important, and because knee arthroscopy is one of
the most commonly performed orthopedic proce-
dures, authors debate which anesthetic technique is
the best for such procedures.
Anterior. Mulroy et al.62 evaluated femoral
nerve block for postoperative analgesia after outpa-
tient arthroscopic anterior cruciate ligament repair.
Despite aggressive analgesia with oral and intra-
articular drugs, postdischarge pain is evaluated as
moderate to severe. In this study, the authors
showed that femoral nerve block with 25 mL of
0.25% bupivacaine provided good analgesia for the
first 24 hours after surgery.
Posterior. Jankowski et al.63 compared psoas com-
partment block with low-dose spinal and general an-
esthesia for outpatient knee arthroscopy. This study
involved 60 patients who would undergo elective
knee arthroscopy without ligament repair or recon-
struction. Patients who received psoas compartment
block were administered 40 mL of 1.5% mepivacaine
with epinephrine. For patients who received spinal
anesthesia, 6 mg of isobaric bupivacaine with 15 ␮g of
fentanyl were injected. General anesthesia was in-
duced with propofol and fentanyl and maintained
with propofol and nitrous oxyde. All patients received
20 mL of 0.25% bupivacaine intra-articularly at the
end of the procedure. All patients who received spinal
anesthesia and all except one (epidural extension)
who received a psoas compartment block bypassed
the postanesthesia care unit, whereas only 35% of
general anesthesia patients were able to bypass. Dis-
charge time did not differ among the 3 groups. No
differences occurred among groups in the amount of
opioids required. However, pain scores were highest
in general anesthesia patients until 2 hours postoper-
atively. The authors concluded that spinal anesthesia
or psoas compartment block is superior to general
anesthesia in terms of hospital resource utilization.
Hip Surgery: Lumbar Plexus Block Compared
with Systemic or Neuraxial Alternatives for
Anesthesia or Analgesia
Total-Hip Arthroplasty: Single-Shot Ap-
proaches. Pain after total-hip arthroplasty
(THA), although variable and of unclear duration, is
severe in half of the patients at rest and is often
exacerbated by movement. Postoperative pain con-
trol can be achieved by a variety of techniques, such
as intravenous PCA, epidural analgesia, and lumbar
plexus block. Intravenous PCA is inefficient in con-
trolling pain during mobilization. The benefit of
postoperative analgesia with epidural block is offset
by adverse effects such as nausea, vomiting, pruri-
 Approaches to the Lumbar Plexus
tus, and urinary retention and by the risk of respi-
ratory depression.
Anterior. An anterior approach to the lumbar
plexus with a single-shot block has been described
by Fournier et al.64 Forty milliliters of 0.5% bupiv-
acaine with epinephrine were used and compared
with a group that received a sham block. The au-
thors show that single-injection femoral block for
THA in association with general anesthesia, im-
proves analgesia for 4 to 5 hours after surgery, but
no sparing effect was observed in regard to opioid
requirements intraoperatively and postoperatively
for the 48-hour study period.
Posterior. A posterior approach to the lumbar
plexus should block all major branches, in contrast
to anterior lumbar block which is mainly a femoral
block. Stevens et al.26 reported psoas compartment
block for postoperative analgesia after THA. Poste-
rior lumbar plexus block was combined with gen-
eral anesthesia. A single-shot bolus of 0.4 mL/kg of
0.5% bupivacaine with epinephrine was injected.
Epidural extension of the block was noted in 10.7%
of patients, with no adverse effects. Stevens et al.26
showed not only a decrease in blood loss intraop-
eratively, as previously reported, but also a signifi-
cant 45% reduction of hemorrhage 48 hours after
the surgery. However, the intraoperative blood-
sparing effect was not statistically significant when
patients with epidural distribution of the lumbar
plexus block were excluded. The proportion of pa-
tients who received supplemental analgesia intra-
operatively was significantly greater in the group
administered general anesthesia alone. In the
PACU, VAS pain scores were significantly lower in
the group that received lumbar plexus block. Pain
scores and morphine consumption remained signif-
icantly less in the psoas compartment– block group
until 6 hours postoperatively. Biboulet et al.27 com-
pared intravenous PCA with single-injection femo-
ral and psoas compartment block (Table 2). They
reported an analgesic benefit in patients who re-
ceive psoas compartment block for the first 4 hours
after surgery (less morphine consumption and
lower VAS pain scores). However, after 4 hours no
difference was seen in morphine consumption or
pain scores among the 3 groups, whether at rest or
during mobilization. No difference in hip mobility
or rehabilitation duration was noted. These data
further question the need for regional techniques in
THA, especially psoas compartment block with its
potential serious adverse effects. The authors con-
clude that PCA morphine is an efficient and safe
analgesia technique for THA. In another study,
Souron et al.65 compared prospectively intrathecal
morphine and psoas compartment– block tech-
niques after primary hip arthroplasty. They demon-
• Capdevila et al. 159
strated that 0.1 mg intrathecal morphine provided
better postoperative analgesia than did single-shot
psoas compartment block with more urinary reten-
tion episodes.
Although anterior and posterior lumbar plexus
blocks have been used for THA, their contribution
remains unclear. Femoral nerve blocks provide an
analgesic benefit but it seems of short duration, and
no real opiate-sparing has been noted. Posterior
lumbar plexus block has also shown effective pain
relief, but its usefulness compared with other anal-
gesic methods remains controversial. The difficulty
in establishing the superiority of regional anesthesia
techniques may be in part because pain after THA is
highly variable.
Total-Hip Arthroplasty: Continuous Ap-
proaches. Anterior. Singelyn and Gouverneur66
(Table 3) have shown that the use of a catheter to
provide continuous extended femoral block was
efficient in providing comparable analgesia but with
fewer side effects and technical problems than with
intravenous PCA or patient-controlled epidural an-
algesia. VAS values at rest were 23 ⫾ 20 minutes at
24 hours and 11 ⫾ 17 mm at 48 hours. However,
during mobilization VAS scores increased to 46 ⫾
26 mm at 24 hours and 33 ⫾ 24 mm at 48 hours.
Singelyn et al.67 has also used continuous versus
patient-controlled regimens in the hope of reducing
the volume of local anesthetic administered and,
thereby, decreasing the potential for toxicity (Table
6). As in knee surgery, PCA boluses alone produced
equal analgesia as continuous perfusion but with a
significantly lower local-anesthetic consumption. In
this study, 2 bolus regimens were compared with
the continuous infusion: 5 mL every 30 minutes
and 10 mL with a refractory period of 60 minutes.
The smallest local-anesthetic consumption occurs
with the 5 mL bolus and 30-minute lockout time.
Patient satisfaction is also greatest in this group.
Posterior. Capdevila et al.6 have conducted a clin-
ical evaluation of continuous psoas compartment
blocks (CPCB ) for postoperative analgesia after THA.
Only 3 of the 80 catheters threaded were improperly
placed. One hour after the block, sensory block of the
femoral, obturator, and lateral cutaneous femoral
nerves was successful in 95%, 90%, and 85% of
patients, respectively. Postoperative analgesia was ad-
equate, as only 6.5% of the patients required rescue
analgesia. VAS pain scores during the 48-hour study
period had a median value of 10 mm at rest and
ranged from 18 to 25 mm during physiotherapy. This
finding proves the efficacy of CPCB for pain control
after THA. Few adverse effects were reported, and
although 5% of patients showed a peridural exten-
sion, no hemodynamic consequences were observed.
160 Regional Anesthesia and Pain Medicine Vol. 30 No. 2 March–April 2005
Hip Fracture Surgery: Single-Shot and Con-
tinuous Posterior Approaches. De Visme et
al.20 have shown that the psoas compartment block
associated with a parasacral block provides similar
anesthesia to plain bupivacaine spinal anesthesia for
the repair of hip fractures in elderly patients. Al-
though spinal anesthesia is a simple technique with a
high success rate, advantages of peripheral blocks in-
clude less urinary retention, possibly less hypoten-
sion, and especially the possibility of prolonged anal-
gesia. Chudinov et al.68 evaluated continuous
posterior lumbar plexus blocks for anesthesia as well
as perioperative analgesia in patients with hip frac-
tures. Although the block was successfully performed
in all patients, surgical anesthesia was only achieved
in 15% of patients. This result might be caused in part
by the anatomic landmarks used. The authors used
the method of Chayen et al.,24 which, as tomo-
graphic studies show, is slightly too lateral. How-
ever, analgesia was adequate, with all patients un-
der CPCB presenting pain scores below 3 cm at all
times during the 72 hours after surgery. However,
these values were only significantly lower com-
pared with the control group at 16, 24, 32, and 64
hours.
Femoral Shaft Fractures: Anterior Ap-
proaches. Lumbar plexus block has also been
evaluated in a prehospital-care setting. The fascia
iliaca compartment block involves a puncture site
away from the neurovascular sheath and requires
no specific material. Its use was evaluated in pre-
hospital care, where anesthesiologists were the
physicians present at an accident site, for femoral
shaft fractures. Lopez et al.69 demonstrated that
fascia iliaca block is simple, safe, and efficient in
providing pain relief for femoral fractures at the
accident site. Only 1 block failure was reported out
of 27 patients recruited. This method facilitates
transport to trauma care center and earlier manage-
ment at arrival. Even patients with partial block
required no further analgesia before going to the
operating room.
Conclusion
We conclude that lumbar plexus blocks may offer
advantages after lower-limb orthopedic surgery and
femoral shaft trauma. They provide good quality
perioperative analgesia, increased patient satisfac-
tion, and positive influence on the surgical outcome
compared with intravenous opioids. They have a
lower incidence of side effects and complications
compared with epidural analgesia. Despite these
advantages, concerns exist about failure of obtura-
tor nerve block with the anterior approaches, the
success rate of current approaches, the better infu-
sion regimen of local anesthetics, and the risks for the
posterior approaches. Large studies are still required
to investigate the incidence of complications associ-
ated with continuous lumbar plexus blocks.70
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