Suprainguinal Fascia Iliaca Block for a Postoperative Neurosurgical Complication: Regional Anesthesia to the Rescue!

A 45-year-old lady with adrenocorticotropic hormone (ACTH) dependent Cushing's disease was planned for transnasal transsphenoidal (TNTS) pituitary tumor decompression. She was a known diabetic, hypertensive, and obese, with a body mass index of 38. She had a moderate risk of obstructive sleep apnea with a STOP-BANG score of 4/8.[1] After establishing American Society of Anesthesiologists (ASA) standard monitors, intravenous access, and adequate preoxygenation, general anesthesia was administered. In view of the anticipated difficult airway, a C-MAC video-laryngoscope-aided endotracheal intubation was performed, and a throat pack was placed. The patient was maintained on sevoflurane and air oxygen mixture with intermittent boluses of fentanyl and atracurium. During the procedure, an arachnoid tear was closed with a fascia lata graft harvested from the left thigh. Postsurgery bilateral nostrils were packed with Merocel (Medtronic Inc., Minneapolis, MN, United States), and the patient was extubated awake. She was transferred to the intensive care unit (ICU) for monitoring. In the ICU, an hour later, a swelling was noticed at the fascia lata harvest site. This gradually increased to a size of 15 × 10 cm over the next hour and was accompanied by hypotension with a blood pressure of 98/56 mm Hg and a heart rate of 106 bpm. She was hence planned for an emergency surgical exploration of the thigh hematoma. In view of the difficult airway, oral trickling of blood and secretions from the nose, and the anticipated morbidity associated with mask ventilation and reintubation in a postoperative TNTS case, a plan to opt for the regional anesthetic technique was made. After adequate resuscitation with crystalloids, 500 mL of colloid, and ASA monitoring, an ultrasound-guided suprainguinal fascia iliaca block (US-SIFIB) was planned. The procedure was explained to the patient and she gave her consent. She was positioned semi-siting after ensuring hemodynamic stability, and the left US-SIFIB was given using a 30-mL injection of ropivacaine 0.2%. The spread of the drug between the fascia iliaca and iliacus muscle was observed. After confirming sensory loss over the anterior and lateral thigh after about 15 minutes, the surgeon re-explored the graft site, evacuated the hematoma, and achieved hemostasis. The estimated blood loss was 400 mL, leading to a decrease in hemoglobin from a baseline of 12.6 to 9 g/dL, and she received 1 unit of blood transfusion. She was hemodynamically stable and comfortable throughout the procedure and was transferred to the ICU postoperatively.

As new techniques emerge, the applications of regional anesthesia are broadening beyond just “scalp blocks” in neurosurgery.[2] The US-SIFIB has emerged as a safe and technically straightforward procedure that entails administering local anesthetic into the fascial compartment between the iliacus muscle and the fascia iliaca, superior to the inguinal ligament.[3] This technique effectively blocks the lateral cutaneous nerve of the thigh and the lateral cutaneous branch of the subcostal nerve, which provides sensory innervation to the skin of the lateral thigh. Furthermore, this block can potentially block the ilioinguinal and genitofemoral nerves, providing anesthesia to the upper anterior thigh. The TNTS approach creates an iatrogenic connection between the nasal and intracranial cavities. Postoperation, positive pressure ventilation may force air into the intracranial cavity and produce tension pneumocephalus.[4] In our case, the surgery was successfully completed by blocking the sensory supply to the anterior thigh. This technique effectively circumvented potential complications associated with airway manipulation. Our report emphasizes the versatility of regional techniques applicable to the neurosurgical operating rooms, contributing to better patient outcomes.

Conflict of Interest

None declared.

Acknowledgments

We would like to thank Dr. Nitish Vijayanand, Assistant Professor in the Department of Anaesthesia at CMC Vellore, for his assistance with the block and his involvement in patient care.

• References

• 1 Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 2016; 149 (03) 631-638
• 2 Sethuraman M, Bidkar PU, Mariappan R, Deopujari RC, Vanamoorthy P, Massand M. Recent advancements in the practice of neuroanaesthesia and neurocritical care: an update. Indian J Anaesth 2023; 67 (01) 85-90
• 3 O'Reilly N, Desmet M, Kearns R. Fascia iliaca compartment block. BJA Educ 2019; 19 (06) 191-197
• 4 Bharadwaj S. Yet another absolute indication for rapid sequence intubation. J Neurosurg Anesthesiol 2018; 30 (02) 194-195

Publication History

Article published online:
05 March 2025