No iPACK-related complications were reported.Īdding iPACK to ACB in the setting of periarticular LIA does not improve analgesic outcomes following TKA. Functional recovery was also improved by a log(odds ratio) (95% CI) of 1.28 (0.45 to 2.11) (p=0.003). In contrast, in the absence of LIA, adding iPACK to ACB reduced pain at 12 hours, and 24 hours by a WMD (95% CI) of −0.98 (−1.79 to –0.17) (p = 0.02) and −0.69 (−1.18 to –0.20) (p=0.006), respectively, when compared with ACB alone, but did not reduce opioid consumption. For the secondary outcome comparisons in the presence of LIA, adding iPACK to ACB did not improve postoperative pain at all other time points, opioid consumption or functional recovery. However, in the absence of LIA (eight trials, 631 patients), adding iPACK to ACB reduced pain by a weighted mean difference (WMD) (95% CI) of −1.33 cm (−1.57 to –1.09) (p<0.00001). For the primary outcome comparison in the presence of LIA (four trials, 273 patients), adding iPACK to ACB did not improve postoperative pain at 6 hours. Opioid consumption at 24 hours, functional recovery, and iPACK-related complications were secondary outcomes.įourteen trials (1044 patients) were analyzed. We a priori planned to stratify analysis for use of LIA. We conducted a meta-analysis of randomized trials comparing the effects of adding iPACK block to ACB versus ACB alone on pain severity at 6 hours postoperatively in adult patients undergoing TKA. To evaluate the analgesic benefits of adding iPACK to ACB, compared with ACB alone, in the setting of LIA following TKA. However, the analgesic benefits of adding iPACK to ACB in the setting of surgeon-administered periarticular local infiltration analgesia (LIA) are unclear. The site of TFP injection is posterior to the mid-axillary line, unlike the classic ultrasound-guided TAP block.When combined with adductor canal block (ACB), local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) is purported to improve pain following total knee arthroplasty (TKA). Local anesthetic is injected deep to the transversus abdominis muscle for the TFP block versus superficial to the muscle for the TAP block. The TFP block does not cover the dermatomes above L1 and T12 while the TAP block does. The TFP block is designed to block the L1 nerve branches, which the TAP block does not reliably cover. The TFP block is different from the transversus abdominis plane (TAP) block in a number of ways. This block is also an analgesic option for inguinal hernia repair, open appendectomy and any surgery involving the L1 dermatome. Local anesthetic spread can also involve the subcostal nerve (T12 spinal nerve). The TFP block is indicated for pain relief following anterior iliac crest bone graft harvesting as the block is performed proximal to the L1 branches that innervate the anterior iliac crest. However the location at which this occurs varies widely between individuals. The transversalis fascia is a thin aponeurotic membrane which lies between the transversus abdominis muscle and the extraperitoneal fascia, and is part of the general layer of fascia lining the abdominal cavity.Īnatomical Relationship of the Iliohypogastric and Ilioinguinal Nerves with the Surrounding MusclesĪnterior to the iliac crest, the nerves travel towards the anterior abdominal wall, piercing first the internal oblique muscle, and then the external oblique muscle. The fascia of the transversus abdominis muscle, also called the thoracolumbar fascia, is formed when the transversus abdominis and internal oblique muscles taper off posteriorly into a common aponeurosis and abuts the lateral border of quadratus lumborum muscle. The TFP block targets the ilioinguinal and iliohypogastric nerves where they are between the fascia of the transversus abdominis muscle and the transversalis fascia. Lateral to the quadratus lumborum muscle, they initially run deep to transversus abdominis muscle for a variable distance before piercing the transversus abdominis muscle to enter the transversus abdominis plane between the internal oblique and transversus abdominis muscles. The transversalis fascia plane block, or TFP block, is a truncal block that targets the L1 nerve branches, namely the ilioinguinal and iliohypogastric nerves.The ilioinguinal and iliohypogastric nerves emerge from the lateral border of psoas major muscle, inferior to the 12 th rib, and course over the anterior surface of the quadratus lumborum muscle. Ilioinguinal / Iliohypogastric Nerve Block.Third Occipital Nerve and Cervical Medial Branch Block.Transmuscular Quadratus Lumborum (TQL) Block.Transversus Abdominis Plane (TAP) Block.Sciatic Nerve Block - Subgluteal Region.
Sciatic Nerve Block - Proximal Thigh Region.Peripheral Nerve Block - Musculocutaneous Nerve.
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