Ilioinguinal – Iliohypogastric Nerve Block

Anatomy
The nerves are formed by the ventral rami of L1/L2 and L12/L1, respectively. Both nerves emerge
from the lateral border of the psoas manor muscle, pass across the ventral surfaces of the quadratus
lumborum muscle and run in a distal direction medial to the iliac crest. Medial to the anterior
superior iliac spine, the nerves pierce the transverse abdominal muscle and are in a position
between the internal oblique and transverse abdominal muscle. The ilioinguinal and
iliohypogastric nerves may arise as a common trunk and become separated between the internal
oblique and transverse abdominal muscles. The ilioinguinal nerve may be absent in some case.

Ultasound Scan Technique

The ilioinguinal and iliohypogastric nerves medial to the anterior superior iliac spine are usually
loacted between the internal oblique and transverse abdominal muscles (fig 9). Both nerves are
detectable via ultrasound in transverse scan. It is not always the case that the two nerves can be
clearly distinguished from each other. Subsequently, it is not always possible to block the
particular nerves separately. In the clinical practice, one single needle position and subsequent
injection lateral or medial to the nerve structures is sufficient. The depth of the needle and final
position in between the correct space is the main determinant for successful blockade. The
ultrasonographic appearance of the nerves is typically hyperechoic and can be followed in a distal
and proximal direction. This tracking of the nerves is useful to distinguish between parts of fascial
layers and nerve structures. Sometimes the nerves appear as one nerve bundle.

Transverse sonogram of the inguinal region in an adult volunteer, from the level of the anterior superior
iliac spine (ASIS), showing the ilioinguinal and iliohypogastric nerves and their relation to the abdominal
musculature. EOM, indicates external oblique muscle, IOM, internal oblique muscle, and TA – transverse
abdominis.
 Transverse sonogram of the inguinal region in a child, from the level of the anterior superior iliac spine
(ASIS). Note that unlike that in the adult only two layers of muscle i.e. the IO, internal oblique and TA,
transversus abdominis muscle are visualized. The external oblique muscle is seen as a hyperechoic
aponeurotic layer at this level. The ilioinguinal and iliohypogastric nerves are seen in between the IO and
TA muscle at this level.

Ilioinguinal iliohypogastric nerve block in a child. Note the block needle (insert image) is inserted in-
plane and from a medial to lateral direction toward the iliac bone. We prefer this aproach to avoid
inadvertent deep needle insertion and potential bowel punture. ASIS, indicates anterior superior iliac
spine, IO, internal oblique muscle, and TA, transverse abdominis muscle.
Ilioinguinal iliohypogastric nerve block in a child. Transverse sonogram of the inguinal region after the
local anesthetic injection. Note the extensive spread of the local anesthetic. TA, indicates transversus
abdominis muscle.
 Saphenous Nerve Block

Anatomy
The spahenous nerve is a branch of the anterior division of the femoral nerve and supplies the skin
on the medial aspect of the leg and foot up to the ball of big toe. It travels with femoral artery
within the anterior fascial compartment of the thigh under the sartorius muscle (subsartorial), and
local anesthetic injected into this intermuscular space produces saphenous nerve block. The
“subsartorial canal” is also referred to as the adductor canal or Hunter's canal and is located on the
medial aspect of the middle one third of the thigh. It contains the following structures: femoral
artery and vein, saphenous nerve, anterior and posterior division of the obturator nerve, nerve to
vastus medialis. The saphenous nerve crosses the femoral artery anteriorly from a lateral to medial
direction. At the adductor hiatus, the saphenous nerve leaves the femoral artery and travels along
the lower edge of the aponeurosis of the canal and is closely related to the saphenous branch of the
descending genicular artery. The saphenous nerve sends off cutaneous branches to the medial leg,
up to the medial malleolus where the saphenous vein and nerve diverge. It continues
subcutaneously into the medial ankle and foot. It innervates osteotomes of the medial tibia, talus,
navicular, medial cuneiform and proximal medial portion of the first metatarsal.

Transverse anatomical illustration of the mid-thigh showing the anatomy of the adductor canal

Ultrasound Scan Technique

Patient is positioned supine with the bed completely flat or head slightly elevated. The leg is
externally rotated and the knee in the slight flexion. The anesthesiologist stands at the patient's
side with the ultrasound machine on the opposite side of the leg to be blocked. The primary surface
landmark is the mid-thigh, half way between the knee and either the inguinal crease or anterior
superior iliac spine (ASIS). Using ultrasound, the femoral artery should be the focus.
The transducer is placed transversely at the mid-point between the inguinal crease and the patella.
The femur is first visualized and as the transducer is passed medially the vastus medialis is seen
and then the femoral artery. The saphenous nerve may or may not be visible as a hyperechoic
structure just lateral to the artery in this canal, which is bounded superficially by the sartorius and
lareally by the vastus medialis muscles.

Figure showing the position and orientation of the ultrasound transducerduring a transverse ultrasound
scan of the adductor canal at the mid-thigh. The ultrasound transducer is placed at the mid-thigh level
with the knee in slight flexion and hip externally rotated for an ultrasound guided adductor canal block.
Figure highlighting the anatomical structures that are insonated during a transverse ultrasound scan of the
mid-thigh for a saphenous nerve block at the adductor canal. Sart, indicates sartorius, RF, rectus femoris,
VM, vastus medialis, VI, vastus intermedialis, VL, vastus lateralis, AL, adductor longus, AB, adductor
brevis, AM, adductor magnus, SN, sciatic nerve, SM, semimembranosus, ST, semitendinosus.

Transverse ultrasound scan of the adductor canal at the mid-thigh for a saphenous nerve block. FA,
indicates femoral artery.
Color Doppler ultrasound imaging of the adductor canalat the mid-thigh. FA, indicates femoral artery,
FV, femoral vein.

A sequence of transverse sonogram captured during an ultrasound guided saphenous nerve block at the
adductor canal. Note the orientation label has been placed below. (A) scout scan, (B) in-plane needle
insertion from a lateral to medial direction, (C) local anethetic (LA) injection with the needle tip
positioned in the adductor canal, (D) LA surrounding the saphenous nerve, (E-F) spread of the local
anesthetic distal to the site of injection. FA, indicates femoral artery, ST, sartorius, VM, vastus medial,
AL, adductor longus, SN, saphenous nerve.