Journal of Clinical Anesthesia xxx (xxxx) xxxx
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Journal of Clinical Anesthesia
journal homepage: www.elsevier.com/locate/jclinane
Correspondence
Can high volume pericapsular nerve group (PENG) block act as a lumbar plexus block?
ARTICLE INFO
Keywords:
Pericapsular nerve group block
Lomber plexus block
High volume
Dear editor,
Pericapsular nerve group (PENG) block has been recently re-
commended by Girón-Arango et al. for use as postoperative analgesia in
hip surgeries [1]. It is a new regional anesthesia method based on
blocking the articular branches of femoral nerve (FN) and accessory
obturator nerve (AON) in the region between the anterior inferior iliac
spine (AIIS) and iliopubic eminence (IPE).
To demonstrate the effectiveness of PENG block, Girón-Arango et al.
[1] used 20 ml local anesthetic (LA) with PENG block on 5 patients who
underwent hip surgery and reported an average decrease of 7 points in
the pain scales of the patients. Yu et al. [2] reported quadriceps
weakness possibly related to the FN block in two patients in whom
PENG block was applied with the same volume. Although Girón-Arango
et al. [3] stated that the possibility of quadriceps weakness develop-
ment owing to femoral block is extremely low as long as the end of the
needle stays deep in the tendon of the psoas muscle, clinical use of the
blocks with high volume LA applications is interesting. In our last case
report, we successfully used the PENG block as the main anesthetic
method; we applied 30 ml of PENG block in the medial thigh region for
mass excision [4]. We also reported PENG block for prevention of ad-
ductor muscle spasm and varicose vein surgery (ligation and stripping)
with high volumes [5,6].
It is deemed possible to apply high volume LA in the interfascial
plane to the region between the psoas tendon and the bone tissue in the
plain between AIIS and IPE, to advance from the deep iliopsoas muscle
toward the lateral and surround the muscle and reach the lateral fe-
moral cutaneous nerve (LFCN) and continue from the medial of this
muscle and reach FN. The answer to the question whether the PENG
block can spread to obturator nerve depends on the volume adminis-
tered. Iliopectineal fascia, which forms the medial end of the iliac
fascia, can be a barrier preventing the LA to move further medial and
reach the obturator nerve in the deep pectineus muscle. However,
considering that iliopectineal fascia has a short course in the cranio-
caudal direction, it can be speculated that application of high volume
LA with PENG block results in subpectineal ON block [7]. However, it
must be considered that pushing the needle under the pectineus muscle
to administer high volume can result in ureter damage [8].
When all these possibilities are evaluated together, can we admin-
ister the 3 in1 block and perhaps even more (almost the lumbar plexus
block) we expected from the fascia iliaca compartment block with the
https://doi.org/10.1016/j.jclinane.2019.109650
Received 23 October 2019; Accepted 10 November 2019
0952-8180/ © 2019 Published by Elsevier Inc.
applied high volume PENG block (will its name still remain as PENG?)
Herein, we present the results of the PENG block that we applied in
high volumes.
The patients whose data is used in this report provided written,
informed consent to publish the case.
Case 1 was of a 43-year-old male who presented with right leg re-
current varicose veins. In venous Doppler ultrasonography, great sa-
phenous vein and anterior accessory saphenous vein showed reflux. It
was decided that PENG block would be applied as the region for liga-
tion and stripping was in both femoral and obturator dermatomes.
PENG block was applied with 15 ml 0.5% bupivacaine plus 15 ml 2%
lidocaine (total volume: 30 ml). In the sensory examination performed
20 min later, sensory loss was noted in the LFCN, genitofemoral, ante-
rior femoral cutaneous, obturator, and saphenous nerves. Moreover
patient reported significant quadriceps weakness with the inability to
achieve a straight leg raise. The surgery was performed without com-
plications and there was no need for any additional analgesics.
Case 2 was of a 65-year-old female who presented with left femur
intertrochanteric fracture. It was decided to administer PENG block for
positioning prior to spinal anesthesia. The VAS score was 9 before ap-
plying PENG block. PENG block was applied on the patient with total
volume of 30 ml (15 ml 0.5% bupivacaine +15 ml 2% lidocaine). VAS
score decreased to 1 within 10 min after the application. After 20 min,
sensory testing of the femoral, obturator, lateral femoral cutaneous
(LFCN), and genitofemoral nerves dermatomes revealed a sufficient
level of anesthesia. Motor examination could not be performed because
of the patient's fracture. The patient was put into right lateral decubitus
position without any pain, and there was no need for any additional
opioids during this process. The VAS score during positioning was 2.
The advantages of PENG block to LPB are as follows: it can be ap-
plied in the supine position; injection point is far from neurovascular
tissues; it is relatively safer for patients using anticoagulants; and bi-
lateral block probability is nearly zero. Moreover, although quadriceps
weakness has been previously reported after PENG block [2], its
probability is delivered at high volumes as in our case 1.
In conclusion, although it is not yet possible, in the future, cada-
veric, radiologic, and randomized controlled studies will provide an-
swers to the following questions: can PENG block be an alternative to
lumbar plexus block? In which surgeries and new indications can it be
used?
Correspondence Journal of Clinical Anesthesia xxx (xxxx) xxxx

Funding [5] Ahiskalioglu A, Aydin ME, Ozkaya F, Ahiskalioglu EO, Adanur S. A novel indication
of Pericapsular Nerve Group (PENG) block: prevention of adductor muscle spasm. J
Clin Anesth 2019;60:51–2.
The authors have no sources of funding to declare for this manu- [6] Aydin ME, Borulu F, Ates I, Kara S, Ahiskalioglu A. A novel indication of Pericapsular
script. Nerve Group (PENG) block: surgical anesthesia for vein ligation and stripping. J
Cardiothorac Vasc Anesth 2019. https://doi.org/10.1053/j.jvca.2019.08.006. pii:
S1053-0770(19)30827-4 [Epub ahead of print].
Declaration of competing interest [7] Nielsen TD, Moriggl B, Soballe K, Kolsen-Petersen JA, Borglum J, Bendtsen TF. A
cadaveric study of ultrasound-guided subpectineal injectate spread around the ob-
All authors declare no conflicts of interest. turator nerve and its hip articular branches. Reg Anesth Pain Med 2017;42:357–61.
[8] Mistry T, Sonawane KB, Kuppusamy E. PENG block: points to ponder. Reg Anesth
Pain Med 2019. https://doi.org/10.1136/rapm-2018-100327. rapm-2018-100327
References [Epub ahead of print].

[1] Giron-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group Ali Ahiskalioglu (Assoc. Prof.)a, , Muhammed Enes Aydin (Assistant
⁎

(PENG) block for hip fracture. Reg Anesth Pain Med 2018;43:859–63.
[2] Yu HC, Moser JJ, Chu AY, Montgomery SH, Brown N, Endersby RVW. Inadvertent
Prof.)a, Mine Celik (Assoc. Prof.)a, Elif Oral Ahiskalioglu (Assoc. Prof.)a,
quadriceps weakness following the pericapsular nerve group (PENG) block. Reg Serkan Tulgar (Assoc. Prof.)b
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Anesth Pain Med 2019;44:611–3. Department of Anesthesiology and Reanimation, Ataturk University School
[3] Giron Arango L, Peng P. Reply to Dr Yu et al: inadvertent quadriceps weakness
of Medicine, Erzurum, Turkey
following the pericapsular nerve group (PENG) block. Reg Anesth Pain Med b
2019;44:613–4. Department of Anesthesiology and Reanimation, Maltepe University School
[4] Ahiskalioglu A, Aydin ME, Ahiskalioglu EO, Tuncer K, Celik M. Pericapsular nerve of Medicine, Istanbul, Turkey
group (PENG) block for surgical anesthesia of medial thigh. J Clin Anesth E-mail address: ali.ahiskalioglu@atauni.edu.tr (A. Ahiskalioglu).
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⁎
Corresponding author at: Ataturk University School of Medicine, Department of Anesthesiology and Reanimation, 25070 Erzurum, Turkey.