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Fascia, once viewed as a passive structural tissue, is now recognized as a biologically active interface integral to musculoskeletal stability, force transmission, proprioception, and nociception. Despite the increasing clinical use of fascial plane blocks, the microanatomy of fasciae relevant to regional anesthesia remains poorly characterized. Understanding their histological features—including innervation, vascularization, and microstructure—is critical to optimizing anesthetic efficacy and elucidating mechanisms of pain and tissue response.
Methods
This systematic review was prospectively registered on the Open Science Framework (reference: yk4ua, 19 September 2025) and reported according to PRISMA guidelines. MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to September 2025 without language or date restrictions. Eligible studies included histological or microanatomical investigations of human fascial planes relevant to regional anesthesia (e.g., pectoral, thoracolumbar, abdominal, and fascia lata). Data were extracted independently by multiple reviewers, and study quality was assessed using the Anatomical Quality Assessment (AQUA) tool. Findings were synthesized qualitatively by anatomical region.
Results
Seventeen studies met inclusion criteria, encompassing fasciae from the thoracic, abdominal, lumbar, and lower limb regions. Fasciae exhibited considerable structural heterogeneity but shared a multi-layered organization of dense and loose connective tissue laminae rich in type I collagen. The fascia lata and thoracolumbar fascia demonstrated highly ordered collagen fiber orientation, multilaminar organization, and dense innervation, whereas thinner fasciae (e.g., pectoral fascia) showed simpler single-layer structures with fewer neural and vascular elements. Hyaluronic acid content ranged from 29 to 35 µg/g, with fasciacytes identified as the principal secretory cells. Nerve fibers—often associated with vessels and collagen bundles—were consistently present across all deep fasciae, with regional variations in density and mechanoreceptor type. Pathological changes, such as thickening, increased vascularization, and inflammatory infiltration, were reported in chronic pain states.
Conclusions
The fascia should be viewed as a dynamic, active tissue network rather than a passive sheath. Methodological limitations—including small sample sizes, regional heterogeneity, and histological artifacts—restrict current understanding. Future multimodal studies integrating histology, imaging, and biomechanics are warranted to clarify how fascial microstructure affects anesthetic diffusion, pain modulation, and postoperative recovery.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Fascia, long considered a passive, inert supporting structure, has emerged in recent decades as a dynamic, biologically active connective tissue interface central to musculoskeletal integrity, force transmission, sensorimotor integration, and nociception [1]. Its ubiquitous presence throughout the body—from the subcutaneous layers to the deep musculoskeletal compartments and visceral sheaths [2]—and its functional coupling with nerves, vasculature, and extracellular matrix render fascia a tissue of increasing interest in perioperative and pain medicine [3, 4].
Despite this growing interest and the widespread clinical application of fascial plane techniques in recent years—both as anatomical targets for various interfascial blocks and as potential sources of myofascial or postoperative pain—our understanding of their histological structure remains surprisingly limited. Most traditional descriptions are based on macroscopic dissection [5, 6], whereas histological and ultrastructural studies are few, heterogeneous, and often restricted to specific anatomical regions [7, 8].
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However, understanding fascia at the histological level is especially relevant in anesthesiology and regional analgesia. All the interfascial blockade techniques aim to deposit local anesthetic into fascial planes. Nevertheless, several key characteristics, such as the efficacy, spread, and duration of analgesia, may depend on the microstructure, permeability, and nerve density of those fasciae. Moreover, surgical manipulation, scarring, or inflammation of fascial tissues may incite remodelling or sensitization, with implications for post-operative pain or chronic pain states. The histologic diversity of different fasciae underscores the need for region-specific studies correlating microscale structure to anesthetic diffusion and nerve block outcomes. In this systematic review, we aim to synthesize current histologic knowledge of fasciae relevant to regional anesthesia practice and highlight gaps relevant to anesthesiology practice.
Methods
This systematic review was prospectively registered on Open Science Framework (reference: yk4ua, first registered on 19 September 2025). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed in the preparation of this manuscript [9, 10].
Search strategy
We conducted a systematic search of the medical literature for the identification, screening, and inclusion of relevant studies. The databases MEDLINE, Embase, and Cochrane CENTRAL, all accessed through Ovid, were searched from inception to 19 September 2025, with no restrictions on language or publication year. The search string used to query the Ovid database is shown in Supplementary material 1.
Inclusion/exclusion criteria
Studies were included and excluded according to the following PIOS criteria: (P) human subjects or human cadaveric specimens (I) studies were included if they involved micro-anatomical investigations using dissection and/or histological examination of the following fascial planes–pectoralis fascia, serratus anterior investing fascia, thoracolumbar fascia, abdominal fasciae (transversalis fascia, fascia of the internal oblique muscle, fascia of the transversus abdominis muscle, rectus sheath), fascia iliaca/fascia lata, (O) innervation patterns, microvascular architecture, and histological characteristics encompassing fascial composition, collagen fibers’ orientation, and layer thickness (S) eligible study designs included original anatomical research based on cadaveric dissection and/or histological analysis.
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Study selection
All retrieved records were exported and uploaded into the web-based software Rayyan (https://www.rayyan.ai/), a web-based tool for systematic review management. Two reviewers (FM and YS) independently screened titles and abstracts, classifying each study as included, excluded, or undecided. Any discrepancies between reviewers were resolved by consultation with a third investigator (ADC).
Data extraction and retrieval
Following identification of eligible studies, three reviewers (FM, YS, and ADC) independently extracted data from each included article using a standardized form. Disagreements were resolved through discussion and reassessment of the original publication. For continuous variables, means and standard deviations (or medians and interquartile ranges when appropriate) were extracted. For categorical variables, absolute counts and percentages were recorded.
Risk of bias assessment
The risk of bias of included anatomical studies was appraised using the Anatomical Quality Assessment (AQUA) tool, adapted where appropriate [11]. The AQUA tool is a structured instrument designed to evaluate the methodological quality and risk of bias in anatomical research. It assesses key domains such as study objectives, methodology, reporting transparency, and reproducibility.
Two independent reviewers (YS and FM) assessed the risk of bias, and any disagreements were resolved by consulting a third reviewer (ADC).
Data synthesis
A qualitative synthesis was performed summarizing findings for innervation, vascularization, and histological structure of each fascial plane. When comparable quantitative data were available (e.g., fascial thickness), descriptive statistics were reported. Results were presented in structured tables and summarized narratively according to anatomical region.
Results
Flow of the study with research articles’ retrieval is depicted as PRISMA flowchart in Fig. 1.
Initial screening identified 1997 studies, and 14 additional studies were checked by reviewing the references of included articles and evaluating the articles citing the included articles. Of these, 1152 search results were excluded during the preliminary screening as they were unrelated or duplicates. Of the remaining 58 articles, 41 articles were further excluded according to our inclusion/exclusion criteria, leaving a total of 17 articles included for qualitative synthesis. The list of articles excluded at the full-text review stage, along with the corresponding reasons for exclusion, is provided in the Supplementary material 1 (SDC1).
Study characteristics
The characteristics of the included studies are presented in Table 1, while a summary of the main features of the fasciae investigated is provided in Table 2. In summary, we included 17 research articles from 10 different countries [12‐28]. Tissues were harvested from surgical patients in five articles, from cadavers in nine, from both in one study, while in two studies it was not explicitly stated. Most of the studies were at low risk of bias; two had an unclear risk, and four were at high risk of bias (Table 3).
C cadaver, FL fascia lata, NS not stated, P pectoralis fascia, RS rectus sheath, TLF thoraco lumbar fascia. Numerical data are presented as reported in the primary sources, either as mean with or without standard deviation, or as a range
Table 2
Micro-anatomical characteristics of key fascial planes and their potential relevance to regional anesthesia
Fascia
RA technique of interest
Mean thickness and structure
Mean HA content (µg)
Nerve fibers
Fascia lata
Fascia iliaca block
805 to 944 µm with anterior to posterior thickness gradient
35.4 ± 3
+
Pectoral fascia
Interpectoral plane block
Pectoserratus plane block
297 µm with cranio-caudal thickness gradient
NI
+
Rectus sheath
Rectus sheath block
densely packed fibrous bundles interspersed with small amounts of adipose tissue
29.1 ± 0.2
NI
Fascia transversalis
Transversalis fascia plane block
Quadratus lumborum plane block
thin layer composed by an elastic system comprising three distinct fiber types—oxytalan, elaunin, and elastic fibers
NI
NI
Thoracolumbar fascia
Erector spinae plane block
Retrolaminar plane block
Quadratus lumborum plane block
Up to 1500 µm. Two-layers with a trilaminar structure with each lamina separated by thin, loose connective tissue rich in type I collagen
D1 objectives and subject characteristics, D2 study design, D3 methodology characterization; D4 descriptive anatomy, D5 reporting of results
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Fascia lata (FL)
The mean thickness of FL ranges approximately from 805 [27] to 944 µm [23], showing regional variation along the limb. An anterior-to-posterior thickness gradient has been demonstrated, with FL tending to be thinner on the medial surface of the thigh. Measured thicknesses across regions were 556.8 ± 176.2 µm anteriorly, 820.4 ± 201 µm medially, 1112 ± 237.9 µm laterally, and 730.4 ± 186.5 µm posteriorly [27]. The mean hyaluronic acid (HA) content is 35.4 ± 3 μg per gram of tissue [13]. The HA is produced by small clusters of fibroblast-like cells that are positive for the fibroblast marker vimentin, but not for anti-CD68, the fasciacytes [29].
The micro-architecture of the FL exhibits a multi-layered structure, with each layer separated by thin, loose connective tissue rich in type I collagen [17, 27]. In each layer, the fibers are parallel to each other, whereas the orientation of the fibers varies from one layer to the adjacent one [23]. The outer layers (superficial and deep) show characteristics similar to those of the epimysial fascia, while the median layer shows an aponeurotic aspect [21]. The outer layers form a thin lamina characterized by a high density of nerve fibers. The superficial layer comprises fibroblasts, adipocytes, nerve fibers, and blood vessels [27] with a particularly rich presence of neurovascular and elastic components [23]. The deep layer shares a similar composition, consisting of loosely arranged collagen and numerous fibroblasts, but exhibits a lower density of neurovascular and elastic elements [27]. The intermediate layer is composed of several different layers of densely packed collagen fibers regularly aligned but varying from layer to layer [21] with a characteristic crimped pattern and sparse elongated fibroblasts aligned parallel to the fibers; elastic fibers are nearly absent [27]. Numerous vessels, averaging 102 ± 35 μm in diameter, coursed tortuously through the collagen layers of the muscular fascia. Nerve fibers were present in all deep fascia specimens—abundant around vessels and evenly distributed within the fibrous matrix [21]. Larger nerves were encased in loose connective tissue, while smaller fibers attached to collagen bundles, often running perpendicularly and likely responsive to collagen stretch [21, 23].
Pectoral fascia
The pectoral fascia appears as a thin collagen layer (mean thickness of 297 μm) with a thickness that increases in a cranio-caudal direction, demonstrating a mean thickness of 131 μm (± 19 μm) in the subclavicular region, 182 μm (± 84 μm) in the mammary region, and 578 μm (± 42 μm) in the inferior thorax region.
The micro-architecture of the pectoral fascia is composed of a single layer of undulated collagen fibers interspersed with numerous elastic fibers, within which small nerves can be identified. Multiple septa extend from its inner surface, establishing close connections between the fascia and the pectoralis major muscle. The proportion of elastic fibers relative to collagen fibers is estimated to be approximately 15%. S100 staining revealed nerve endings distributed homogeneously throughout the entire pectoral fascia [22, 23]. These correspond to mechanoreceptors—such as Ruffini and Pacinian corpuscles—as well as free nerve endings, the latter predominantly located in proximity to blood vessels [20].
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Rectus sheath and fascia transversalis
The rectus sheath is composed of densely packed fibrous bundles interspersed with small amounts of adipose tissue, with a mean HA content of 29.1 ± 0.2 µg per gram of tissue [13].
The fascia transversalis is a thin layer of deep fascia that lies deep to the rectus sheath and runs throughout the abdominal wall. It is composed of an elastic system comprising three distinct fiber types—oxytalan, elaunin, and elastic fibers—arranged in a precise hierarchical sequence among fibrils, fibers, and collagen fiber bundles, respectively [19]. With aging, the proportion of oxytalan fibers decreases, while the amorphous component of the elastic fibers increases [19]. In morbidly obese individuals, fiber density is reduced, the normal architecture is disrupted, and the bundles appear thinner, less regularly arranged, and contain approximately five times less elastin [24].
The hydration percentage is comparable between the fascia transversalis and the rectus sheath; however, the collagen concentration per milligram of dry weight is significantly higher in the rectus sheath. Conversely, the percentages of extractable collagen obtained using NaCl, acetic acid, and pepsin are significantly greater in the fasciae. Qualitatively, fasciae show a decrease in the proportion of β-chains and a trend toward a lower type I/III collagen ratio compared with the rectus sheath [16].
Thoracolumbar fascia (TLF)
The thoracolumbar fascia has been described as a tri-layer or two-layer structure. In the three-layer model, the thoracolumbar fascia has posterior, middle, and anterior layers that enclose the erector spinae and quadratus lumborum muscles, with the anterior layer covering the psoas major. In the two-layer model, the fascia is simplified into superficial and deep parts, excluding the psoas fascia, which is considered a separate structure. In this manuscript, we will refer to the two-layer model.
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The posterior layer presents a progressive thickness from thoracic to sacral regions varying from 190 to 450 μm [15], while some studies reported even greater thicknesses, up to 1500 μm [30].
The micro-architecture of the TLF is complex, with specific characteristics for each of the layers. However, each of the two layers has a trilaminar structure, with each lamina separated by thin, loose connective tissue rich in type I collagen [27].
In the superficial layer, the superficial lamina contains fibroblasts, adipocytes, and neurovascular elements, while the deep lamina consists of loosely arranged collagen fibers and abundant fibroblasts, but fewer elastic and vascular components [27].
The intermediate lamina, which has the greatest volume fraction, comprises dense collagen sublayers with different spatial orientations—each separated by a thin layer of loose connective tissue. Fibroblasts and elastic fibers are sparse throughout this region [27]. The number of intermediate laminae varies with spinal level, showing a gradual increase from the cranial to the sacral regions [26].
Nerve endings in the TLF were first identified 50 years ago [14], but a more detailed characterization has been accomplished only recently. Anti-S100 immuno-stain revealed the presence of small nerves in both the borderline between the muscle and the inner surface of the TLF superficial layer, as well as on the medial side of the TLF superficial layer [18]. However, the innervation is not evenly distributed among the two layers of the TLF; the outer lamina of the superficial layer is the most densely innervated, whereas the deep layer, corresponding to the tendon of the latissimus dorsi muscle, is largely devoid of nerve endings [25]. Moreover, the sacral region is more highly innervated than the thoracic regions [15]. Some authors identified two types of mechanoreceptors—Ruffini corpuscles (Type I) and Vater–Pacini corpuscles (Type II)—along with nerve bundles [28]. However, these findings should be interpreted with caution, as several studies have been unable to replicate them [31].
Alterations of the TLF have been reported in patients with chronic back pain and no history of surgery or interventional pain treatments (such as epidural injections). In these patients, the TLF exhibits thickening, microcalcification, infiltration by lymphocytes and plasmacells, together with increased vascularization [12].
Discussion
This systematic review synthesizes current histological evidence on human fasciae relevant to regional anesthesia, highlighting substantial anatomical diversity among fascial planes. Across regions, fascia exhibits a multi-layered architecture, with alternating dense and loose connective tissue laminae containing variable concentrations of collagen, elastic fibers, vessels, and nerve endings. Such heterogeneity likely underpins the differing patterns of anesthetic spread and efficacy observed in interfascial plane blocks (Fig. 2). The fascia lata and thoracolumbar fascia, for instance, display highly organized collagen networks and abundant innervation—features that may influence both mechanical tension and nociceptive sensitivity—whereas thinner fasciae such as the pectoral fascia show simpler collagen organization and fewer layers. All these considerations are crucial for fully understanding the potential effects of fascial blocks in regional anesthesia [32].
The structural complexity of fascia suggests that its role extends far beyond a passive supporting framework. Contemporary fascial research [31] proposes that fascia is a dynamic, continuous tissue network that evolves hierarchically from embryonic development and continuously adapts to mechanical stress. This conceptual shift reframes fascia as an active participant in force transmission, proprioception, and tissue homeostasis—an understanding increasingly relevant to perioperative medicine, where fascial integrity and remodelling may affect postoperative pain and functional recovery [33].
Clinical implications
A growing body of literature supports the notion that the structural characteristics of fascial planes actively influence the effectiveness of regional anesthesia techniques. However, quantitative data directly linking measured fascial thickness or nerve density to predictable changes in block duration remains limited. Consequently, most of the discussion points addressed in this paragraph are based on pragmatic and physiological reasoning rather than evidence from large cohort studies or randomized controlled trials.
Fascial microstructure and the anatomical variability of different fascial layers may exert a substantial influence on the clinical performance of fascial plane blocks. Among the most important features to consider is fascial innervation. The presence of abundant free nerve endings in some fascial layers—but not in others—suggests that certain fasciae may themselves serve as primary targets of local anesthetic, rather than functioning solely as conduits to larger peripheral nerves. This concept is particularly relevant in the context of myofascial pain, where the fascia has been proposed as a true “pain generator” [34] and where direct modulation of fascial nociceptors may contribute substantially to the analgesic effect of fascial plane blocks [35], while variability in fascial innervation and microstructure may partly explain the inconsistent clinical block patterns and dermatomal coverage frequently observed with these techniques [36].
Indeed, emerging evidence suggests that even microanatomical variations in fascial layers—including layer thickness and extracellular-matrix composition—play a critical role in modulating the spread, onset, and duration of local anesthetic in fascial plane blocks [37]. Denser or thicker fascial layers may act as partial barriers to bulk flow, thereby limiting immediate transverse distribution of the injected solution and slowing onset, whereas looser layers facilitate more widespread dispersion [36, 37], while a richness in HA may promote local anesthetic spread. Finally, the pharmacokinetics of FPBs appear to reflect both local diffusion and systemic absorption, with unpredictable contributions from each pathway, further modulated by fascial vascular microstructure; this underlies not only the variable block durations reported in clinical practice but also explains the rapid adsorption and the increased risk of local anesthetic toxicity when compared with peripheral nerve blocks [38‐40]. However, despite these mechanistic hypotheses, there remains a lack of quantitative, patient-level data correlating measured fascial thickness or nerve density with clinical outcomes, underlining the need for future imaging–anatomy–pharmacokinetic studies.
Risk of bias
Assessment of the included studies using the AQUA tool highlighted important sources of potential bias. Several studies were rated as high risk due to incomplete reporting of subject characteristics, lack of prospective study registration, or partial description of results, which limits confidence that our review captures all relevant data. Consequently, some observed features may reflect particular subsets of patients rather than generalizable findings. Given the small sample sizes across studies, further stratification or subgroup analysis was not feasible. To mitigate the impact of these biases, we deliberately avoided quantitative synthesis and instead performed a qualitative, narrative synthesis of the retrieved results. This approach allows integration of the available histological evidence while minimizing the risk of overinterpretation of findings derived from methodologically limited studies.
Limitations
Interpretation of histological findings must be tempered by methodological limitations. Classical anatomical dissection traditionally removes fascial layers to reveal muscle, thereby emphasizing myocentric over fascial structures and underestimating fascia’s continuity and mechanical significance. Furthermore, conventional histological processing—particularly fixation, dehydration, and staining—may introduce artifacts such as shrinkage, distortion, and disruption of the delicate collagen-elastin-hyaluronan matrix, potentially obscuring the true in vivo architecture of the deep fascia [41‐43]. These technical constraints underscore the need for more advanced imaging and preservation methods, such as confocal microscopy, multiphoton imaging, or cryo-histology, to better capture the living dynamics of fascial tissue. A further limitation of our review is that, while we identified relevant micro-anatomical data for several fascial planes, we were unable to locate histological studies in humans for others. Although some animal studies were available, these were excluded in accordance with our PICOS criteria, as their findings could not be reliably translated to human anatomy. Similarly, given our PICOS, we excluded studies not specifically focusing on histological examination, which means we may have missed relevant information that could have been retrieved from macroscopic dissection or imaging studies. The absence of human histological evidence for certain fasciae may reflect a true lack of distinct anatomical structures; however, it is also possible that relevant studies were missed due to the search strategy employed, including the choice of keywords, databases, and search filters. We also acknowledge that our investigation was not exhaustive for all fasciae of potential relevance to anesthesiologists. While many key fascial planes were examined, others remain uninvestigated and warrant future systematic exploration. Finally, while several studies report associations between fascial thickening, increased vascularization, and inflammatory infiltration in chronic pain states, these findings derive largely from small, heterogeneous samples. The evidence base remains limited by regional variability, small sample sizes, and inconsistent methodological rigor.
Conclusions
The fascia should be viewed as a dynamic, active tissue network rather than a passive sheath. Methodological limitations—including small sample sizes, regional heterogeneity, and histological artifacts—restrict current understanding. Future multimodal studies integrating histology, imaging, and biomechanics are warranted to clarify how fascial microstructure affects anesthetic diffusion, pain modulation, and postoperative recovery.
Acknowledgements
None.
Declarations
Competing interests
Alessandro De Cassai serves as an Associate Editor for the Journal of Anesthesia, Analgesia and Critical Care and was invited to submit this manuscript. This role had no influence on the editorial or peer review process. The other authors declare no conflicts of interest
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Beim Abwaschen wurden die Rückenschmerzen jedes Mal unerträglich. Eine 74-Jährige behalf sich mit einem Trick – und erreichte damit, dass ihr nun auch noch der Arm wehtat und die Finger kribbelten.
Als „gefährliches Duo“ bezeichnen zwei Ärzte aus Südkorea die gleichzeitige Anwendung von nichtsteroidalen Antirheumatika (NSAR) und Metformin. Sie schildern den Fall einer älteren Patientin, die mit einer lebensbedrohlichen Laktatazidose in der Notaufnahme vorgestellt wurde.
Den heißen Tee in der Hand und die Wärmflasche auf dem Bauch: Gerade im Winter bringt man solche Situationen im Allgemeinen mit Wohlbehangen in Verbindung. Ein chirurgisches Team warnt jedoch mit einer Serie von Verbrühungsfällen vor Unachtsamkeit.
Einfach alles beim alten lassen, oder doch für die Vorhaltepauschale Abläufe ändern? Arzt und Praxisberater Dr. Georg Lübben erläutert im Interview, für wen es sich lohnen könnte, aktiv zu werden.
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