peripheral nerve blocks lower extremity

7/26/2019 PERIPHERAL NERVE BLOCKS LOWER EXTREMITY

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PERIPHERAL NERVE BLOCKS

LOWER EXTREMITY


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Spinal and epidural anesthesia aremost often employed for regional

anesthesia of the lowerextremities. Peripheral nerveblocks in the lower extremity canalso provide excellent surgicalanesthesia for some proceduresbut require multiple injectionsand may be tehchnicallly more

challengging in some cases.

Introduction


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Anatomi of Lumar!acra" #"$%u!&


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'$rmatom$! and o!t$otom$! of t($

"umo!acra" #"$%u! ar$ i""u!trat$d&


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NerveSpinal

Segment

Motor Innervation Motion Observed* Sensory InnervationArticularBranches

Iliohypogastric T12 !1 Int"e#t obli$ueTransverse

abdominis

Ant abdominal%all

In&erior abd %all'pper lat $uadrant o&

buttoc(

None

Ilioinguninal !1 Int obli$ue Ant andominal%all

In&erior to medial aspecto& inguinal ligament

)ortion o& genitalia

None

enito&emoral !1 !2 +remaster Testicular In&erior to mind portiono& inguinal ligament

Spermatic cord

None

!ateral,emoral+utaneous

!2 !- None Anterior lateral andposterior aspects o&thigh terminating inprepatellar ple#us

,emoralAnterior

division

)osteriordivision

!2 !.Sartorious

)ectineus/uadriceps

Saphenous

Medial aspect o&the lo%er thigh

Adductor o& thigh0nee e#tension

patellarascension

Anterior medial s(in o&the thigh

NoneAnt Thigh

Medial leg &rom the tibiato the medial aspect o&the &oot

None

ip and

0nee

OburatorAnterior

division

)osteriordivision

!2 !.racilus adductor

brevis 3 longuspectineus

Obturator e#ternusadductor magnus

Thigh adduction

Thigh adduction%ith lateral hiprotation

4ariabel posteriormedial thigh medial(nee

ip

0nee

abel Lumbar Plexus natomy

ions: Int, internal; Ext, external; Ant, anterior; Abd, abdominal; Lat, lateral.bserved refers to the observed motor response with electrical stimulation of that nerve.


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NerveSpinalSegme

ntMotor Innervation Motion Observed* Sensory

Innervation

ArticularBranches

luteal nerves !. S2 )iri&ormis sup"in&gemellus obturatorinternus $uadratus&emoris

Buttoc(s %ith lathip rotation

'pper medialaspect o& buttoc(

ip

Sciatic tibial !. S- Biceps &emorissemitendinosusadductor magnus

)opliteus

astrocnemius

soleus 5e#ors o&&oot

amstrings %ith(nee e#tension

0nee 5e#ion)lantar 5e#ion

Toe 5e#ion

Medial and lat heelsole o& &oot

ip (nee andan(le

Sciaticperoneal

Super6cial

7eep

Sural

+omponents&rom peroneal3 tibial

!. S-

None

Short head o& biceps&emoris peroneuslongus brevis

8#tensors o& &oot toes

None

0nee 5e#ion,oot inversion

7orsi5e#ion o&&oot an(le

None)ost cal& lat

border o& &ootand 9thtoe

7istal anterior legdorsum o& &oot

:eb space o& 1sttoe

None

None

0nee and an(le

An(le

)ost cut nerveo& thigh

S1 S- None None 7istal medial$uadrant o&buttoc(perineum postthigh including

popliteal &ossa

None

abel Sacral Plexus natomy

ions: up, superior; Inf, inferior; Lat, lateral; !ost, posterior; "ut, cutaneous.

bserved refers to the observed motor response with electrical stimulation of that nerve.


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P!oa! Com#artm$nt B"oc)&

!escribed by "hayen et al# in$%&'

Single injection or with cateter

(ndication )peratif prosedure in the lumbarplexus suplay area *T+,T-

nalgesia


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Side e/ects,complications0essel puncture *paravertebral

veins !issemination similar to epiduralanesthesia *contralateral

+igh *total spinalnatomical landmarks Posterior superior iliac spine

(liac crest Spinous process L1 "ostal process L2


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Blockade technique

The patient is in the lateral recumbent

position (or seated), the cervical spine isflexed backwards

Puncture site3 cm caudad, cm midline to the spinous

process !"#

Puncture depth $ % & ' cm


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P!oa! com#artm$nt "oc) * Punctur$ !it$

(liac crestSpinous process of

the 1thlumbarvertebraPosterior superior

iliac spine Puncture site

Positive stimulatoryrespon from the

femoral nerve 3quadriceps muscle*usually the vastuslateral muscle


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+$mora" N$r,$ B"oc)&ndication

*perative procedure in areas suppl+in the

femoral and lateral femoral cutaneus

nerves

n combination with proximal sciatic nerveblock, operative procedures on the whole

le (from dista! to foot)

-nalesia -.! (anterior cruciate liament

reconstruction), T/-


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0ide 1ffect2.omplication

essel puncture (of the femoral vein or

arter+)

-natomical !andmarks

4roin

5emoral arter+

-nterior superior iliac spine

Pubic tubercle

nuinal liament


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Blockade technique

The patient lies on his back, his le loosel+

abducted and turned to the outside#

Puncture site

6 cm caudad to the roin, ' & 6 cm lateral

to the lateral femoral arter+#

Puncture direction

3 & "7 cranial pararel to the arter+

Puncture deep

6 & " cm


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Ant$rior and cro!!-!$ctiona" ,i$.! of t($

f$mora" n$r,$


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+$mora" n$r,$ "oc) anatomic "andmar)!

'# -nterior superior

iliac spine

6# Pubic tubercle

3# Puncture site


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+$mora" n$r,$ "oc) * Punctur$ !it$

(nguinal ligamen4emoral arterynterior superior

iliac spine

Puncture site

Positive stimulatoryresponse from thefemoral nerve 3

5ectus muscle of thethigh *6dancingpatella7


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+$mora" n$r,$ "oc) * Punctur$ t$c(ni/u$


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Sciatic N$r,$ B"oc)

ndications *perative procedure in areas suppl+in the

sciatic nerve

n combination with psoas compartementblock2 femoral nerve block for operations on

the whole le

-nalesia


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0ide effects2complications

essel puncture (inferior luteal arter+)-rter+, vein and neural femoral in8ur+ if use

approach accordin to 9eier (anterior

sciatic nerve block)

-pproach

Parasacral sciatic nerve block ( 9ansour)

Transluteal sciatic nerve block (!abat)

-nterior sciatic nerve block (9eier)


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Para!acara" Sciatic N$r,$ B"oc)

0Man!our1

-natomical landmarks

Posterior iliac spine

schial tuberosit+Blockade technique

The patient is placed in the lateral recumbent

position, hip flexed "7, knee flexed :7, orboth knee aainst the abdomen


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Para!acara" !ciatic n$r,$ "oc)

0Man!our1

Puncture site

-pprox & % cm caudad to the posterior

superior superior iliac spine alon theconnectin line to the ischial tuberosit+

nsertion direction

67;37 caudad to midline between ischialtuberosit+ and reater trochanter#

Puncture deep $ % & < cm


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Para!acara" Sciatic N$r,$ B"oc)0Man!our1

'# 4reat trochanter

6# Posterior superior iliac

spine

3# schial tuberosit+

"# Puncture site

Positive stimulatoryresponse from theperoneal andtibial nerves3

extensors or8exors of thefoot,toes


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Tran!2"ut$a" !ciatic n$r,$ "oc)

0Laat1

-natomical landmarks

Posterior superior iliac spine

4reater trochanter 0acral hiatus

Blockade technique

The patient is palced in the lateral recumbentposition= hip flexed "7, knee flexed :7

(>stable recumbent position?)

T " t " i ti " )


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Tran!2"ut$a" !ciatic n$r,$ "oc)

0Laat1

Puncture site"; cm mediocaudal on the midperpendicular

lines between reater trochanter and posterior

superior iliac spine= connectin line betweenthe reater trochanter and sacral hiatus

intersecs the insertion point at the mid;

perpendicular line#

nsertion direction $ perpendicular to the surface

Puncture deep $ & < cm


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Tran!2"ut$a" a##roac( * Po!itionin2 of t($

#ati$nt


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Tran!2"ut$a" a##roac( * Punctur$ !it$

9reatertrochanter

Posterior

superior iliacspine (schial

tuberosity Sacral hiatus : Puncture site

Positivestimulatoryresponse fromthe peroneal and

tibial nerves3


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Ant$rior !ciatic n$r,$ "oc) 0M$i$r1

'# -nterior superior iliac

spine

6# Pubic s+mph+sis

3# 4reater trochanter

"# Puncture site

Positive stimulator+

response from the

peroneal and tibial

nerves $

1xtensor or flexor of the

foot2toes


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Po#"it$a" +o!!a B"oc)&

ndication

*perative procedures in the area suppl+in

the sciatic nerve of the lower le @ foot n combination with saphenous nerve block,

operations on the whole lower extremit+

-nalesia


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Po#"it$a" +o!!a B"oc)

0ide effects2complications essel puncture (popliteal arter+2vein)

-natomical landmarks Popliteal fossa

Popliteal fold

!on head of the biceps femoris muscle 9edial and lateral epicond+le of the femur


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Blockade technique

The patient is either in the prone position or

l+in on his side, le extended

Puncture site

-pprox < & '6 cm above the fold of the

popliteal fossa at the medial ede of the

biceps femoris muscle, laterall+ markin the

popliteal fossa

nsertion direction $ 37 cranial and lateralPuncture deep $ 6 & " cm


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Po#"it$a" +o!!a B"oc) * Punctur$ !it$

Lateral;edial Puncture site

Positivestimulatoryrespons from theperoneal andtibia nerves3


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Po#"it$a" +o!!a B"oc) * Punctur$ t$c(ni/u$


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'ru2! and E/ui#m$nt! for P$ri#($ra" B"oc)!&


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'ru2! and E/ui#m$nt! for P$ri#($ra" B"oc)!&


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TERIMA KASIH


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R$2iona" An$!t($!ia in C(i"dr$n


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+$mora" N$r,$ B"oc)

4emoral nerve blockade can be quiteuseful in procedures such as surgery onthe femoral shaft# osteotomies# quadriceps

muscle biopsy# knee surgery and evenclubfoot repairs *with some peripherallocal supplementation. This block can beplaced by using a knowledge of the

anatomy of the femoral region and alsowith judicious use of a nerve stimulator.=hen using a nerve stimulator inanestheti>ed pediatric patients# it is useful

to remember that the current applied


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'ra.in2 !(o.in2 anatom3 and #"ac$m$nt of a f$mora" n$r,$

"oc) .it( t($ aid of a n$r,$ !timu"ator


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P(oto2ra#( of f$mora" n$r,$ "oc) $in2 #"ac$d .it(

aid of a n$r,$ !timu"ator


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Sciatic N$r,$ B"oc)ad$

The block provides excellent analgesia forsurgery to the foot and knee *and incombination with blockade of the femoral

nerve# provide excellent analgesia forsurgery in the knee or below. Theimportant anatomy to recall is that thepopliteal fossa is a diamond?shape area

behind the knee# bordered by the bicepsfemoris laterally# medially by the tendonsof the semitendonous andsemimembranous muscles# and inferiorly

by the heads of the gastrocnemious


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P(oto2ra#( of #o#"it$a" fo!!a "oc) 0of !ciatic n$r,$1

$in2 #"ac$d for #ain contro" aft$r r$#air of c"ufoot&


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Loca" An$!t($tic! 'o!$

A 12 (g t%o year old child having a hernia repair %ould re$uire2 # ;

$dan$!t($ti4d$rmatom$!ofnum$rd$rmatom$

mL5&6A2$'o!$

=

$dan$!t($ti4!$2m$nt

mL5&578.$i2(t'o!$

=


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Loca" An$!t($tic! 'o!$

'sing Ta(asa(i?s &ormula the same t%o year old%ould receive 12 # ;

peripheral nerve blocks lower extremity

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