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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 # ;
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