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Lower Extremity BlockLower Extremity Block
A.Ghaleb,M.D.Associate professor
Medical director Acute and chronic Pain management
Dept. of AnesthesiologyUAMS
Lumbar plexusLumbar plexus
• The lumbar plexus is formed by the The lumbar plexus is formed by the ventral rami of the first ventral rami of the first three lumbar nervesthree lumbar nerves and the and the greater part of the fourthgreater part of the fourth
• Two major anastomosis involving the lumbar plexusTwo major anastomosis involving the lumbar plexus one with a branch of the last thoracic nerve one with a branch of the last thoracic nerve and another between the fourth and fifth lumbar nervesand another between the fourth and fifth lumbar nerves give birth respectively to the :give birth respectively to the : IInfracostal nervenfracostal nerve LLumbosacral trunk which contributes to the sacral plexus.umbosacral trunk which contributes to the sacral plexus.
A.Ghaleb,M.D.
Lumbar plexus(T12,L1-4)Lumbar plexus(T12,L1-4)
Lumbar plexus
**Ilioinguinal**Iliohypogastric**Genito femoral
**Lateral fem.cut.Supply lat. Thigh + buttocks
**FemoralSupply ant thigh+hip+knee
**ObturatorSupply adductors ms.
Saphenous
A.Ghaleb,M.D.
Plexus locationPlexus location
• The lumbar plexus is located in a virtual The lumbar plexus is located in a virtual space space inside the Psoas major muscleinside the Psoas major muscle. This . This space is limited medially by Psoas major space is limited medially by Psoas major insertions on the bodies of the vertebrae and insertions on the bodies of the vertebrae and their transverse processes and by the lumbar their transverse processes and by the lumbar spine itself. The aponeurosis surrounding the spine itself. The aponeurosis surrounding the plexus inside the Psoas major constitutes the plexus inside the Psoas major constitutes the anterior, posterior and lateral limits of this anterior, posterior and lateral limits of this space.space.
A.Ghaleb,M.D.
From skin to plexusFrom skin to plexus
A.Ghaleb,M.D.
A.Ghaleb,M.D.
Blocked nervesBlocked nerves
• Upper thigh Upper thigh Ilio-inguinal nerve, Ilio-inguinal nerve, Iliohypogastric nerve, Genitofemoral Iliohypogastric nerve, Genitofemoral nerve. nerve.
• Lower limb Lower limb Femoral nerve, Lateral Femoral nerve, Lateral femoral cutaneous nerve, Obturator femoral cutaneous nerve, Obturator nerve. nerve.
A.Ghaleb,M.D.
Frequency of anesthesia in the three Frequency of anesthesia in the three major nerves' territoriesmajor nerves' territories
FemorFemoral al nerve nerve
ObturObturator ator nerve nerve
Lateral Lateral femoral femoral cutaneous cutaneous nervenerve
Piffaut, 1996 Piffaut, 1996 (single injection) (single injection)
100%100% 100%100% 96%96%
Rickwaert, 2000 Rickwaert, 2000 (catheter) (catheter)
97.5%97.5% 88%88% 92%92%
Indications Of L.P.B.Indications Of L.P.B.
• Alone: Alone:
It can be used for hip or knee surgery It can be used for hip or knee surgery
• Combined with a sciatic nerve block:Combined with a sciatic nerve block:
The lumbar plexus block can be used for The lumbar plexus block can be used for most surgeries involving the lower limb most surgeries involving the lower limb
Contraindications Contraindications
• Vertebromeningeal infections. Vertebromeningeal infections. • Lumbar vertebral trauma. Lumbar vertebral trauma. • Associated trauma or disorders making Associated trauma or disorders making
lateral positioning impossible (Femoral neck lateral positioning impossible (Femoral neck fracture is no contraindication to the lateral fracture is no contraindication to the lateral position). position).
• Coagulation abnormalities, Coagulation abnormalities, • In patients exhibiting severe lumbar In patients exhibiting severe lumbar
scoliosis, the landmarks may be modifiedscoliosis, the landmarks may be modified
The patient lays on the side opposite to the block (thigh flexion: 30°; knee flexion: 90°) while the physician stands behind. An assistant facing the patient with hands on the upper thorax and thigh will help maintain correct position and identify thigh movements during neurostimulation.
Landmarks Landmarks
• An horizontal line joining the An horizontal line joining the top of top of the iliac crests at the L4-L5the iliac crests at the L4-L5 level. level.
• A line joining the A line joining the spinous spinous processes of L3, L4 and L5processes of L3, L4 and L5. .
• A line parallel to the line joining the A line parallel to the line joining the spinous processes and spinous processes and passing passing over the posterior superior iliac over the posterior superior iliac spine. spine.
• A line starting at the A line starting at the spinous spinous process of L4 and reaching process of L4 and reaching perpendicularly the line passingperpendicularly the line passing by by the posterior superior iliac spine the posterior superior iliac spine
Puncture sitePuncture site
• The puncture site is located at the The puncture site is located at the union of the lateral 1/3 and medial union of the lateral 1/3 and medial 2/3 of the line joining the spinous 2/3 of the line joining the spinous process of L4 to the line passing process of L4 to the line passing through the posterior superior iliac through the posterior superior iliac spine (approximately 40 mm lateral spine (approximately 40 mm lateral the spinous process of L4).the spinous process of L4).
• This site differs from the classic one This site differs from the classic one located at the junction of the line located at the junction of the line passing through the posterior passing through the posterior superior iliac spine and the line superior iliac spine and the line joining the top of the iliac crests. joining the top of the iliac crests. Anatomical studies suggest that the Anatomical studies suggest that the location of the classic site is in fact location of the classic site is in fact too lateral. See the scanners above too lateral. See the scanners above where we can see the puncture site where we can see the puncture site and the anatomical cut .and the anatomical cut .
Puncture Puncture
• A septic TechniqueA septic Technique• The needle is introduced perpendicularly to the skinThe needle is introduced perpendicularly to the skin• Stimulation intensity is adjusted between 1 and 2 ma for a 0.1-ms period Stimulation intensity is adjusted between 1 and 2 ma for a 0.1-ms period
of stimulation.of stimulation.• The needle is inserted slowly through the muscles until it reaches the The needle is inserted slowly through the muscles until it reaches the
transverse process of L4. transverse process of L4. This contact is expected and provides a real This contact is expected and provides a real safeguard. safeguard.
• Anatomical studies have shown that the distance between the posterior Anatomical studies have shown that the distance between the posterior edge of the costal process and the lumbar plexus is 15-20 mm . The edge of the costal process and the lumbar plexus is 15-20 mm . The insertion depth of the needle is then noted. After adding 20 mm to the insertion depth of the needle is then noted. After adding 20 mm to the depth indicator, the needle is withdrawn and reoriented with a 5° angle depth indicator, the needle is withdrawn and reoriented with a 5° angle in cephalic or caudal direction, thus avoiding the transverse process. in cephalic or caudal direction, thus avoiding the transverse process.
• The needle is inserted more deeply (without exceeding the additional 20 The needle is inserted more deeply (without exceeding the additional 20 mm) until the required stimulation of the femoral nerve (ascension of the mm) until the required stimulation of the femoral nerve (ascension of the patella) can be observed. The intensity of the stimulation is then patella) can be observed. The intensity of the stimulation is then gradually reduced until the motor response disappears (0.5 ma).gradually reduced until the motor response disappears (0.5 ma).
• An aspiration test is then carried out to avoid vascular or spinal An aspiration test is then carried out to avoid vascular or spinal injection.injection.
Suitable responsesSuitable responses
• Stimulation of Erector spinae or Stimulation of Erector spinae or Quadratus lumborum musclesQuadratus lumborum muscles: : This is a usual response to initial needle This is a usual response to initial needle insertion. Poorly defined contractions are insertion. Poorly defined contractions are observed around the puncture site. observed around the puncture site. Progression must continue. Progression must continue. Stimulation of the femoral nerve:Stimulation of the femoral nerve: Contraction of the Quadriceps femoris muscle Contraction of the Quadriceps femoris muscle is noted. This is the ideal and sought-after is noted. This is the ideal and sought-after response response
Unsuitable responsesUnsuitable responses
• Stimulation of the obturator nerve: Stimulation of the obturator nerve: Contraction of the adductors, felt by Contraction of the adductors, felt by palpation of the internal portion of the thigh, reveals that the needle is palpation of the internal portion of the thigh, reveals that the needle is located too medially. The needle is withdrawn and reoriented laterally with a located too medially. The needle is withdrawn and reoriented laterally with a 5° angle.5° angle.
• Stimulation causing thigh adduction and patella ascension.Stimulation causing thigh adduction and patella ascension. It may It may correspond to a stimulation of nerve near the spinal canal. This reveals that correspond to a stimulation of nerve near the spinal canal. This reveals that the needle is located too medially. The needle should then be withdrawn the needle is located too medially. The needle should then be withdrawn and reoriented with a 5° angle laterally.and reoriented with a 5° angle laterally.
• Thigh flexion on the pelvis is caused by stimulation of a motor branch Thigh flexion on the pelvis is caused by stimulation of a motor branch to the Psoas majorto the Psoas major. Needle reorientation with a 5° angle toward cephalic or . Needle reorientation with a 5° angle toward cephalic or caudal direction should allow for stimulation of the femoral nerve at caudal direction should allow for stimulation of the femoral nerve at approximately the same depth.approximately the same depth.
• Sciatic nerve stimulationSciatic nerve stimulation may happens if the puncture site is either too may happens if the puncture site is either too caudal or too medial (stimulation of the lumbosacral trunk). The needle must caudal or too medial (stimulation of the lumbosacral trunk). The needle must be reoriented with a 5° angle in both, cephalic and lateral directionbe reoriented with a 5° angle in both, cephalic and lateral direction
Vertical paravertebral opacity from L2 to L5.
Bundle-shaped, which parallels the Psoas major location
ComplicationsComplications
• Venous puncture:Venous puncture:The lumbar vein may be punctured. The needle is then located too medially and The lumbar vein may be punctured. The needle is then located too medially and must be reoriented with a 5° angle laterally.must be reoriented with a 5° angle laterally.
• Ureter puncture:Ureter puncture:Needle tip is too deep.Needle tip is too deep.Kidney puncture :Kidney puncture :The needle is inserted too deep and too cephalic. Avoid puncture at the L3 level, The needle is inserted too deep and too cephalic. Avoid puncture at the L3 level, particularly on the right side.particularly on the right side.
• Peritoneal puncture:Peritoneal puncture:Needle tip is too deep.Needle tip is too deep.Spinal or epidural puncture:Spinal or epidural puncture:The puncture site or the direction of the needle are too medial. Always aspirate The puncture site or the direction of the needle are too medial. Always aspirate before injecting slowly small quantities of anesthetic solution.before injecting slowly small quantities of anesthetic solution.
• Epidural extension of anesthesia :Epidural extension of anesthesia :In this case, whether the catheter is located in the paravertebral space or in the In this case, whether the catheter is located in the paravertebral space or in the Psoas compartment, the anesthetic solution reaches the epidural space. Psoas compartment, the anesthetic solution reaches the epidural space. Analgesia is effective. The catheter can be left in place Analgesia is effective. The catheter can be left in place
• Intravascular injection: Intravascular injection: Intravascular injection can be prevented with a proper test dose and divided Intravascular injection can be prevented with a proper test dose and divided injections. injections.
Fascia Iliaca BlockFascia Iliaca Block
Identify Identify *ASIS*ASIS *Pubic tubercle *Pubic tubercle Connect & divide into thirdsConnect & divide into thirds Junction of lateral 1/3rd & medial 2/3 Junction of lateral 1/3rd & medial 2/3rdrd
1 cm inferior to mark1 cm inferior to mark
TechniqueTechnique
• Insert the needle at right angles to the skin until two clearly Insert the needle at right angles to the skin until two clearly identifiable losses of resistance are felt, respectively at the identifiable losses of resistance are felt, respectively at the crossing of the fascia lata then the fascia iliacacrossing of the fascia lata then the fascia iliaca
Single shot technique: inject the local anaesthetic through the Single shot technique: inject the local anaesthetic through the lumen of the needle according the usual safety rules, then lumen of the needle according the usual safety rules, then massage the swelling produced in order to favour the upward massage the swelling produced in order to favour the upward spread of the local anaestheticspread of the local anaesthetic
Continuous infusion or iterative injection technique: when the Continuous infusion or iterative injection technique: when the tip of the needle is below the fascia iliaca, remove the obturator tip of the needle is below the fascia iliaca, remove the obturator and introduce the catheter through the lumen in order to insert and introduce the catheter through the lumen in order to insert 2-3 cm of catheter at the inner aspect of the fascia iliaca. Set 2-3 cm of catheter at the inner aspect of the fascia iliaca. Set the connecting device and interpose an antibacterial filter the connecting device and interpose an antibacterial filter before carefully dressing and fixing the catheter on the skin. before carefully dressing and fixing the catheter on the skin.
Ilio inguinal blockIlio inguinal block
• ASIS ASIS • 2 cm inferior, 2 cm medial 2 cm inferior, 2 cm medial • perpendicular perpendicular
• advance needle through skinadvance needle through skin
• discern a 'pop' or click as external oblique aponeurosis penetrateddiscern a 'pop' or click as external oblique aponeurosis penetrated
• inject 5 - 7 ml LA to block iliohypogastric nerveinject 5 - 7 ml LA to block iliohypogastric nerve
• advance needle a further 1 - 2 cm to penetrate softer resistance of advance needle a further 1 - 2 cm to penetrate softer resistance of internal oblique muscleinternal oblique muscle
• inject 5 - 7 ml LA to block ilioinguinal nerveinject 5 - 7 ml LA to block ilioinguinal nerve
Femoral Nerve BlockFemoral Nerve Block
provides sensory anesthesia of :provides sensory anesthesia of :the anterior thighthe anterior thigh
kneeknee medial aspect of the calf, ankle and footmedial aspect of the calf, ankle and foot
IndicationsIndications
• foot and ankle surgeryfoot and ankle surgery
• femoral neck fracturesfemoral neck fractures
• total hip arthroplastytotal hip arthroplasty
• foot and ankle surgeryfoot and ankle surgery
• femoral shaft fracturesfemoral shaft fractures
• saphenous vein strippingsaphenous vein stripping
• outpatient knee arthroscopy etc..outpatient knee arthroscopy etc..
ContraindicationsContraindications
• prosthetic femoral artery graft prosthetic femoral artery graft
• dense sensory block could mask the dense sensory block could mask the onset of lower extremity compartment onset of lower extremity compartment syndrome (e.g., fresh fractures of the syndrome (e.g., fresh fractures of the tibia and fibula)tibia and fibula)
The point of needle insertion is marked 1.5 cm lateral and 1.5 cm distal to the intersection of the inguinal ligament and the femoral artery
TechniquesTechniques
• NERVE STIMULATOR NERVE STIMULATOR
• PARESTHESIAE PARESTHESIAE • LOSS OF RESISTANCE LOSS OF RESISTANCE lies below two facial lies below two facial
planes: the fascia lata and the fascia iliacus planes: the fascia lata and the fascia iliacus
• FIELD BLOCK FIELD BLOCK
"Three-in-One" Block"Three-in-One" Block
• INGUINAL PARAVASCULAR THREE-IN-ONE BLOCKINGUINAL PARAVASCULAR THREE-IN-ONE BLOCK
• A single injection of large volume within the neural "sheath" A single injection of large volume within the neural "sheath" with the needle directed cephalad + pressure applied distal to with the needle directed cephalad + pressure applied distal to the femoral nerve sheaththe femoral nerve sheath
• Block obturator and lateral femoral cutaneous nerves as well Block obturator and lateral femoral cutaneous nerves as well as the femoral nerveas the femoral nerve
Sacral plexus ( L4-5,S1-2-3)Sacral plexus ( L4-5,S1-2-3)
Sciatic
TibialSupply medial foot
planter flexion
Common peroneal arround head of fibula
SuralTibial+ comm.per.
*Super. PeronealSupply ant foot
Deep peronealSupply web space 1st & 2nd toe
Dorsi flexion
Sciatic Nerve BlockSciatic Nerve Block
• Anatomy Anatomy The largest single nerve trunk of the body (a diameter The largest single nerve trunk of the body (a diameter about as large as the thumb (16-20 mm). about as large as the thumb (16-20 mm).
• It arises from the L4, L5, S1, S2, S3 spinal roots and exits It arises from the L4, L5, S1, S2, S3 spinal roots and exits the pelvis posteriorly through the greater sciatic foramen the pelvis posteriorly through the greater sciatic foramen and runs laterally along the posterior surface of the and runs laterally along the posterior surface of the ischium anterior to the piriformis muscle. ischium anterior to the piriformis muscle.
• The posterior cutaneous nerve of the thigh accompanies The posterior cutaneous nerve of the thigh accompanies the sciatic nerve as it exits the greater sciatic foramen. the sciatic nerve as it exits the greater sciatic foramen. The sciatic nerve has medial and lateral components The sciatic nerve has medial and lateral components which separate into the tibial and the common peroneal which separate into the tibial and the common peroneal nerves in the superior aspect of the popliteal fossa. nerves in the superior aspect of the popliteal fossa.
Classic Posterior ApproachClassic Posterior Approach
• lateral (Sim's) position, with the operative side lateral (Sim's) position, with the operative side nondependent. The operative extremity is flexed 45 nondependent. The operative extremity is flexed 45 degrees at the hip and 90 degrees at the knee and degrees at the hip and 90 degrees at the knee and rests against the dependent lower extremityrests against the dependent lower extremity
• The posterior superior iliac spine (PSIS), greater The posterior superior iliac spine (PSIS), greater trochanter, and sacral hiatus are identified and trochanter, and sacral hiatus are identified and marked marked
• A line is drawn between the greater trochanter and A line is drawn between the greater trochanter and PSIS . This line is bisected. A perpendicular is PSIS . This line is bisected. A perpendicular is dropped 3-5 cm from the midpoint of this line to the dropped 3-5 cm from the midpoint of this line to the point of needle insertion. point of needle insertion.
Classic Posterior ApproachClassic Posterior Approach
• The point of needle insertion should lie along a The point of needle insertion should lie along a third line drawn between the greater trochanter third line drawn between the greater trochanter and the sacral hiatus . and the sacral hiatus .
• 6 inch nerve stimulator needle is advanced 6 inch nerve stimulator needle is advanced perpendicular to the skin. The nerve lies about perpendicular to the skin. The nerve lies about 6-8 cm deep6-8 cm deep
• motor response . Plantar flexion (downgoing motor response . Plantar flexion (downgoing toes) at less than 0.5 mA is the desired motor toes) at less than 0.5 mA is the desired motor response and indicates placement of the needle response and indicates placement of the needle near the medial part (tibial component) of the near the medial part (tibial component) of the nervenerve
Parasacral approchParasacral approch
• lateral recumbent position lateral recumbent position • thigh slightly folded forming an angle of 135 -thigh slightly folded forming an angle of 135 -
140° with the trunk. 140° with the trunk. • The knee flexed at 90°. The knee flexed at 90°. • A line is drawn between the postero-superior A line is drawn between the postero-superior
iliac spine and the ischial tuberosity iliac spine and the ischial tuberosity • puncture point is situated at 6 cm from the puncture point is situated at 6 cm from the
postero-superior iliac spine following this postero-superior iliac spine following this lineline
PROCEDUREPROCEDURE
• The needle is inserted perpendicularly and The needle is inserted perpendicularly and progressed slowly, progressed slowly,
• at approximately 6 cm-8 cm a motor response is at approximately 6 cm-8 cm a motor response is obtained rarely more than 8 cm obtained rarely more than 8 cm
• A bone contact may be the sacral ala or the iliac A bone contact may be the sacral ala or the iliac bone, superior and near the greater sciatic foramen. bone, superior and near the greater sciatic foramen. In this case needle should be withdrawn and In this case needle should be withdrawn and reinserted inferior to the first point. reinserted inferior to the first point.
• Moreover this bone contact can be used as a depth Moreover this bone contact can be used as a depth test. Needle depth should be noted and it is test. Needle depth should be noted and it is recommended not to go more than 2 cm beyond this recommended not to go more than 2 cm beyond this depth depth
Popliteal BlockPopliteal Block
• Prone position Prone position
• Tendons of biceps femoris (lateral) and Tendons of biceps femoris (lateral) and semitendinosus (medial) semitendinosus (medial)
• Popliteal crease Popliteal crease
• Midpoint between tendons at a point 7 -Midpoint between tendons at a point 7 -10 cm superior to popliteal crease .10 cm superior to popliteal crease .
Lateral poplitealLateral popliteal
Anatomy Anatomy • In the mid thigh, the sciatic nerve more In the mid thigh, the sciatic nerve more
superficial lies medial to the biceps superficial lies medial to the biceps femoris femoris
• It is also distant from the femoral It is also distant from the femoral vessels vessels
• The sciatic nerve is reached at a depth The sciatic nerve is reached at a depth averaging 6 cm averaging 6 cm
Position :Position :
• The patient lies in supine. The ankle is posed on The patient lies in supine. The ankle is posed on a pillow to raise the lower limb from the table. a pillow to raise the lower limb from the table.
• places one hand on the knee to move the leg to places one hand on the knee to move the leg to zero rotation for better exposure. With other zero rotation for better exposure. With other hand insert the needle at the puncture site hand insert the needle at the puncture site
• Landmarks : A line is drawn from the posterior Landmarks : A line is drawn from the posterior aspect of the great trochanter towards the knee, aspect of the great trochanter towards the knee, parallel to the femur. The puncture site is parallel to the femur. The puncture site is situated along this line, at mid thigh, from the situated along this line, at mid thigh, from the knee to the great trochanterknee to the great trochanter
PearlsPearls
• Anaesthetic injection after stimulation of the common Anaesthetic injection after stimulation of the common peroneal nerve provides blockade of the latter within peroneal nerve provides blockade of the latter within 10-20 min followed by the blockade of the tibial nerve 10-20 min followed by the blockade of the tibial nerve being effective within 40-60 min. Anaesthetic injection being effective within 40-60 min. Anaesthetic injection after stimulation of the tibial nerve provides blockade after stimulation of the tibial nerve provides blockade of the two nerves in much less time. of the two nerves in much less time.
• If no stimulation is obtained, it is recommended to re-If no stimulation is obtained, it is recommended to re-insert a centimetre above or below the initial puncture insert a centimetre above or below the initial puncture site, instead of probing in vain.site, instead of probing in vain.
•Hamstring Contractions indicate that the needle is Hamstring Contractions indicate that the needle is beneath the sciatic nerve. Try and insert the needle beneath the sciatic nerve. Try and insert the needle one centimetre aboveone centimetre above
Motor response
Stimulation of
tibial (plantar flexion +Inversion )
common peroneal (dorsiflexion + eversion)
Saphenous blockSaphenous block
• Sartorious muscle on medial aspect of Sartorious muscle on medial aspect of thighthigh
• Grip muscle between index finger & Grip muscle between index finger & thumb at distal end of thigh. Midpoint thumb at distal end of thigh. Midpoint of muscle belly between fingersof muscle belly between fingers
Lateral Popliteal BlockLateral Popliteal Block
• Lateral femoral condyleLateral femoral condyle
• Groove between biceps femoris (posterior) Groove between biceps femoris (posterior) and vastus lateralis (anterior)and vastus lateralis (anterior)
• Horizontal plane to contact femur (approx 5 Horizontal plane to contact femur (approx 5 cm) cm)
• Re-direct needle posteriorly at 30° angleRe-direct needle posteriorly at 30° angle
Ankle BlockAnkle Block
• medial malleolus medial malleolus SaphenousSaphenous nervenerve1cm anterior to malleolus, 1cm proximal to 1cm anterior to malleolus, 1cm proximal to inter-malleolus line (skin crease) 5ml LAinter-malleolus line (skin crease) 5ml LA
Tibial nerveTibial nerve Posterior to Posterior to posterior tibial artery Contact bone and posterior tibial artery Contact bone and withdraw needle by 1mm 5ml LAwithdraw needle by 1mm 5ml LA
Hip
Lumbar plexus Best Psoas Block
Except
Ilio ing.
Ilio hypo
Major thigh operation
L.F.C, Obturator Femoral Sciatic
CombinedSciatic & psoas block
three in one +sciatic
Tourniquet pain
L.F.C
Femoral
Sciatic
Open Knee
L.F.C
Femoral
Obturator
Sciatic
Thigh operation
Combined
Sciatic + psoas block
Quadriceps PlastyPatellar surgery
Femoral block
Distal to the Knee
Sciatic Saphenous
popliteal
