PERIPHERAL NERVE BLOCKS

LOWER EXTREMITY

Introduction
Spinal and epidural anesthesia are
most often employed for regional
anesthesia
of
the
lower
extremities.
Peripheral
nerve
blocks in the lower extremity can
also provide excellent surgical
anesthesia for some procedures
but require multiple injections
and may be tehchnicallly more
challengging in some cases.

Anatomi of Lumbarsacral plexus.

Dermatomes and osteotomes of the

lumbosacral plexus are illustrated.

Tabel Lumbar Plexus Anatomy

Nerve

Spinal
Segmen
t

Iliohypogastric

T12 L1

Motor Innervation

Motion Observed*

Sensory Innervation

Articular
Branches

Int/ext oblique
Transverse
abdominis

Ant abdominal
wall

Inferior abd wall

Upper lat quadrant of
buttock

None

L1

Int oblique

Ant andominal
wall

Inferior to medial aspect

of inguinal ligament
Portion of genitalia

None

Genitofemoral

L1 L2

Cremaster

Testicular

Inferior to mind portion

of inguinal ligament
Spermatic cord

None

Lateral
Femoral
Cutaneous

L2 L3

None

Femoral
Anterior
division

L2 L4

Ilioinguninal

Sartorious
Pectineus
Quadriceps

Posterior
division

Oburator
Anterior
division

Saphenous

Anterior lateral and

posterior aspects of
thigh terminating in
prepatellar plexus
Medial aspect of
the lower thigh
Adductor of thigh
Knee extension,
patellar
ascension

Anterior medial skin of

the thigh
None
Ant Thigh

None
Hip and
Knee

Medial leg from the tibia

to the medial aspect of
the foot

L2 L4

Gracilus, adductor
Thigh adduction
Variabel, posterior
brevis & longus
medial thigh, medial
pectineus
Thigh adduction
knee
Posterior
Obturator externus,
with lateral hip
division
adductor magnus
rotation
tions: Int, internal; Ext, external; Ant, anterior; Abd, abdominal; Lat, lateral.
observed refers to the observed motor response with electrical stimulation of that nerve.

Hip
Knee

Tabel Sacral Plexus Anatomy

Nerve

Spinal
Segme
nt

Gluteal nerves

L4 S2

Piriformis, sup/inf
gemellus obturator
internus, quadratus
femoris

Buttocks with lat

hip rotation

Upper medial
aspect of buttock

Hip

Sciatic, tibial

L4 S3

Biceps femoris,
semitendinosus,
adductor magnus
Popliteus

Hamstrings with
knee extension

Medial and lat heel

sole of foot

Hip knee, and

ankle

Knee flexion
Foot inversion

Distal anterior leg,

dorsum of foot

Knee and ankle

Web space of 1st

toe

Ankle

None

Dorsiflexion of
foot, ankle
None
Post calf, lat
border of foot
and 5th toe

None

None

Motor Innervation

Gastrocnemius,
soleus, flexors of
foot
Sciatic,
peroneal
Superficial
Deep

L4 S3

None

Sural
Components
from peroneal
& tibial
Post cut nerve
of thigh

S1 S3

Short head of biceps

femoris peroneus
longus, brevis
Extensors of foot, toes

Motion Observed*

Articular
Branches

Sensory
Innervation

Knee flexion
Plantar flexion
Toe flexion

None
None

Distal medial
None
quadrant of
buttock
perineum, post
thigh including
tions: Sup, superior; Inf, inferior; Lat, lateral; Post, posterior; Cut, cutaneous.
popliteal
fossanerve.
observed refers to the observed motor response with electrical stimulation
of that

Psoas Compartment Block.

Described by Chayen et al, in
1976
Single injection or with cateter
Indication
Operatif prosedure in the lumbar
plexus suplay area (THA/TKA)
Analgesia

Side effects/complications
Vessel puncture (paravertebral
veins)
Dissemination similar to epidural
anesthesia (contralateral)
High (total) spinal
Anatomical landmarks
Posterior superior iliac spine
Iliac crest
Spinous process L4
Costal process L5

Blockade technique
The patient is in the lateral recumbent
position (or seated), the cervical spine is
flexed backwards
Puncture site
3 cm caudad, 5 cm midline to the spinous
process L4.
Puncture depth : 6 10 cm

Psoas compartment block Puncture site

Iliac crest
Spinous process of
the 4th lumbar
vertebra
Posterior superior
iliac spine
Puncture site
Positive stimulatory
respon from the
femoral nerve :
quadriceps muscle
(usually the vastus
lateral muscle)

Femoral Nerve Block.

Indication
Operative procedure in areas supplying the
femoral and lateral femoral cutaneus
nerves
In combination with proximal sciatic nerve
block, operative procedures on the whole
leg (from distaL to foot)
Analgesia
ACL (anterior cruciate ligament
reconstruction), TKA

Side Effect/Complication
Vessel puncture (of the femoral vein or
artery)
Anatomical Landmarks
Groin
Femoral artery
Anterior superior iliac spine
Pubic tubercle
Inguinal ligament

Blockade technique
The patient lies on his back, his leg loosely
abducted and turned to the outside.
Puncture site
2 cm caudad to the groin, 1 2 cm lateral
to the lateral femoral artery.
Puncture direction
30 45 cranial pararel to the artery
Puncture deep
2 4 cm

Anterior and cross-sectional views of the

femoral nerve

Femoral nerve block anatomic landmarks

1. Anterior superior
iliac spine
2. Pubic tubercle
3. Puncture site

Femoral nerve block Puncture site

Inguinal ligamen
Femoral artery
Anterior superior
iliac spine
Puncture site
Positive stimulatory
response from the
femoral nerve :
Rectus muscle of the
thigh (dancing
patella)

Femoral nerve block Puncture technique

Sciatic Nerve Block

Indications
Operative procedure in areas supplying the
sciatic nerve
In combination with psoas compartement
block/ femoral nerve block for operations on
the whole leg
Analgesia

Side effects/complications
Vessel puncture (inferior gluteal artery)
Artery, vein and neural femoral injury if use
approach according to Meier (anterior
sciatic nerve block)
Approach
Parasacral sciatic nerve block ( Mansour)
Transgluteal sciatic nerve block (Labat)
Anterior sciatic nerve block (Meier)

Parasacaral Sciatic Nerve Block

(Mansour)
Anatomical landmarks
Posterior iliac spine
Ischial tuberosity
Blockade technique
The patient is placed in the lateral recumbent
position, hip flexed 45, knee flexed 70, or
both knee against the abdomen

Parasacaral sciatic nerve block

(Mansour)
Puncture site
Approx 5 6 cm caudad to the posterior
superior superior iliac spine along the
connecting line to the ischial tuberosity
Insertion direction
20-30 caudad to midline between ischial
tuberosity and greater trochanter.
Puncture deep : 6 8 cm

Parasacaral Sciatic Nerve Block

(Mansour)
1. Great trochanter
2. Posterior superior iliac
spine
3. Ischial tuberosity
4. Puncture site
Positive stimulatory
response from the
peroneal and
tibial nerves :
extensors or
flexors of the
foot/toes

Transgluteal sciatic nerve block

(Labat)
Anatomical landmarks
Posterior superior iliac spine
Greater trochanter
Sacral hiatus
Blockade technique
The patient is palced in the lateral recumbent
position; hip flexed 45, knee flexed 70
(stable recumbent position)

Transgluteal sciatic nerve block

(Labat)
Puncture site
4-5 cm mediocaudal on the midperpendicular
lines between greater trochanter and posterior
superior iliac spine; connecting line between
the greater trochanter and sacral hiatus
intersecs the insertion point at the midperpendicular line.
Insertion direction : perpendicular to the surface
Puncture deep : 5 8 cm

Transgluteal approach Positioning of the

patient

Transgluteal approach Puncture site

Greater
trochanter
Posterior
superior iliac
spine
Ischial
tuberosity
Sacral hiatus
X Puncture site
Positive
stimulatory
response from
the peroneal and
tibial nerves :

Anterior sciatic nerve block (Meier)

1. Anterior superior iliac
spine
2. Pubic symphysis
3. Greater trochanter
4. Puncture site
Positive stimulatory
response from the
peroneal and tibial
nerves :
Extensor or flexor of the
foot/toes

Popliteal Fossa Block.

Indication
Operative procedures in the area supplying
the sciatic nerve of the lower leg & foot
In combination with saphenous nerve block,
operations on the whole lower extremity
Analgesia

Popliteal Fossa Block

Side effects/complications
Vessel puncture (popliteal artery/vein)
Anatomical landmarks
Popliteal fossa
Popliteal fold
Long head of the biceps femoris muscle
Medial and lateral epicondyle of the femur

Blockade technique
The patient is either in the prone position or
lying on his side, leg extended
Puncture site
Approx 8 12 cm above the fold of the
popliteal fossa at the medial edge of the
biceps femoris muscle, laterally marking the
popliteal fossa
Insertion direction : 30 cranial and lateral
Puncture deep : 2 4 cm

Popliteal Fossa Block Puncture site

Lateral
Medial
Puncture site
Positive
stimulatory
respons from the
peroneal and
tibia nerves:
Extensor or flexors
of the foot/toes

Popliteal Fossa Block Puncture technique

Drugs and Equipments for Peripheral Blocks.

Drugs and Equipments for Peripheral Blocks.

TERIMA KASIH

Regional Anesthesia in Children

Femoral Nerve Block

Femoral nerve blockade can be quite
useful in procedures such as surgery on
the femoral shaft, osteotomies, quadriceps
muscle biopsy, knee surgery and even
clubfoot repairs (with some peripheral
local supplementation). This block can be
placed by using a knowledge of the
anatomy of the femoral region and also
with judicious use of a nerve stimulator.
When using a nerve stimulator
in
anesthetized pediatric patients, it is useful
to remember that the current applied

Drawing showing anatomy and placement of a femoral nerve

block with the aid of a nerve stimulator

Photograph of femoral nerve block being placed with

aid of a nerve stimulator

Sciatic Nerve Blockade

The block provides excellent analgesia for
surgery to the foot and knee (and in
combination with blockade of the femoral
nerve, provide excellent analgesia for
surgery in the knee or below). The
important anatomy to recall is that the
popliteal fossa is a diamond-shape area
behind the knee, bordered by the biceps
femoris laterally, medially by the tendons
of
the
semitendonous
and
semimembranous muscles, and inferiorly
by the heads of the gastrocnemious

Photograph of popliteal fossa block (of sciatic nerve)

being placed for pain control after repair of clubfoot.

Local Anesthetics Dose

Age, weiht, and height were all important in determining the dosage.
Both of their formulas approximately simplify to:

Dose

Age 0.1 mL
dermatome number of dermatomes anesthetiz ed

A 12 kg two year old child having a hernia repair would require

2 x 0.1 mL x 12 = 2.4 mL.
This dose would be inadequate for most small patients.
Takasaki developed a formula based on weight which could be
simplified to:

weight 0.056 mL
Dose
segment anesthetiz ed

Local Anesthetics Dose

Using Takasakis formula the same two year old
would receive 12 x 0.056 mL x 12 = 8 mL.
This appears to be a more reasonable dose for a
smaller child but might be a large volume in the
bigger patient.
Simplified dose = 1 mL/kg (0.25% bupivacaine)
(maximum volume 30mL)