Lower limb blocks

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Lower limb blocks

  1. 1. LOWER LIMB BLOCKS Moderator: Presented By: Dr. Ani Gopinath Dr. Vijay Kumar Dr. Geetesh
  2. 2. <ul><li>INTRODUCTION </li></ul><ul><li>American surgeons – Halsted and Hall described the </li></ul><ul><li>injection of cocaine into peripheral sites in 1880’s. </li></ul><ul><li>Peripheral blockade remains a well accepted </li></ul><ul><li>component of comprehensive anesthetic care. </li></ul><ul><li>Its role has expanded from the operating suite into the </li></ul><ul><li>arena of the post-op and chronic pain management. </li></ul>
  3. 3. <ul><li>Lower limb blocks are safe and have certain advanatages </li></ul><ul><ul><ul><ul><li>Post-op pain relief. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lack of complete sympathectomy. </li></ul></ul></ul></ul><ul><li>They are less popular than upper limb blocks because </li></ul><ul><ul><ul><ul><li>Wide spread acceptance and safety of central neuraxial blockade </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Unlike the brachial plexus, nerves supplying the lower extremity are not anatomically clustered where they can be blocked. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Technically more difficult and require more training and practice. </li></ul></ul></ul></ul>
  4. 4. <ul><li>Lower extremity nerve blocks can be divided into: </li></ul><ul><li>Lumbar Plexus Nerve Blocks: </li></ul><ul><ul><li>Femoral N. block </li></ul></ul><ul><ul><li>Obturator N. block </li></ul></ul><ul><ul><li>Lateral Femoral Cutaneous N. block </li></ul></ul><ul><ul><li>3 in 1 block (Inguinal Paravascular Block) </li></ul></ul><ul><li>Sacral Plexus Nerve Blocks: </li></ul><ul><ul><li>Sciatic N. Block </li></ul></ul><ul><ul><li>Popliteal N. Block </li></ul></ul><ul><ul><li>Ankle Block </li></ul></ul>
  5. 5. <ul><li>ANATOMY OF LUMBAR PLEXUS </li></ul><ul><li>Formed by the ventral primary divisions of the first 4 </li></ul><ul><li>lumbar nerve roots. </li></ul><ul><li>Situated in front of the transverse processes of the </li></ul><ul><li>lumbar vertebrae posterior to the Psoas major muscle. </li></ul><ul><li>Derivatives of this plexus are: </li></ul><ul><ul><ul><ul><li>Ilio-hypogastric </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ilio-inguinal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Genito femoral </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lateral femoral cutaneous </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Femoral </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Obturator </li></ul></ul></ul></ul>
  6. 9. <ul><li>LATERAL FEMORAL CUTANEOUS NERVE BLOCK </li></ul><ul><li>Anatomy: </li></ul><ul><li>Arises from the dorsal divisions of second and third </li></ul><ul><li>lumbar nerves. </li></ul><ul><li>Emerges behind the Psoas major muscle  while </li></ul><ul><li>lying on the Iliacus muscle  crosses pelvis  </li></ul><ul><li>reach anterior superior iliac spine  passes under </li></ul><ul><li>the inguinal ligament to enter thigh. </li></ul><ul><li>Divides into 2 branches, which are distributed to the </li></ul><ul><li>anterior & lateral aspects of thigh as far as the knee. </li></ul>
  7. 11. <ul><li>LATERAL FEMORAL CUTANEOUS NERVE BLOCK </li></ul><ul><li>Technique: </li></ul><ul><li>Supine position </li></ul><ul><li>Anterior Superior Iliac spine and inguinal ligament </li></ul><ul><li>identified. </li></ul><ul><li>Skin wheal is raised on the skin 2 to 3cms medial to the </li></ul><ul><li>iliac spine and just superior to the inguinal ligament. </li></ul><ul><li>2inch, 22guage needle is inserted perpendicular to skin </li></ul><ul><li>until contact is made with the iliac bone. 10ml of anesthetic </li></ul><ul><li>solution injected while the needle being advanced. </li></ul>
  8. 12. <ul><li>LATERAL FEMORAL CUTANEOUS NERVE BLOCK </li></ul><ul><li>Needle is re-introduced 2-3cm medial to spine but 2- </li></ul><ul><li>3cms inferior to inguinal ligament. 5-10ml of anesthetic </li></ul><ul><li>solution injected. </li></ul><ul><li>Indications: </li></ul><ul><ul><li>In combination with other nerve blocks for surgery of thigh. </li></ul></ul><ul><ul><li>Neuralgia of thigh. </li></ul></ul><ul><ul><li>Fascia Lata Pain syndrome </li></ul></ul>
  9. 13. <ul><li>FEMORAL NERVE BLOCK </li></ul><ul><li>Anatomy: </li></ul><ul><li>Largest branch of lumbar plexus. </li></ul><ul><li>Arises from the dorsal portion of the anterior primary </li></ul><ul><li>divisions of the 2 nd , 3 rd & 4 th lumbar nerves. </li></ul><ul><li>Descends through the psoas major  emerge in its lateral </li></ul><ul><li>border  passes along the pelvic wall on the iliacus </li></ul><ul><li>muscle  reaches superior pubic ramus & crosses over </li></ul><ul><li> passes beneath the inguinal ligament  divides into </li></ul><ul><li>anterior and posterior divisions. </li></ul>
  10. 14. <ul><li>FEMORAL NERVE BLOCK </li></ul><ul><li>It supplies: </li></ul><ul><ul><ul><li>Four parts of quadriceps femoris. </li></ul></ul></ul><ul><ul><ul><li>Skin of medial and anterior parts of thigh. </li></ul></ul></ul><ul><ul><ul><li>Skin of the front and medial side of the leg below </li></ul></ul></ul><ul><ul><ul><li>patella (Saphenous nerve) </li></ul></ul></ul>
  11. 17. <ul><li>FEMORAL NERVE BLOCK </li></ul><ul><li>Technique: </li></ul><ul><li>Mark the inguinal ligament. </li></ul><ul><li>Palpate the femoral artery about 2 to 3cms below the </li></ul><ul><li>ligament. </li></ul><ul><li>Insert a 22 gauge, 3 inch needle perpendicular to skin </li></ul><ul><li>until it is just lateral to femoral artery and elicit </li></ul><ul><li>paresthesias. </li></ul><ul><li>Inject 10ml of anesthetic solution. </li></ul>
  12. 20. <ul><li>FEMORAL NERVE BLOCK </li></ul><ul><li>Indications: </li></ul><ul><li>In combination with the Lateral Femoral cutaneous nerve </li></ul><ul><li>block, it provides anesthesia for many orthopaedic & </li></ul><ul><li>plastic surgical procedures. </li></ul><ul><li>Very useful in case of Burns, Split Thickness Grafting & </li></ul><ul><li>Other procedure as far down as the knee. </li></ul><ul><li>Paediatric practice for post-operative pain relief. </li></ul>
  13. 21. <ul><li>OBTURATOR NERVE BLOCK </li></ul><ul><li>Anatomy: </li></ul><ul><li>Arises from the ventral divisions of the 2 nd , 3 rd & 4 th </li></ul><ul><li>lumbar nerves (chief contribution – L 3 ) </li></ul><ul><li>Descends through the psoas major muscle  brim of </li></ul><ul><li>pelvis  enters lesser pelvis  along the lateral wall </li></ul><ul><li> reaches upper part of the obturator foramen  </li></ul><ul><li>enters the thigh through obturator foramen. </li></ul><ul><li>It divides into two branches: Anterior & Posterior </li></ul>
  14. 22. <ul><li>OBTURATOR NERVE BLOCK </li></ul><ul><li>Anterior division supplies: </li></ul><ul><ul><ul><li>Adductor longus </li></ul></ul></ul><ul><ul><ul><li>Adductor brevis </li></ul></ul></ul><ul><ul><ul><li>Gracilis </li></ul></ul></ul><ul><ul><ul><li>Hip joint </li></ul></ul></ul><ul><li>Posterior division supplies: </li></ul><ul><ul><ul><li>Obturator externus </li></ul></ul></ul><ul><ul><ul><li>Adductor magnus </li></ul></ul></ul><ul><ul><ul><li>Adductor brevis </li></ul></ul></ul><ul><ul><ul><li>Knee joint </li></ul></ul></ul>
  15. 24. <ul><li>OBTURATOR NERVE BLOCK </li></ul><ul><li>Technique: </li></ul><ul><li>Supine position </li></ul><ul><li>Make a skin wheal at a point 2 cm lateral & 2 cm </li></ul><ul><li>inferior from pubic tubercle. </li></ul><ul><li>Insert a 22 gauge, 3 inch needle perpendicular and </li></ul><ul><li>advance until contact is made with bone (Inferior or </li></ul><ul><li>Horizontal ramus of pubic bone). </li></ul><ul><li>Withdraw the needle and redirect laterally so that the </li></ul><ul><li>needle slides off the pubis into the obturator foramen. </li></ul><ul><li>Aspirate and then inject 10 ml of anesthetic solution. </li></ul>
  16. 25. <ul><li>OBTURATOR NERVE BLOCK </li></ul><ul><li>Indications: </li></ul><ul><li>Painful hip joints. </li></ul><ul><li>Adductor muscle spasm especially in paraplegics. </li></ul>
  17. 26. <ul><li>THE INGUINAL PARAVASCULAR TECHNIQUE OF LUMBAR PLEXUS ANESTHESIA (3 IN 1 BLOCK) </li></ul><ul><li>Introduction: </li></ul><ul><li>Blocking of three nerves Femoral, Obturator & Lateral </li></ul><ul><li>cutaneous with injection of local anesthetic into the </li></ul><ul><li>sheath of the femoral nerve in the thigh. </li></ul><ul><li>When these nerves emerge from the lumbar plexus, </li></ul><ul><li>they are sandwiched between the fascial covering of </li></ul><ul><ul><ul><ul><li>Posteriorly  Quadratus lumborum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anteriorly  Psoas major </li></ul></ul></ul></ul>
  18. 27. <ul><li>THE INGUINAL PARAVASCULAR TECHNIQUE OF LUMBAR PLEXUS ANESTHESIA (3 IN 1 BLOCK) </li></ul><ul><li>The compartment continues with Femoral nerve and </li></ul><ul><li>extends below the inguinal ligament. </li></ul><ul><li>Just above the inguinal ligament, Femoral nerve lies in a </li></ul><ul><li>groove bounded </li></ul><ul><ul><ul><li>Medially  by Psoas Fascia </li></ul></ul></ul><ul><ul><ul><li>Posterolateraly  by Iliac Fascia </li></ul></ul></ul><ul><ul><ul><li>Anteriorly  by Transversalis Fascia </li></ul></ul></ul><ul><li>Hence drugs injected into the Femoral sheath will travel </li></ul><ul><li>upwards provided </li></ul><ul><ul><ul><li>Enough volume is given </li></ul></ul></ul><ul><ul><ul><li>Pressure is applied below the site of injection. </li></ul></ul></ul>
  19. 28. <ul><li>THE INGUINAL PARAVASCULAR TECHNIQUE OF LUMBAR PLEXUS ANESTHESIA (3 IN 1 BLOCK) </li></ul><ul><li>Technique: </li></ul><ul><li>Supine position with anesthesiologist standing opposite the </li></ul><ul><li>site of operation. </li></ul><ul><li>Femoral artery palpated below the inguinal ligament and </li></ul><ul><li>retracted medially. </li></ul><ul><li>Immobile needle (a short bevel needle with translucent hub </li></ul><ul><li>connected by an extension tube to a syringe) inserted lateral </li></ul><ul><li>to Femoral artery and angulated cephalad. </li></ul><ul><li>The needle is advanced until paresthesia of the femoral </li></ul><ul><li>nerve obtained ( response is quadriceps contracture) </li></ul>
  20. 29. <ul><li>THE INGUINAL PARAVASCULAR TECHNIQUE OF LUMBAR PLEXUS ANESTHESIA (3 IN 1 BLOCK) </li></ul><ul><li>The finger palpating Femoral artery is removed and </li></ul><ul><li>placed firmly below the needle which facilitates cephalad </li></ul><ul><li>movement of anesthetic. </li></ul><ul><li>20 to 25 ml of anesthetic solution used. </li></ul><ul><li>Simultaneous block of lateral Femoral cutaneous nerve is </li></ul><ul><li>recommended. </li></ul>
  21. 30. <ul><li>THE INGUINAL PARAVASCULAR TECHNIQUE OF LUMBAR PLEXUS ANESTHESIA (3 IN 1 BLOCK) </li></ul><ul><li>Indication: </li></ul><ul><ul><li>For operation on the thigh. </li></ul></ul><ul><ul><li>For management of fracture of Femur shaft. </li></ul></ul><ul><ul><li>For acute knee injuries (Along with sciatic N. block) </li></ul></ul><ul><ul><li>For knee arthroscopy. </li></ul></ul><ul><li>Advantages: </li></ul><ul><ul><li>One Injection used. </li></ul></ul><ul><ul><li>Less local anesthetic needed. </li></ul></ul><ul><ul><li>High success rate. </li></ul></ul>
  22. 31. Thank You

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