Lower Extremity Regional Anesthesia

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A primer on lower extremity regional anesthesia, including instructions for sciatic, parasacral, lumbar plexus, femoral, saphenous, popliteal, lateral femoral cutaneous, obturator, and ankle blocks

Published in: Health & Medicine

Lower Extremity Regional Anesthesia

  1. 1. BFSA Slide by Brian F S Allen BFSA BFSA BFSA Slide by Brian F S Allen BFSA BFSA Lower Extremity Regional Anesthesia Brian Allen 09/2015
  2. 2. BFSA Slide by Brian F S Allen BFSA BFSA Scalp* (U,P){2} Interscalene (S,L){2} Transgluteal Sciatic (L,P){4,6} Paravertebral (U,L){4,6} Thoracic Epidural (U,L){4,6} Lumbar Plexus† (L){4,6} TAP (S){4} Superficial Cervical Plexus* (S){2} Axillary* (S,A){2} Infraclavicular (S,A){4} Supraclavicular (S){2} Lumbar Epidural (U,L){4,6} Infragluteal Sciatic (S,L,P){4,6} Ankle* (S){2} Lat Fem Cut* (S){2,4} Popliteal Sciatic (S,L,P){4} Femoral (S){2,4} Obturator* (S){4} Saphenous (S,P){4} HEENT*{2} Wrist* (S){2} Legend: * = Only Single Shot Bold = May Place Catheter Underline = uncommonly done † = Nerve Stimulator always used Positioning ( ): S = Supine U = Sitting Up P = Prone L = Lateral Decubitus or Simms A = Arm Over Head Needle Length { in inches } Common Regional and Neuraxial Blocks Suprascapular* (U){2,4} Spinal (U,L){3.5,6} Parasacral† (L){4,6}
  3. 3. BFSA Slide by Brian F S Allen BFSA BFSA Lumbosacral PlexusLumbar Plexus Caudad to: Lumbosacral Plexus Cephalad to: Lumbar Plexus Lateral Femoral Cutaneous N. Ilioinguinal N. Iliohypogastric N. Femoral N. Obturator N. Sciatic N. L1 to L4 L4 to S3
  4. 4. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Parasacral Femoral Saphenous Lateral Femoral Cutaneous Obturator Ankle High Sciatic (Anterior, Transgluteal, Infragluteal) Popliteal Sciatic Tibial Peroneal
  5. 5. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Parasacral Femoral Saphenous Lateral Femoral Cutaneous Obturator Ankle High Sciatic (Anterior, Transgluteal, Infragluteal) Popliteal Sciatic Tibial Peroneal Hip, Thigh, Knee Thigh, Knee, Calf Foot Knee, Calf, Foot
  6. 6. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Parasacral Femoral Saphenous Lateral Femoral Cutaneous Obturator High Sciatic (Anterior, Transgluteal, Infragluteal) Popliteal Sciatic These blocks cover: ¾ of the Thigh ¼ of the Calf ¾ of the Calf ¼ of the Thigh
  7. 7. BFSA Slide by Brian F S Allen BFSA BFSA Lower Extremity Exam: 4 P’s Pinch Lateral Femoral Cutaneous N. Push Sciatic (Tibial) N. Pull Obturator N. Punt Femoral N.
  8. 8. BFSA Slide by Brian F S Allen BFSA BFSA Lower Extremity Dermatomes L2 L3 L4 L5 S1 S2 S3 S1 L5 L4 L4 L5 L5 L3 L2 L1 L3 S1 S2 L5 L5 L1
  9. 9. BFSA Slide by Brian F S Allen BFSA BFSA Lower Extremity Osteotomes Femoral N Obturator N Common Peroneal N Tibial N
  10. 10. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Surface Anatomy Palpate: Iliac Crest Draw: Intercristal Line
  11. 11. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Surface Anatomy Palpate: Spinous Processes Draw: Midline
  12. 12. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Surface Anatomy Palpate: PSIS Draw: Line thru PSIS parallel to midline
  13. 13. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Surface Anatomy Measure: 2/3rds distance from midline to PSIS line Mark: This site along intercristal line 5 cm
  14. 14. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Surface Anatomy Needle Insertion Site 3-4 cm
  15. 15. BFSA Slide by Brian F S Allen BFSA BFSA Transverse Process Lamina ObtN FN LFCN LFCN Fem N Ob N Quadratus Femoris Psoas Genitofemoral N Sympathetics ~2 cm Needle Insertion
  16. 16. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Side Effects, Complications Common • Epidural Spread +/- Hypotension Rare • Retroperitoneal Hematoma Contraindications • Anticoagulation • Observe same guidelines as with spinal or epidural
  17. 17. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Neurostimulation Neurostimulation – goal 0.5-1.0 mA • Expected: Quadriceps (Rarely Obturator) • Unfavorable: – Local Twitch = Paraspinous muscles – Pelvic tilt = Quadratus Lumborum (Needle too lateral) – Hip Flexion = Psoas (Needle too deep) – Hamstrings twitch = L4, L5 root (Needle too medial or caudal) Joint Analgesia
  18. 18. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Block Success Weak/Numb in 3 nerves Pull - Obturator N. Pinch - LFCN Punt - Femoral N.
  19. 19. BFSA Slide by Brian F S Allen BFSA BFSA Parasacral Surface Anatomy Palpate: PSIS Mark: PSIS
  20. 20. BFSA Slide by Brian F S Allen BFSA BFSA Parasacral Surface Anatomy Palpate: Ischial Tuberosity Draw: Line from PSIS to Ischial Tuberosity
  21. 21. BFSA Slide by Brian F S Allen BFSA BFSA Parasacral Surface Anatomy Measure: 6 cm caudal to PSIS along line Mark: Needle insertion site 6 cm
  22. 22. BFSA Slide by Brian F S Allen BFSA BFSA Parasacral Neurostimulation Neurostimulation • Expected: Foot • Eversion or Dorsiflexion • Lateral aspect of N. • Inversion or Plantarflexion • Medial aspect of N. • Either pattern acceptable • Unfavorable: • Hamstring, Gluteus Max Joint Analgesia
  23. 23. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Palpate: PSIS Mark: PSIS
  24. 24. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Palpate: Greater Trochanter Draw: Line from PSIS to Greater Trochanter
  25. 25. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Measure: ½ distance along line Mark: Midpoint of line
  26. 26. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Draw: 4 to 5 cm Perpendicular line thru PSIS-GT line midpoint 4 to 5 cm Labat approach
  27. 27. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Palpate: Sacral Hiatus Draw: Line from Sacral Hiatus to Greater Trochanter
  28. 28. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Surface Anatomy Needle Insertion: Where lines intersect Winnie approach
  29. 29. BFSA Slide by Brian F S Allen BFSA BFSA Transgluteal Sciatic Neurostimulation ? Neurostimulation • Expected: Foot • Eversion or Dorsiflexion • Lateral aspect of N. • Inversion or Plantarflexion • Medial aspect of N. • Either pattern acceptable • Unfavorable: Proximal (hamstring), Gluteus Max (too superficial), Quad (too deep) Joint Analgesia
  30. 30. BFSA Slide by Brian F S Allen BFSA BFSA Infragluteal Sciatic Surface Anatomy Draw: Line between them Palpate: Ischial Tuberosity Palpate: Greater Trochanter
  31. 31. BFSA Slide by Brian F S Allen BFSA BFSA Infragluteal Sciatic Surface Anatomy Measure: ½ distance along line Mark: Midpoint of line
  32. 32. BFSA Slide by Brian F S Allen BFSA BFSA Infragluteal Sciatic Surface Anatomy 4 cm Draw: 4 to 5 cm Perpendicular line thru IT-GT line midpoint
  33. 33. BFSA Slide by Brian F S Allen BFSA BFSA Infragluteal Sciatic Surface Anatomy Confirmation: Needle insertion is 10 cm off midline Needle Insertion 10 cm
  34. 34. BFSA Slide by Brian F S Allen BFSA BFSA Infragluteal Sciatic Neurostimulation Neurostimulation • Expected: Foot • Eversion or Dorsiflexion • Lateral aspect of N. • Inversion or Plantarflexion • Medial aspect of N. • Either pattern acceptable • Unfavorable: Proximal (hamstring), Gluteus Max (too superficial), Quad (too deep) ? Joint Analgesia
  35. 35. BFSA Slide by Brian F S Allen BFSA BFSA High Sciatic Insertion Site Comparison Infragluteal Transgluteal Parasacral Sciatic Nerve
  36. 36. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Surface Anatomy Quadriceps: Vastus Lateralis, Vastus Medialis Vastus Intermedius Rectus Femoris Inguinal Ligament
  37. 37. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Surface Anatomy Iliopsoas Pectineus Sartorius
  38. 38. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Surface Anatomy Acronym: NAVEL to the Navel Femoral N. Femoral A. Femoral V. Saphenous N.
  39. 39. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Surface Anatomy Palpate Femoral Artery Needle Insertion 1 cm lateral to Femoral pulse for nerve stim approach
  40. 40. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Surface Anatomy Ultrasound Probe
  41. 41. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Femoral
  42. 42. BFSA Slide by Brian F S Allen BFSA BFSA FA Iliopsoas MedialLateral Femoral
  43. 43. BFSA Slide by Brian F S Allen BFSA BFSA Femoral FA Iliopsoas Fascia Lata MedialLateral Fascia Iliaca
  44. 44. BFSA Slide by Brian F S Allen BFSA BFSA FA MedialLateral Femoral
  45. 45. BFSA Slide by Brian F S Allen BFSA BFSA In Plane Needle Approach MedialLateral Femoral FA
  46. 46. BFSA Slide by Brian F S Allen BFSA BFSA In Plane Needle Approach Avoid Nerve, Pierce Fascia MedialLateral Femoral FA
  47. 47. BFSA Slide by Brian F S Allen BFSA BFSA Out of Plane Needle Approach MedialLateral Femoral FA
  48. 48. BFSA Slide by Brian F S Allen BFSA BFSA Out of Plane Needle Approach In Practice, Only Needle Tip Visible MedialLateral Femoral FA
  49. 49. BFSA Slide by Brian F S Allen BFSA BFSA Femoral Neurostimulation, Block Success Neurostimulation • Expected: Quad (Patella) • Unfavorable: • Sartorius (too medial or superficial • Adduction (too deep or Anterior Division of Fem N.) • Block Success: • Quad Weak • Punt Joint Analgesia
  50. 50. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Surface Anatomy Adductor Canal Adductor Canal Contents: Femoral Nerve, Artery, Vein sandwiched between Sartorius and Adductors
  51. 51. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Surface Anatomy Ultrasound Probe A block anywhere along Adductor Canal can be called: Subsartorial, Periarterial, or Adductor Canal Saphenous Block
  52. 52. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral
  53. 53. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral FA FV
  54. 54. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral FA Sartorius Adductor Longus Vastus Medialis
  55. 55. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral FA Saph N? Saph N?
  56. 56. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral FA
  57. 57. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral FA Ideal Periarterial Spread
  58. 58. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Surface Anatomy Femoral Artery penetrates dorsally thru Adductor Magnus, becoming the Popliteal Artery, marking the distal end of the adductor canal
  59. 59. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Surface Anatomy Descending Geniculate Artery
  60. 60. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Surface Anatomy A block distal to Adductor Canal is called: Subsartorial Saphenous Block NOT called Periarterial or Adductor Canal Block Ultrasound Probe
  61. 61. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral
  62. 62. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Sartorius
  63. 63. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Saph N. ?
  64. 64. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Ideal Fascial Spread
  65. 65. BFSA Slide by Brian F S Allen BFSA BFSA Saphenous Neurostimulation, Block Success Neurostimulation – not typically used • Expected: No motor response, only Medial Calf Paresthesia Block Success: • No motor weakness • Sensory only ?Joint Analgesia
  66. 66. BFSA Slide by Brian F S Allen BFSA BFSA Lateral Femoral Cutaneous Surface Anatomy Inguinal Ligament Anterior Superior Iliac Spine
  67. 67. BFSA Slide by Brian F S Allen BFSA BFSA Lateral Femoral Cutaneous Surface Anatomy Anterior Superior Iliac Spine LFCN Needle Insertion: 2 cm medial and caudal to ASIS Medial & superficial to Sartorius
  68. 68. BFSA Slide by Brian F S Allen BFSA BFSA Lateral Femoral Cutaneous Surface Anatomy Needle Insertion Needle Insertion: 2 cm medial and caudal to ASIS Medial & superficial to Sartorius
  69. 69. BFSA Slide by Brian F S Allen BFSA BFSA Lateral Femoral Cutaneous Surface Anatomy Ultrasound Probe Needle Insertion: 2 cm medial and caudal to ASIS Medial & superficial to Sartorius
  70. 70. BFSA Slide by Brian F S Allen BFSA BFSA LFCN Neurostimulation, Block Success Neurostimulation • Expected: No motor response, only Lateral Thigh Paresthesia Block Success: • No motor weakness • Sensory only
  71. 71. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Surface Anatomy
  72. 72. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Surface Anatomy Iliopsoas Pectineus Adductor Magnus
  73. 73. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Surface Anatomy Iliopsoas Pectineus Adductor Brevis Adductor Magnus
  74. 74. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Surface Anatomy Iliopsoas Pectineus Adductor Brevis Adductor Longus Adductor Magnus
  75. 75. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Surface Anatomy •3+ branches of Obturator Nerve (highly variable) •Anterior – runs between Brevis & Longus •Posterior – between Longus & Magnus •Hip Branch •Anterior Branch: Innervates Adductor Longus, Brevis, Gracilis •Posterior Branch: Innervates Adductor Brevis, Magnus, Obturator Externus, Knee Joint •Hip Branch: Innervates part of Hip Joint
  76. 76. BFSA Slide by Brian F S Allen BFSA BFSA Obturator Neurostimulation, Block Success Neurostimulation • Expected: Adduction Block Success: • Pull – Obturator • Sensory highly variable • Only 50% have any detectable skin surface numbness Joint Analgesia 50%
  77. 77. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Greater Trochanter Lesser Trochanter Femur Anterior Superior Iliac Spine
  78. 78. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Pubic Tubercle Pubic Symphysis
  79. 79. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Sciatic Nerve Common Peroneal Tibial
  80. 80. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy
  81. 81. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Draw: Line between ASIS & Pubic Tubercle
  82. 82. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Divide ASIS-PT line into thirds
  83. 83. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Draw: Line perpendicular from medial third of ASIS-PT line to GT line
  84. 84. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Draw: Line from Greater Trochanter parallel to ASIS-PT line
  85. 85. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Needle Insertion Beck Approach
  86. 86. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Surface Anatomy Needle Insertion Chelly Approach 8 cm
  87. 87. BFSA Slide by Brian F S Allen BFSA BFSA Anterior Sciatic Neurostimulation Neurostimulation • Expected: Foot • Eversion or Dorsiflexion • Lateral aspect of N. • Inversion or Plantarflexion • Medial aspect of N. • Either pattern acceptable • Unfavorable: Proximal (hamstring), Gluteus Max (too deep), Quad (too superficial) Joint Analgesia ?
  88. 88. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Anatomy Popliteal Crease Ischial Tuberosity
  89. 89. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Anatomy Semimembranosus Biceps Femoris, Short Head
  90. 90. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy Semitendinosus Biceps Femoris, Long Head Gastrocnemius
  91. 91. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy Popliteal Fossa
  92. 92. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy 7 cm proximal to popliteal crease 1 cm lateral to midpoint of popliteal crease Biceps Femoris Tendon Semitendinosus Tendon Needle Insertion for nerve stim approach
  93. 93. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy Probe location for Ultrasound approach 7 cm proximal to popliteal crease
  94. 94. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy Sciatic N. Common Peroneal N. Tibial N. Popliteal A. Popliteal V.
  95. 95. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Sciatic Surface Anatomy Probe location for Ultrasound approach
  96. 96. BFSA Slide by Brian F S Allen BFSA BFSA Image: Pedro Simoes Note difference in angle Popliteal Sciatic Surface Anatomy
  97. 97. BFSA Slide by Brian F S Allen BFSA BFSA Image: Pedro Simoes Popliteal Sciatic Surface Anatomy Ultrasound Probe
  98. 98. BFSA Slide by Brian F S Allen BFSA BFSA Image: Pedro Simoes Popliteal Sciatic Surface Anatomy Ultrasound Probe Biceps Femoris Vastus Lateralis
  99. 99. BFSA Slide by Brian F S Allen BFSA BFSA Image: Pedro Simoes Popliteal Sciatic Surface Anatomy Ultrasound Probe Biceps Femoris Vastus Lateralis Needle Insertion
  100. 100. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Deep, Ventral Superficial, Dorsal
  101. 101. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Deep, Ventral Superficial, Dorsal Biceps Femoris Semimembranosus
  102. 102. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Deep, Ventral Superficial, Dorsal Sciatic Nerve
  103. 103. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Deep, Ventral Superficial, Dorsal Common Peroneal Tibial
  104. 104. BFSA Slide by Brian F S Allen BFSA BFSA MedialLateral Deep, Ventral Superficial, Dorsal
  105. 105. BFSA Slide by Brian F S Allen BFSA BFSA Popliteal Neurostimulation, Block Success Neurostimulation • Expected: TIP (medial) or PED (lateral) • TIP – Tibial N. = Inversion or Dorsiflexion • PED – Peroneal N. = Eversion or Plantarflexion Block Success: weakness • Push - Tibial • Dorsiflexion - Peroneal Joint Analgesia
  106. 106. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar
  107. 107. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Lateral Maleolus Medial Maleolus
  108. 108. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Superficial Nerves
  109. 109. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral Ankle Saphenous N. Images: Phulvar Superficial Nerves Superficial Peroneal N. Sural N.
  110. 110. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Superficial Nerves Needle Insertion
  111. 111. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Superficial Nerves
  112. 112. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Lateral Maleolus Medial Maleolus Deep Nerves
  113. 113. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Flexor Digitorum Longus Tendon Tibialis Posterior Tendon Deep Nerves
  114. 114. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Medial Ankle Lateral AnkleImages: Phulvar Posterior Tibial Artery Posterior Tibial Nerve Deep Nerves
  115. 115. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Images: Phulvar Injection Site Deep Nerves Landmark Approach
  116. 116. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Images: Phulvar Deep Nerves Ultrasound Approach Ultrasound Probe
  117. 117. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Dorsum of the Foot Ankle Sprain
  118. 118. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Dorsum of the Foot Extensor Hallucis Longus Tendon Extensor Digitorum Longus Tendon Deep Nerves
  119. 119. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Dorsum of the Foot Deep Peroneal Nerve Dorsalis Pedis A. Deep Nerves
  120. 120. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Dorsum of the Foot Injection Site Deep Nerves Landmark Approach
  121. 121. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Surface Anatomy Dorsum of the Foot Deep Nerves Ultrasound Approach Ultrasound Probe
  122. 122. BFSA Slide by Brian F S Allen BFSA BFSA Ankle Block Success Block Success: • Numbness in 5 terminal nerve distributions
  123. 123. BFSA Slide by Brian F S Allen BFSA BFSA • Posterior Tibial • Plantar Foot • Deep Peroneal • Web space between 1st & 2nd toe • Superficial Peroneal • Dorsal Foot • Saphenous • Medial Calf • Sural • Lateral Calf
  124. 124. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Parasacral Femoral Saphenous Lateral Femoral Cutaneous Obturator Ankle High Sciatic (Anterior, Transgluteal, Infragluteal) Popliteal Sciatic Tibial Peroneal Hip, Thigh, Knee Thigh, Knee, Calf Foot Knee, Calf, Foot
  125. 125. BFSA Slide by Brian F S Allen BFSA BFSA Lumbar Plexus Effect Comparisons Saphenous Ankle ObturatorLat Fem CutFemoralLumbar Plexus 50 %
  126. 126. BFSA Slide by Brian F S Allen BFSA BFSA Sciatic Block Effect Comparisons ?? ? Popliteal Ankle Anterior SciaticInfraglutealTransglutealParasacral
  127. 127. BFSA Slide by Brian F S Allen BFSA BFSA Quiz Questions 1. All of the following nerves innervate part of the hip or knee joint EXCEPT: A. Obturator B. Lateral Femoral Cutaneous C. Sciatic D. Saphenous 2. Which nerve, blocked during an ankle block, is a terminal branch of the femoral nerve? A. Sural B. Deep Peroneal C. Saphenous D. Posterior Tibial
  128. 128. BFSA Slide by Brian F S Allen BFSA BFSA Quiz Questions 3. The most proximal approach to to the sciatic nerve is called what? A. Popliteal sciatic block B. Transgluteal sciatic block C. Parasacral block D. Anterior sciatic block 4. The adductor canal is surrounded by all of the following muscles EXCEPT: A. Vastus medialis B. Rectus femoris C. Adductor longus D. Sartorius
  129. 129. BFSA Slide by Brian F S Allen BFSA BFSA References • LE Lecture References by Slide • Slide 3 • Clinical Anesthesia 7th Edn. P. G. Barash, B. F. Cullen and R. K. Stoelting (editors). Published by Lippincott, Williams and Wilkins, Philadelphia, USA. 2013 • • Slide 7 & 39 • Enneking F, Chan V, GREGER J, Hadzic A, LANG S, Horlocker T. Lower-extremity peripheral nerve blockade: Essentials of our current understanding. Reg Anesth Pain Med. 2005;30(1):4-35. • • Slide 10 • Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002;94(6):1606-1613. • • Slide 14 • Heller AR, Fuchs A, Rössel T, et al. Precision of traditional approaches for lumbar plexus block: impact and management of interindividual anatomic variability. Anesthesiology. 2009;111(3):525-532. • • Slide 15 • Ilfeld BM, Loland VJ, Mariano ER. Prepuncture Ultrasound Imaging to Predict Transverse Process and Lumbar Plexus Depth for Psoas Compartment Block and Perineural Catheter Insertion. Anesth Analg. 2010;110(6):1725-1728. • • Slide 16 • Gadsden JC, Lindenmuth DM, Hadzic A, Xu D, Somasundarum L, Flisinski KA. Lumbar plexus block using high-pressure injection leads to contralateral and epidural spread. Anesthesiology. 2008;109(4):683-688. • • Slide 21 • Ripart J, Cuvillon P, Nouvellon E, Gaertner E, Eledjam J. Parasacral approach to block the sciatic nerve: A 400-case survey. Reg Anesth Pain Med. 2005;30(2):193-197. • • Slide 21 • OʼConnor M, Coleman M, Wallis F, Harmon D. An Anatomical Study of the Parasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers. Anesth Analg. 2009;108(5):1708-1712. • • Slide 28 • Brown, D.L. (2010). Sciatic Block in 4th Ed. Atlas of Regional Anesthesia. (pp. 101-110) Philadelphia. Elsevier. • • Slide 7 & 39 • Enneking F, Chan V, GREGER J, Hadzic A, LANG S, Horlocker T. Lower-extremity peripheral nerve blockade: Essentials of our current understanding. Reg Anesth Pain Med. 2005;30(1):4-35. • • Slide 49 • Anns JP, Chen EW, Nirkavan N, McCartney CJ, Awad IT. A Comparison of Sartorius Versus Quadriceps Stimulation for Femoral Nerve Block. Anesth Analg. 2011;112(3):725-731. • • Slide 50 • Jaeger P, Nielsen ZJK, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology. 2013;118(2):409-415. • • Slide 54 • Lund J, Jenstrup MT, Jaeger P, Sørensen AM, Dahl JB. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand. 2010;55(1):14-19. • • Slide 60 • Marian AA, Ranganath Y, Bayman EO, Senasu J, Brennan TJ. A Comparison of 2 Ultrasound-Guided Approaches to the Saphenous Nerve Block. Reg Anesth Pain Med. 2015;40(5):623-630. • • Slide 67 • Brown, D.L. (2010). Lateral Femoral Cutaneous Block in 4th Ed. Atlas of Regional Anesthesia. (pp. 121-124) Philadelphia. Elsevier. •

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