Abraham Tarekegn (Anesthetist) University of Gondar Department of Anesthesia Gondar, Ethiopia

1. Lower limb
blocks
Abraham Tarekegn
University of Gondar
Department of Anesthesia
1/4/2018 1

2. Spinal cord
• Lumbar and sacral
enlargement
 The sites where the nerves
serving the lower limbs,
emerge.
• Conus Medullaris:
 The terminal portion of the
spinal cord
• Cauda equina:
 The collection of nerve roots
at eh inferior end of the
vertebral canal.
• Spinal cord ends at the level
of L2 vertebrae (adults).
L.S Plexus by IM

3. L.S Plexus by IM

4. L.S Plexus by IM

5. Nerve supply to the lower extremity
 Composed of the lumbar
and sacral plexuses.
 The lumbar plexus is formed
in the psoas muscle by the
first four lumbar nerves,
including, frequently, a
branch from the 12th
thoracic nerve and
occasionally one from the
5th lumbar nerve.
 The sacral plexus is derived
from the anterior rami of the
4th and 5th lumbar and the
first two or three sacral
nerves.1/4/2018 5

6. The five major nerves to the
lower extremity
 The lumbar plexus:
1. The femoral nerve
2. The lateral femoral cutaneous
nerve
3. The obturator nerve
 Minor contributions
 Iliohypogastric innervate to the
skin of the buttock and the
muscles of the abdominal wall
 ilioinguinal supplies the skin of
the perineum and adjoining
portion of the inner thigh,
 Genitofemoral nerves It
supplies filaments to the genital
area and adjacent parts of the
thigh.1/4/2018 6

7. 1/4/2018 7

8. The five major nerves to the lower
extremity….  4. The posterior cutaneous
nerve - the "small sciatic" nerve
- from the first, second, and
third sacral nerves
 5. The larger sciatic nerve,
which also receives branches
of the anterior rami of the fourth
and fifth lumbar nerves.
 The two nerves course through
the pelvis together and out
through the greater sciatic
foramen, they are considered
together when techniques for
blocking the sciatic nerve are
discussed.
1/4/2018 8

9. 1/4/2018 9

10. Sensory
Distribution
of the Lower
Limb
L.S Plexus by. IM. 12-08-2014 10

11. Lumbar plexus
 The lumbar plexus is formed by the ventral
rami of first four lumber nerve roots (L1, L2,
L3 (major) & part of L4).
 In 50% of cases it receives a contribution
from the ventral rami of last thoracic root
(T12).
 It lies within the substance of the posterior
part of psoas major muscle, anterior to the
transverse processes of the lumbar
vertebrae.
 The branches emerge to both lateral and
medial side of psoas major muscles.1/4/2018 11

12. Components of lumbosacral plexus
 Components of the lumbosacral plexus
are as,
1. Lumbar plexus = L1, L2, L3, L4
2. Lumbosacral Trunk = L4, L5
3. Sacral Plexus = S1, S2, S3, S4
 Smaller branches of the lumber plexus
innervate the posterior abdominal wall
and psoas muscles (psoas major,
iliacus).
 Main branches innervate the anterior
thigh and their relative muscles.
L.S Plexus by IM

14. Lumbar plexus
 Root:
These are constituted by the anterior
primary rami of L1, L2, L3, L4 (T12).
 Branches:
L1 root gives an upper and lower branch
L2 Root gives and upper and lower
branch
L3 does not give any branch
L4 gives an upper and lower branch
1/4/2018 14

15. Division:
Lower branch of L2, upper branch of
L4 and ventral rami of L3 nerve roots
divide into small anterior and large
posterior division.
From L2 and L3 each gives two and
L4 one posterior divisions, with single
anterior division from all branches (L2,
L3, L4).
Lower branch of L4 and L5 unite to
form lumbosacral trunk
1/4/2018 15

16. Terminal Branches of Lumbar Plexus
 L1 unites with a small branch from T12
and splits into an upper and lower
branches.
 The upper larger branch divides into two:
Iliohypogastric (T12, L1) and
Ilioinguinal nerves (L1).
 The lower smaller branch of L1 unites
with a branch from L2 to form the
genitofemoral nerve.
 The remainders of L2, L3 and L4 divide
into ventral and dorsal branches. Ventral
(Anterior) divisions of L2, L3, L4 unite to
form obturator nerve.
1/4/2018 16

17. Branches…
 The dorsal (posterior) divisions of L2
and L3 divide into small and larger parts.
Smaller parts of dorsal divisions of L2
and L3 unite to form the lateral femoral
cutaneous nerve.
 Larger parts of dorsal divisions of L2
and L3 unite with L4 to form femoral
nerve.
1/4/2018 17

18. L.S Plexus by IM

20. L.S Plexus by IM

22. Sacral plexus
 The sacral plexus is formed by the
lumbosacral trunk (L4 ,L5 ), & ventral rami
of S1, S2, S3, S4 .
 Contribution of the fourth sacral ventral
rami is partial & the remainder of the last
(S5 ) joins the coccygeal plexus.
 Key to remember sacral plexus:
 Root  Divisions Terminal Branches
1/4/2018 22

23. Sacral plexus….
 Roots: These are constituted by the
anterior primary rami of L4 , L5, S1, S2, S3,
& S4
 Divisions: The lower branch of L4
ventral rami & ventral rami of L5 , S1 &
S2 give anterior and posterior divisions.
While S3 forms & shares only anterior
division.
 Terminal Branches: These anterior and
posterior divisions unite to form the
terminal nerve branches.1/4/2018 23

24. Terminal Branches
 The posterior division of L4 ,L5 & S1
joins to form Superior Gluteal Nerve
.
 The posterior divisions of L5,S1 & S2
unites to form the Inferior Gluteal
Nerve.
 The posterior divisions of L4 ,L5 ,S1
& S2 joins to form Common fibular
or Peroneal Nerve. It’s the about
one-half the size of the tibial nerve.
L.S Plexus by IM

25. Terminal Branches…
 The anterior divisions of L4 ,L5 ,S1,S2 &
S3 unites to form Poterior Tibial Nerve.
 The anterior divisions of S2,S3& S4
unites to form Pudendal Nerve.
 Both Tibial and peroneal nerves run in
a single covering of sheath and called
as Sciatic Nerve (L4 ,L5,S1,S2 &S3) .
Which is the largest nerve of the body.
1/4/2018 25

26. L.S Plexus by IM

27. L.S Plexus by IM

28. Nerve Name Origin Supplies
Iliohypogastric T12,L1 Motor supply to internal oblique, transverses
muscles, sensation over lower anterior abdominal
wall
Ilioinguinal L1 Sensation over anterior pubis (mons) and anterior
scrotum or labia
Genitofemoral L1, L2 Genital branch: motor supply to cremastor muscle,
sensation to anterior scrotum; femoral branch:
sensation to anterior thigh
Femoral L2, L3, L4 Motor supply to extensors of the knee, sensation to
anterior thigh
Obturator L2, L3, L4 Motor supply to adductors of the thigh, sensation to
medial thigh
Lumbosacral trunk L4, L5 Joins the sacral nerves to form the lumbosacral
plexus that supplies motor and sensory innervations
to the lower extremities
Posterior femoral
cutaneous
S2, S3 Sensation to perineum, posterior scrotum, and
posterior thigh
Pudendal S2, S3, S4 Motor to levator ani, muscles of the urogenital
diaphragm, anal and striated urethral sphincter,
sensation to the perineum, scrotum, and penisL.S Plexus by IM

29. 12/08/2014
Nerve Name Origin Supplies
Nerve to quadratus femoris
L4,L5,S1
quadratus femoris, inferior gemellus
Superior gluteal L4,L5,S1 gluteus medius & minimus, tensor fasciae latae
Inferior gluatel L5,S1,S2 Gluteus maximus
Nerve to obturator internus
L5,S1,S2 obturator internus, superior gemellus
sciatic
sacral plexus
(ventral primary
rami of L4-L5, S1-
S3)
(via its tibial & common peroneal branches)
semitendinosus, semimembranosus, biceps
femoris, part of adductor magnus, muscles of
leg & foot
skin of leg & foot (excluding medial side of leg
& foot)
L.S Plexus by IM

30. Lumbar plexus block
 The lumbar plexus is located in a
virtual space inside the Psoas major
muscle.
 This space is limited medially by
Psoas major insertions on the bodies
of the vertebrae and their transverse
processes and by the lumbar spine
itself.
 The aponeurosis surrounding the
plexus inside the Psoas major
constitutes the anterior, posterior and
lateral limits of this space.1/4/2018 30

31. 1/4/2018 31

32. Lumbar plexus block…
 Formed from the ventral rami of L1–
L3 and the major part of the L4 nerve.
It gives rise to the:
Iliohypogastric nerve (L1&T12)
Ilioinguinal nerve (L1)
Genitofemoral nerve (L1–L2)
Lateral femoral cutaneous nerve (L2–
L3)
Femoral nerve (L2–L4)
Obturator nerve (L2–L4).
1/4/2018 32

33. Lumbar plexus block…
 The depth at which the plexus is
located varies.
 To reach it, the needle goes through
skin, subcutaneous fat, Erector
spinae, Quadratus lumborum, and
Psoas major muscles.
 During its progression, the needle may
come into contact with the transverse
process of L4, providing an excellent
landmark.
1/4/2018 33

34. Blocked nerves
Upper thigh
 Ilio-inguinal nerve
 Iliohypogastric
nerve
 Genitofemoral
nerve
Lower limb
 Femoral nerve
 Lateral femoral
cutaneous nerve
 Obturator nerve
1/4/2018 34

35. Indications
 Analgesia for fractured neck of femur
and femoral shaft.
 It can be used for hip, knee and
femoral shaft surgery.
 In combination with sciatic nerve block
it can be used for all operations on the
knee, ankle, and foot.
1/4/2018 35

36. Landmarks
 Midline(spinous process)
 Posterior superior iliac spine (PSIS),
 Line joining the iliac crests (Tuffier's
line) intercristine line.
1/4/2018 36

37. Technique
 Position the patient laterally
and operative side
uppermost.
 Horizontal line joining the
top of the iliac crests at the
L4-L5 level.
 A line joining the spinous
processes of L3, L4 and L5.
 A line parallel to the line
joining the spinous
processes and passing over
the posterior superior iliac
spine.
 A line starting at the spinous
process of L4 and reaching
perpendicularly the line
passing by the posterior
superior iliac spine. 1/4/2018 37
Posterior
superior
iliac spine
Iliac crest

38. Technique…
 The puncture site is located
at the union of the lateral 1/3
and medial 2/3 of the line
joining the spinous process
of L4 to the line passing
through the posterior superior
iliac spine (approximately 40
mm lateral the spinous
process of L4).
 22G 100 mm insulated
needle perpendicular to the
skin with a slight caudal
angle needle is inserted
slowly through the muscles
until it reaches the transverse
process of L4. This contact is
expected and provides a real
safeguard. 1/4/2018 38

39. Technique…
 If there is bony contact
redirect the needle to
pass beneath the
transverse process or
quadriceps stimulation is
encountered
approximately 8–10 cm.
 The needle is inserted
more deeply until the
required stimulation of the
femoral nerve (ascension
of the patella) can be
observed.
 Inject at the site and
aspiration test is then
carried out to avoid
vascular or spinal
injection.
 nerve block vedio 1/4/2018 39

40. Doses
 Approximately 0.5ml/kg of LA.
 For a single injection, a volume of 20-
30 ml of anesthetic solution is
required.
 Injection must be slow and divided.
 1% Prilocaine, 1% Lidocaine
 0.25%-0.5% Levobupivacaine.
1/4/2018 40

41. Complications
 Kidney puncture : The needle is inserted too deep and
too cephalic. Avoid puncture at the L3 level, particularly
on the right side.
 Ureter puncture: Needle tip is too deep.
 Spinal or epidural puncture: The puncture site or the
direction of the needle are too medial. Always aspirate
before injecting slowly small quantities of anesthetic
solution.
 Epidural extension of anesthesia : In this case,
whether the catheter is located in the paravertebral
space or in the Psoas compartment, the anesthetic
solution reaches the epidural space. Analgesia is
effective. The catheter can be left in place but it should
then be treated as an epidural.
1/4/2018 41

42. Femoral Nerve: Anatomy
 The femoral nerve is the largest branch
of the lumbar plexus.
 Femoral nerve is created from
contributions from L2, L3, and L4.
 The femoral nerve enters into the thigh
under the inguinal ligament, between the
psoas and iliacus muscle.

43. Femoral Triangle

44. Anatomy
Pectineous
muscle
Iliopsoas
muscle
Fascia iliaca
Fascia lata
Skin
Femoral Vein
Femoral
Artery
Femoral Nerve

45. Femoral nerve block
 The femoral nerve (L2 - L4) arises
from the lumbar plexus and runs
under the psoas major and iliacus
muscles, covered by illopsoas fascia.
 The psoas fascia separates the nerve
from the femoral artery.
 The femoral nerves lie lateral to the
artery deep to the inguinal ligament.
45

46. Femoral nerve….
 The femoral nerve is the largest
branch of the lumbar plexus.
 It mainly supplies the extensors
muscles of the knee (quadriceps).
 About one inch below the inguinal
ligament the nerve divides in to
branches:
◦ The deep branch that innervate the
muscles of the front of the thigh.
◦ Cutaneous branches that innervate the
lateral of thigh. 1/4/2018 46

47. Femoral nerve block…
 The saphenous nerve which
innervates the medial side of the leg
up to the middle of the medial border
of the foot.
 It is formed by the dorsal or posterior
division of the anterior rami of L2,L3,
& L4 roots.
 The Saphenous Nerve is a purely
sensory nerve which the largest and
longest cutaneous branch of the
femoral nerve. 1/4/2018 47

48. Femoral nerve block…
 The lateral femoral cutaneous nerve of
the thigh emerges from the lateral
border of psoas major which is formed
by the posterior divisions of L2 and L3.
 It gives cutaneous supply to the lateral
part of the thigh.
1/4/2018 48

49. Femoral nerve block
 A femoral block
results in anesthesia
of the entire anterior
thigh and most of
the femur and knee
joint.
 The block also
confers anesthesia
of the skin on the
medial aspect of the
leg below the knee
joint (saphenous 1/4/2018 49

50. 1/4/2018 50

51. Indication of femoral nerve
block
 The femoral block is
primarily used in combined
with other peripheral blocks.
 However, it can be used
alone for muscle biopsies of
the quadriceps muscle or
other surgical procedures
limited to the anterior thigh
such as skin graft
 It is reported effective for
anesthetic management of
knee arthroscopy and
surgical repair of mid
femoral shaft fractures.
1/4/2018 51

52. Land marks for femoral nerve
block
 Inguinal ligament: A line drowns
between the anterior posterior iliac
spine and the pubic tubercle
 Femoral crease (oblique skin fold
positioned a few centimeters below
the inguinal ligament)
 The femoral artery is palpated as
it passes behind the midpoint of the
ligament.
 The needle is inserted just below
the ligament, 1 cm. lateral to the
artery, parallel with the course of
the nerve.
1/4/2018 52

53. Identify the landmarks.
 The femoral nerve is located just below the
inguinal ligament. Locate the anterior
superior iliac spine and the pubic tubercle.
A line between these two structures is
where the inguinal ligament is located.
 Next locate the pulsation of the femoral
artery.
 The site for needle insertion is
approximately 2 cm lateral to the pulsation.
From medial to lateral the structures are
femoral vein, femoral artery, and femoral
nerve.
1/4/2018 53

54. 1/4/2018 54

55. Techniques  The patient is placed in the supine
position.
 A line is drawn between the anterior
superior iliac spine and the pubic
tubercle, identifying the inguinal
ligament.
 Palpate and mark the femoral
artery at the level of the inguinal
ligament.
 Mark a point 1 cm lateral to the
pulsation and 1–2 cm distal to the
ligament.
 Insert a 22G 50 cm needle at 45° to
the skin in a cephalad direction. Two
distinct ‘pops’ may be felt as the
needle passes through fascia lata
then the fascia iliaca respectively.
 nerve block vedio
55

56. Techniques
 Paraesthesia in the
knee or stimulation of
quadratus femoris
‘dancing patella’
indicates correct
location of the needle.
 Inject 10–30 ml of
solution fanwise lateral
to the artery.
 1% Prilocaine, 1%
Lidocaine.
 0.25%-0.5%
Levobupivacaine.
1/4/2018 56

57. Complications
 Intravascular injection and hematoma
are possible because of the close
proximity of the femoral artery.
 Nerve damage
 Vascular puncture
1/4/2018 57

58. Obturator nerve block
 The obturator nerve, which originates from
the ventral rami of L2, L3, L4, is the most
anterior and medial branch of the lumbar
plexus.
 It emerges from posterior and medial border
of the psoas muscle, piercing the iliaca fascia
between L5 and S1.
 It runs on the lateral side of the pelvis over
the obturator muscle.
 It crosses the obturator foramen with the
obturator vessels and gives two divisions,
anterior and posterior, for the medial side of
the thigh.
1/4/2018 58

59. Indications
 Indicated for adductor spasm and knee
surgery (optional).
 For TUR of tumors located on the lateral
and inferolateral bladder combined with
SA or GA.
 For the diagnosis and treatment of
adductor muscle spasticity and in
chronic pain conditions (hip pain, pelvic
tumor).
 Postoperative analgesia after total knee
arthroplasty.
1/4/2018 59

60. Landmarks
 The landmark for the classic approach
to obturator nerve block is the pubic
tubercle.
 Insertion of adductor tendons.
 Inguinal ligament and the femoral
artery.
1/4/2018 60

61. Techniques
 The patient is first asked to flex his/her
hip and a line marked the inguinal crease.
 The adductor longus tendon is identified
as the most superficial palpable tendon in
the medial part of the thigh.
 A mark on the skin is made in the inguinal
crease at the midpoint of the line drawn
between the inner border of the adductor
longus tendon and the femoral arterial
pulse.
 This point corresponds to the center of an
easily palpable groove between the
vascular bundle and the adductor longus
muscle. 1/4/2018 61

62. Technique ….
1. Superior anterior
iliac spine
2. Pubic tubercle
3. Inguinal crease
4. Femoral pulse
5. Insertion point of the
needle in the
inguinal approach
6. Insertion point of
needle in the pubic
approach
1/4/2018 62

63. Technique ….
At a point between the
tendons, 1 cm inferior to the
pubis, insert a 22G 80 mm
insulated needle in the
horizontal plane aiming at
the ipsilateral anterior
superior iliac spine.
 At a depth of 5–6 cm
resistance of the obturator
membrane may be felt.
10 mL of LA is injected for
an adult patient. A volume of
0.3 ml/kg is suggested for
children.
 video
1/4/2018 63

64. Lateral cutaneous nerve block
 Block of this nerve is indicated for
analgesia of lateral femoral incisions
(hip surgery and surgery for fractured
neck of femur).
 It is commonly blocked by a femoral
nerve block or femoral 3:1 block.
1/4/2018 64

65. Landmarks &Technique
 Landmarks:
Anterior superior iliac spine, inguinal
ligament.
 Technique:
At a point 2 cm medial and 2 cm inferior to the
anterior superior iliac spine, below the inguinal
ligament.
Insert a 22G 25–50 cm short-bevelled needle
perpendicular to the skin.
10 -15ml of solution is injected beneath the
fascia lata after appreciation of the “pop”
sensation.
video 1/4/2018 65

66. 1/4/2018 66
Landmarks &Technique….
2 cm
2 cm
Landmarks for lateral femoral cutaneous nerve block.
Needle entry site (indicated by the cross) is 2 cm medial and 2 cm
caudad to the anterior superior iliac spine.

67. The three - in - one block
 The aim is to block the femoral, the lateral
cutaneous and obturator nerves with a
single injection.
 The principle upon which the block is
based is that all three nerves are
branches of the lumbar plexus and lie
sandwiched between the same muscles
and fascia.
 Femoral and/or 3-in-1 nerve blocks are
used for surgical procedures on the front
portion of the thigh down to the knee and
postoperative analgesia.
1/4/2018 67

68. Indications for Femoral/3-in-1
Nerve Block
 Femoral Nerve Block
 Operations on the anterior thigh (i.e. lacerations, skin
graft, muscle biopsy)
 Pin or plate insertion/removal (femur)
 Femur fractures
 Analgesia
 3-in-1 Nerve Block
 Same indications as femoral nerve block
 Analgesia and anesthesia of the hip (dislocations,
femoral neck fractures)
 Analgesia of the knee
1/4/2018 68

69. Innervations of the Femoral, Lateral Femoral
Cutaneous, and Obturator Nerves
 Femoral Nerve-
 Anterior and medial portion of the thigh and
knee.
 Cutaneous innervations of the medial and
lateral portion of the thigh.
 Periosteum of the femur.
 Lateral Femoral Cutaneous Nerve-
 Sensory nerve to the lateral buttock, thigh, and
knee joint.
 Obturator Nerve-
 sensory to the medial thigh, hip joint, and
adductor muscle.
1/4/2018 69

70. Technique
 Technique of 3-in -1 nerve blocks are
basically the same with femoral nerve
block, with some minor alterations.
 vedio
1/4/2018 70

71. Differences between Femoral Nerve
Block and 3-in-1 Nerve Block
 There are two main differences.
1. Volume of local anesthetic.
 For femoral nerve blocks, the volume of
local anesthetic is generally 20 ml or
less.
 For 3-in-1 nerve blocks, the volume of
local anesthetic is 25-30 ml. This allows
the local anesthetic to spread further in
the tissue plane resulting in blockade of
the femoral, lateral femoral cutaneous,
and obturator nerve.
1/4/2018 71

72. Technique…
2. Slight alteration in technique.
Once the needle has been placed in the
correct area, pressure should be applied
2-4 cm below the injection site.
Next, administer the local anesthetic.
Applying distal pressure helps spread
the local anesthetic to the obturator and
lateral femoral cutaneous nerve, in
addition to the femoral nerve.
1/4/2018 72

73. Sciatic nerve
 The largest nerve in the
body (1.5 - 2 cm. in width
and 0.3 to 0.9 cm. in
thickness as it leaves the
pelvis).
 Leaving the pelvis it passes
through a tunnel between
the greater trochanter and
the ischial tuberosity.
 It lies on the muscles
around the hip joint and is
covered by gluteus
Maximus.
1/4/2018 73

74. Sciatic Nerve
 It then runs vertically down wards in
the hamstring compartment of the
thigh to reach the popliteal fossa
where it divides in to common
peroneal and tibial branches.
 Occasionally this division occurs
much higher in the thigh.
 The tibial nerve passes vertically
down wards through the calf to supply
the heel and sole of the foot.
 The common peroneal nerve winds
diagonally across the popliteal fossa
to the lateral part of the calf before
descending to the foot where its
branches innervate the dorsal
structures.
1/4/2018 74

75. Indications of sciatic nerve
block
 Produce anesthesia in the back of the thigh.
 Ankle and foot with saphenous nerve block.
 Surgery of the knee with the block of femoral.
 Surgery of the leg with saphenous block
1/4/2018 75

76. Lateral/Posterior Approaches
 The patient in the Sims position.
Lie with the side to be blocked
upper most.
 The posterior superior iliac spine
and the greater trochanter are
identified and a line is drown
between the two points. A
perpendicular line is dropped at its
mid point
 The point of entry is 1 to 11/2
inches from the midpoint along this
line.
 This point should meet the line
drawn from the sacral hiatus to the
greater trochanter.
1/4/2018 76

77.  Skin cleansing and local
anesthetic is in filtrated in the
skin and muscle.
 A 22-gauge, 10–12-cm needle is
advanced until a paresthesia or
nerve stimulator response is
elicited or bone is contacted.
 If bone is encountered, the
needle is redirected
systematically in a lateral or
medial direction.
 A 9 spinal needle can be used
(6-8 cm. deep)
 Dosage = 20-30 ml. 1%
lignocaine or prilocaine or 0.5%
bupivacaine.
 vedio
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Lateral/Posterior Approaches…

78. Anterior Approaches of sciatic
nerve
 Supine position
 Identify inguinal ligament
line.
 This line is divided in to
three equal parts and a
perpendicular dropped
from the junction of the
medial and middle thirds.
 The anterior approach
requires a fairly long
needle
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79. Anterior approach
 A line is drawn then from
the top of the grater
trochanter parallel to the
line of the inguinal ligament
and the point where it
meets the perpendicular is
the point of needle
insertion.
 This over lies the lesser
trochanter on the inner
aspect of the femur and at
this level the sciatic nerve
lies close behind the
acetabulum and the lead of
the femur.
 Vedio
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80. Side Effects/Complications
 Technically difficult to perform and can be
quite painful.
 Hematoma formation is possible
 The risk of nerve damage is also reported
 Self limited persistent paresthesia
 A minimal degree of vasodilatation
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81. Sciatica
 Is a term used to describe the symptoms of
low back pain that spreads (radiates) through
the hip, to the back of the thigh, and down the
inside of back the leg via the sciatic nerve,
characterized by pain, tingling, numbness, or
weakness.
 Sciatica (sometimes known as radiculopathy)
is a description of symptoms of inflammation
or compression of the sciatic nerve , not a
diagnosis.
 A herniated disc, spinal stenosis,
degenerative disc disease, and
spondylolisthesis, can all cause sciatica.
81

84. Symptoms of Sciatica
 Cramping sensation in the thigh
 Radiating pain from the buttock down
the back of the leg
 Tingling in the legs
 Numbness in the legs
 Burning sensation in legs or thigh area
 Severe cases present with muscle
weakness
 Literally a pain in the butt!
Thursday, January 4, 2018 TAKE CARE OF YOUR LIFE 84

85. Symptoms of Sciatica…
 In Severe cases lower extremity weakness,
numbness in the upper thighs, and/or loss of
bladder or bowel control.
 Loss of knee flexion due to
weakness of hamstring
group of muscles.

88. Popliteal block
 Popliteal nerve block
provides sciatic nerve
anesthesia near the
point where the sciatic
nerve divides into its
common peroneal and
tibial nerve
components in the
popliteal fossa.
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89. Popliteal block
 Popliteal fossa block is
preferable to ankle block
for surgical procedures
requiring the use of a calf
tourniquet.
 The components of the
sciatic nerve may be
blocked at the level of the
popliteal fossa through
posterior or lateral
approaches.
 Supplemental block of the
saphenous nerve is
required for surgical 1/4/2018 89

90. Technique of popliteal block
 The patient positioned
prone. However, access may
also occur with the patient in
the lateral (operative side
nondependent) or supine
(with leg flexed at the hip
and knee) positions.
 The borders of the
popliteal fossa are identified
by flexing the knee joint.
 A triangle is constructed,
with the base consisting of
the skin crease behind the
knee, and the two sides
composed of the
semimembranosus 1/4/2018 90

91.  A bisecting line is drawn from
the apex to the base of the
triangle, and a 5-cm needle is
inserted at a site 7–10 cm
above the skin fold and 0.5–1
cm lateral to the bisecting line.
 The needle is advanced at a
45° angle until either a
paresthesia or nerve stimulator
response is elicited.
 Injection of approximately 30-
mL of local anesthetic solution
is sufficient.
 Success rate is typically 90–
95%.
 Identification of both tibial and
peroneal components
decreases onset time and
improves success rate.
 vedio
1/4/2018 91

92. 1/4/2018 92

93. Side Effects/Complications
 Neuropathy as with other block, is the
most common complication.
 Intravascular injection may occur as a
result of the presence of vascular
structures within the popliteal fossa.
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94. Ankle block: anatomy
 5 Nerves:
 4 Sciatic
branches:
◦ Deep peroneal
◦ Superficial
peroneal
◦ Posterior tibial
◦ Sural nerve
 1 Femoral
branch:
◦ Saphenous nerve
1/4/2018 94

95. Nerves of foot and ankle
 The ankle and the foot are
innervated by five nerves.
 The Saphenous nerve, is a
branch of the femoral nerve
 The Saphenous nerves
provides sensory
innervation to the medial
aspect of the ankle and the
foot.
 The remaining four, the
tibial, sural, deep peroneal
and superficial peroneal, are
branches of the sciatic
nerve.
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96. 1/4/2018 96

97. 1/4/2018 97

98. Common peroneal nerve
 Before entering
the longus
muscle, the
common peroneal
nerve divides into
the deep and
superficial
peroneal nerves.
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99. Common peroneal nerve
 The Deep Peroneal Nerve
provide sensory
innervation to the tarsal
and metatarsal joint as well
as the first interdigital
space.
 The Superficial Peroneal
Nerve: provides sensory
innervation to the dorsum
of the foot and toes.
1/4/2018 99
Deep Peroneal Nerve

100. Tibial nerve
 The tibial nerve
divides into the
posterior tibial nerve
and the sural nerve.
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101. Tibial nerve
 The tibial nerve provides
motor and sensory
innervation to the heel
and medial side of the
foot below the territory
innervated by the
Saphenous nerve and
above the sural nerve.
 The sural nerve provides
sensory innervation to
the lateral aspect of the
foot above the territory
innervated by the
calcaneal nerve. 1/4/2018 101

102. Ankle block
 The deep peroneal,
superficial peroneal,
and saphenous
nerves can be
blocked through a
single needle entry
site.
 A line is drawn across
the dorsum of the foot
connecting the
malleoli.
1/4/2018 102

103. Deep peroneal, superficial peroneal
and saphenous nerve block
 The extensor hallucis
longus tendon is
identified by having the
patient dorsiflex the big
toe.
 The anterior tibial artery
lies between this
structure and the tendon
of the extensor digitorum
longus muscle and is
palpable at this level.
1/4/2018 103

104. Deep peroneal nerve block
 A skin wheal is raised just
lateral to the pulsation between
the two tendons on the
intermalleolar line.
 A 25-gauge, 3-cm needle is
advanced perpendicular to skin
entry site, and 3–5 mL of local
anesthetic injected deep to the
extensor retinaculum to block
the deep peroneal nerve.
 This technique anesthetizes
the skin between the first and
second toes and the short
extensors of the toes.
1/4/2018 104

105. Superficial peroneal and
saphenous nerve block
 The needle is now directed
laterally through the same
skin wheal while injecting 3–5
mL of solution
subcutaneously, thus blocking
the superficial peroneal
nerve and resulting in
anesthesia of the dorsum of
the foot, excluding the first
interdigital cleft.
 The same maneuver can now
be performed in the medial
direction, thereby
anesthetizing the saphenous
nerve, a terminal branch of
the femoral nerve that
supplies a strip along the
medial aspect of the foot.
 nerve block vedioankle 1/4/2018 105

106. Sural Nerve
 It is located superficially
between the lateral
malleolus and the Achilles
tendon.
 A 25-gauge, 3-cm needle
is inserted lateral to the
tendon and is directed
toward the malleolus as 5–
10 mL of solution is
injected subcutaneously.
 This block provides
anesthesia of the lateral
foot and the lateral aspects
of the proximal sole of the
1/4/2018 106

107. Regional anesthesia in children
1/4/2018 107

108. Advantages
 Intra & postoperative prolonged pain
relief.
 Regional anesthesia suppress
undesirable reflex such as
laryngospasm.
 Spontaneously breathing patient
decrease physiologic dead space.
 Earlier ambulation & discharge from
hospital.
 Modify stress response.
 For G. A contraindicated patient i.e.,
chronic respiratory disease.1/4/2018 108

109. Disadvantages
 Require extra time to perform the block.
 The need of G.A to perform the block- one
may risk the child to possible complications
of both G.A & L.A
1/4/2018 109

110. Anatomic & physiologic consideration
 The tip of the canal cord is at L-3 at birth & L1- L2 at
one Year.
 Infants weighing 15 kg have relatively high volume of
CSF 4ml/kg body weight, compared with adult values
of 2ml/kg body weight.
 The content of epidural space have spongy gelatinous
lobules with distinct spaces permitting the wide
longitudinal spread of injected solution.
 The more extensive spread of caudal injection in
children is attributed to the lower density of their
epidural fat.
1/4/2018 110

111. Caudal block
 It can be used analgesia for surgery up
to and including the umbilicus.
 A short bevel 21-gauge needle.
 0.25 % bupivacaine o.5 ml/kg for lumbo
sacral procedure.
 1ml/kg for thoracolumbar procedure.
 1.25 ml/kg for mid thoracic procedure.
 Lidocaine 1% may be used instead of
.25% bupivacaine
1/4/2018 111

112. Epidural block
 General anesthesia is almost always
required.
 Children have narrow epidural space.
 The distance between the epidural
space & skin depend on the age of the
child.
 Resistance to air technique is used.
 Tuohy needle.
 Dose- 0.5% bupivacaine 0.25 - .5 ml/kg
for subsequent tip up.
1/4/2018 112

113. Spinal block
 Performed below L3
 Lateral position, to avoid neck flexion &
hypoxia.
 A small gauge, 3.5cm. styleted lumbar
puncture needle.
 Mid line approach preferred.
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