Lumbar and Sacral Plexus block; indications precautions and techniques Landmark based Nerve stimulator guided technique. Fluoroscopic technique where boney landmarks are poor.

1. Combined paravertebral lumbar plexus and parasacral
sciatic nerve block for reduction of hip fracture in a
patient with severe aortic stenosis.
Ho AM, Karmakar MK. Can J Anaesth. 2002 Nov;49(9):946-50.
• CLINICAL FEATURES: In an 87-yr-old lady with severe
aortic stenosis and fracture of the right trochanter
due to a fall
• CONCLUSION: Combined paravertebral lumbar
plexus and parasacral sciatic nerve block can be a
viable alternative to general anesthesia and epidural
or spinal block for hip surgery in patients with severe
aortic stenosis.

2. • The lumbar plexus block is an advanced
nerve block technique. The block has
significant clinical applicability. However,
this block has a relatively higher potential
for complications and should be practiced
only after appropriate training. Due to the
placement of the needle in the deep muscle
beds, the potential for systemic toxicity is
greater than in many other techniques.

3. An alternative to Central
Neuraxial Block ; Lumbar Plexus
and Parasacral Bock
Dr Ashok Jadon

4. The lumbar plexus
• L2, L3, and L4 roots split into anterior and posterior
divisions, which then reunite to form the individual
branches (nerves) of the plexus.
• The major branches of the lumbar plexus are
• Genito-femoral,
• Lateral femoral cutaneous,
• Femoral, and
• Obturator
• The femoral nerve is formed by the posterior
divisions & obturator by anterior divisions of the
same roots

6. Precautions for
Possible complications
• Infection
– A strict aseptic technique is used
• Hematoma
– Avoid multiple needle insertions, particularly in
anti-coagulated patients
• Vascular puncture
– Vascular puncture is not common with this
technique. However, deep needle insertion should
be avoided (vena cava, aorta)

7. Precautions cond..
• Local anesthetic toxicity
– Systemic toxicity less common with plexus blocks
due to the location of the plexus in the proximity
of large muscle beds
– Higher volumes result in more solid, complete and
faster blockade, however, it carries a higher risk of
toxicity
– Careful and frequent aspiration should be
performed during the injection
– Avoid forceful, fast injection of local anesthetic

8. Precautions cond..
• Nerve injury
– The risk of nerve injury after lumbar plexus block
is low
– Local anesthetic should never be injected when
the patient complains of pain or abnormally high
pressure on injection is met
– When stimulation is obtained with current intensity of < 0.5 mA, the
needle should be pulled back to obtain the same response with a
current of 0.5mA before injecting local anesthetic to avoid injection
into the dural sleeves and the consequent epidural or spinal spread

9. Precautions contd..
• Hemodynamic consequences
– Lumbar plexus blockade results in unilateral
sympathectomy; as such, significant hypotension
is rare
– Spread of the local anesthetic to the epidural
space may result in significant hypotension and
occurs in as many as 15% of the patients
– Every patient receiving a lumbar plexus block
should be monitored to the same extent as
patients receiving epidural anesthesia

10. Landmarks Marking

11. Localisation for Lumbar Plexus

12. Localisation of sacral plexus & Surgery

13. Lumbar catheter in Situ for
Post-operative pain relief

14. Position of catheter Verified
before removal (USG)

15. Fluoroscopic guided
Lumbar Plexus Block

16. Fluoroscopic guided
Lumbar Plexus Block

17. Contrast Confirmation;
Fluoroscopic guided
Lumbar Plexus Block

18. Thank you