Common regional/ nerve blocks of the lower extremity with help of diagrams/ oictures and video clip have beeen described here.

1. COMMON
OPERATIVE
REGIONAL
BLOCKS:
Inferior Extremity

2. Dr. M. M. PANDITRAO
PROFESSOR/ HEAD & I/C
SICU
DEAN of Faculty of
Medicine
DEPT.OF ANAESTHESILOGY & CRITICAL CARE
Pad. Dr. DY PATIL MEDICAL COLLEGE,
HOSITAL & RESEARCH CENTER
Dr. DY PATIL UNIVERSITY
PIMPRI, PUNE 411018

3. INTRODUCTION
 DEVELOPED EARLY IN HISTORY OF ANAESTHESIA
 OPIUM / ALCOHOL etc. ACT BY CENTRAL DEPRESSION
 IN 1884 “NEW ERA” : COCAINE COULD NUMB A BODY
PART WITHOUT NUMBING THE BRAIN
THIS “PATH-BREAKING” CONCEPT EVOLVED AS
INTERVENTIONAL MANAGEMENT viz.
“BLOCKS”

4. GOLDEN RULES
 RESUSCITATION DRUGS/ EQUIPT./ O2 / I.V. ACCESS
 “XYLOCAINE SENSITIVITY” TEST IS A MISNOMER
 ANAESTHESIOLOGISTS DO NOT CALCULATE AS mls.
 CONSIDER DOSE,CONCENTRATION & VOLUME in toto
 DOSE, MIDPOINT OF RANGE TO PERMIT “TOP-UPS”
 WHEN COMBINATION IS TO BE USED : LOWEST OF
DOSES(mg/kg) OF EACH TO REDUCE TOXICITY

5. GOLDEN RULES
(continued)
 MIX BUPIVACANE WITH XYLOCAINE+ ADRENALINE
 ADJUVANTS: NaHCO3,OPIOIDS,KETAMINE,HYLASE
 “BLOCK” ALWAYS UNDER SUPERVISION
 “PRACTICE MAKES MAN PERFECT”
 “BACK TO BASICS” BEFORE ATTEMPTING BLOCKS
 “SEDATION” SHOULD NOT EVOKE “GUILT COMPLEX”

6. TYPES OF BLOCKS
 HEAD, NECK AND FACE BLOCKS
 UPPER EXTREMITY BLOCKS
 LOWER EXTREMITY BLOCKS
 ABDOMINAL FIELD BLOCKS

7. LOW EXTREMITY BLOCKS
ER
PROBLEMS ENCOUNTERED:
 ANATOMICALLY DIFFICULT TO BLOCK NERVES
 WIDE-SPREAD DISTRIBUTION OF NERVES
 OVERLAPPING OF DISTRIBUTION
 MUSCULARITY OF LOWER EXTREMITY
 UNRELIABILITY & “MISSED SEGMENTS”
 MULTIPLE PUNCTURES / INJECTIONS
SPINAL AND EPIDURAL: EASIER, VERY RELIABLE

8. LOW EXTREMITY BLOCKS:
ER
 INDICATED IF NEURAXIALS NOT FEASIBLE
 ALTHOUGH COMMONLY PERFORMED IN
DIABETICS, EXTRA CAUTION IS NEEDED
 MULTIPLE PUNCTURES = PATIENT
DISCOMFIRT
 “RING / ANKLET” BLOCK IS ESSENTIAL

9. ANATOMY
 LUMBAR PLEXUS:
Investment: L1 - L3 Ventral rami
Contribution From L4
From T12 In 50% patients
Distribution:Ventral Aspect of Inf.Extremity
T12, L1 : Superior; Ilio - inguinal,
Ilio - hypogastric
Inferior; Genito - Femoral
L 2-3-4 : Femoral, Obturator, Lat.Cut. Of Thigh

10. ANATOMY (Contd.)
 Lumbo-sacral: Dorsal aspect of Inf. Extremity
 Investment: L4-5, S1-2-3 Ventral Rami
Occasionally S4
 Of Interest : Sciatic; Combination of Two
Tibial & Common Peroneal
Tibial; Ventral Branches of all 5
Common Peroneal; Dorsal Branches of all 5
Distribution: Leaves Pelvis Via Gr. Sc. Foramen
Enters thigh bet. Gr.Tr. & Isch. Tub.

14. INGUINAL PERI-VASCULAR BLOCK
(3- IN- 1 BLOCK)
 First described by Winnie 1973
 Principle: At the level of Inguinal Ligament Femoral Nerve
“Wrapped Around” by
Fascia Iliacus on lateral border
Psoas Fascia on Medial Border
Transversalis Fascia as Anterior Wall
Drug Injected around the nerve ascends
up to “lumbar Plexus” near Psoas, blocking
“Femoral, Lateral Cutaneous Of Thigh, & Obturator
Viz: “Three-in –One” Block

15. TECHNIQUE (3- IN- 1 BLOCK)
 Inguinal Ligament - ASIS to Pubic Symphisis
 Mid Point
 Femoral Arterial Pulsations
 1cm. Below and lateral
 Insert Needle and direct cephalad at 60o angle
 If nerve-locator needle is used, at 0.5 mA current “
Patellar Dance” will be seen
 Minimum of 30 ml. of LAA to be injected
 If only medial side of thigh stimulated: go laterally

19. OBTURATOR BLOCK (Individually)
 Supine Position
 Extremity to be blocked, Slightly abducted
 Pubic Tubercle
 1.5 cm .Caudally, 1cm. Lateral to Tubercle (also
corresponds to midpoint between Pubic Tubercle and
Femoral Arterial Pulsations
 Spinal Needle, 22 Gz. And about 6-8 Inches long
 insert Perpendicular, till hits Pubic Ramus (1.5-4 cm.)
 Needle re-directed more laterally, 2-3 cms. more
deeper than Ramus (depth of First needle)
 Aspirate & inject 15 mls. in arrow-head manner

22. SCIATIC NERVE BLOCK (Classic)
 Labat in1930
 Lateral Position (Sim’s); affected side up
 Thigh Flexed completely and Knee flexed over Thigh
 Gr. Tr. and PSIS identified and Joined
 Perpendicular line from Midpoint on this line drawn
 Sacral Hiatus marked and line joined Gr. Tr.
 This line intersects Perpendicular
 At this point; Insert, 22 Gz. 6-8 inch long needle
 for about 4 inches/ if electrical stimulation possible then
movement in leg and foot
 20-25 ml of LAA

23. SCIATIC NERVE BLOCK (Raj)
 Raj in 1975
 Patient Supine
 Leg is raised till Thigh is 900 to Trunk
 Knee is flexed at 900 to Thigh
 Gr. Tr. and Isch. Tuberosity marked
 Line joining them along with Gluteal Crease
 Midpoint
 Needle inserted perpendicular to skin and directed
cephalad
 20-25 ml of LAA

27. ANKLE BLOCK
 5 Nerves: Superficial Peroneal, Sural, Posterior
Tibial, Saphenous, and Musculocutanous
 Main 3: First Three.
1. Superficial Peroneal:
Dorsalis Pedis Artery Pulsations, Between Tendons
of Ext. Hallucis longus & Ext. Digitorum longus
22 Gz. needle, perpendicular to skin, 1.5- 2cm.depth
Hit the bone
Withdraw, above Inf. Ext. Retinaculum
Inject 6-8 ml. LAA
Come upto Skin; Raise weal; “Anklet Block”

28. ANKLE BLOCK
(Contd.)
2. Sural (Lateral Calcaneal & Lateral Dorsal Cutaneous)
 Just Behind Lateral Malleolus
 Hit the bone
 7-8 ml. of LAA
 Anklet Block
3. Posterior Tibial
Behind Medial Malleolus
Posterior Tibial Artery
Hit the bone
Inject 7-8 ml LAA
Anklet Block

33. HERNIA BLOCK
LOWER 3 – 6 INTER-COSTALS (IF REQUIRED)
SUBCOSTAL
ILIO-INGUINAL & ILIO- HYPOGASTRIC
GENITAL branch of GENITO-FEMORAL
BEFORE ADVENT OF SAFER INHALATIOAL
AGENTS / RELIABLE NMBDs / MONITORING /
POST-OPERATIVE CRITICAL CARE, POPULAR
“SKILLED” ANAESTHESIOLOGISTS = SAFE G.A.

34. HERNIA BLOCK
(CONTINUED)
 “HYPOTHETICAL” MISSING OF LAT.
CUTANEOUS BRANCH HAS BEEN PROVEN
WRONG
 “DREADED!” COMPLICATION OF
PNEUMOTHORAX, FOUND TO BE
NEGLIGIBLE (0.07% - 0.4%)
SERIES SHOWED SAFE SURGICAL
CONDITIONS PRODUCED WITH SEDATION
AND MONITORING

35. HERNIA BLOCK
Subcostal : Mid- clavicular line, Subcostal Margin
Laterally and Medially
Infiltrate 7-8 mi.
Ilio-Inguinal & Ilio- Hypogastric:
1 finger breadth anterior to ASIS
Hit the Bone
Fan-shaped- “Arrow-head” Block
10-15 ml. of AA
Genital Branch of Genito - Femoral
Pubic Tubercle
Perpendicular to Skin
Hit the Bone
5-7 ml. of LAA

36. CONCLUSION
 “SKILL & THRILL” OF ANAESTHESIOLOGIST
 PROPER SELECTION, SAFE PRECAUTIONS
 COST-EFFECTIVE & LESSER MORBIDITY
 EXCELLENT “TOOL” OF TRAINING