NERVE PLEXUSES IN HUMAN BODY & ITS BLOCKS ....AN ANAESTHETIC IMPLICATION.

1. NERVE PLEXUSES & ITS
ANAESTHETIC
IMPLICATIONS
PRATYUSH KANTI MISRA
1ST YR PG STUDENT
DPT OF ANAESTHESIOLOGY
MKCG MCH

2. Nervous
system
Central nervous
system
Brain
Spinal
cord
Peripheral nervous
system
Cranial
nerves
Spinal
nerves
plexuse
s

3. Nerve plexus
• plexus -- a network of nerves, blood vessels
or lymphatics.
• A nerve plexus is a system of connected nerve
fibers that link spinal nerves with specific areas
of the body.
• A plexus is like an electrical junction box, which
distributes wires to different parts of a house.

4. NERVE
PLEXUS
ANATOMY
• The nerve plexus is actually
made up of a multitude of
nerve branches. These
branches come from the
spinal nerves.
• A nerve plexus is composed
of afferent and efferent
fibers that arise from the
merging of the anterior rami
of spinal nerves and blood
vessels.

5. NErVE PLEXUS STRUCTURE
• Once they connect, they break off again and develop the
network of nerve fibers known as the nerve plexus.
There are actually 4 of these nerve plexuses in the
human body, the brachial plexus, cervical plexus, the
sacral plexus and the lumbar plexus.
• At the root of the limbs, the anterior rami join one
another to form complicated nerve plexus. The
cervical and brachial plexuses are found at the
root of the upper limbs, and the lumbar and sacral
plexuses are found at the root of the lower limbs.

6. The main function of a nerve
plexus
• The main function of a nerve plexus is to ensure
that all areas of the body are innervated,
thereby equipping each region with the ability
to send and receive messages from the
peripheral nervous system.

7. Nerve plexus
Spinal
plexuses
Cervical plexus
Brachial plexus
Lumbar plexus
Sacral plexus
Coccygeal plexus
Autono
mic
plexuses
Auerbach’s plexus
Meissner’s plexus
Celiac plexus

8. 1. Spinal plexus
At each vertebral level, paired
spinal nerves leave the spinal cord
via the intervertebral foramina of
the vertebral column.
There are five spinal nerve
plexuses

9. 1.a. Cervical plexus
• The cervical nerve plexus is a junction
of small nerve fiber network that
transports sensory information to the
shoulder, neck and the head.
• Cervical Plexus—Serves the Head,
Neck and Shoulders
• The cervical plexus is formed by the
ventral rami of the upper four cervical
nerves and the upper part of fifth
cervical ventral ramus. The network of
rami is located deep within the neck.

10. 1.b. the brachial plexus
• The brachial plexus is
formed by the ventral
rami of C5–C8 and the
T1 spinal nerves, and
lower and upper halves
of the C4 and T2 spinal
nerves. The plexus
extends toward the
armpit (axilla).

11. 1.c. Lumbar
plexus
• Lumbar Plexus—Serves the
Back, Abdomen, Groin, Thighs,
Knees, and Calves
• The lumbar plexus is formed
by the ventral rami of L1–L5
spinal nerves with a
contribution of T12 form the
lumbar plexus. This plexus lies
within the psoas major
muscle.

12. 1.d. sacral plexus
• Sacral Plexus—Serves
the Pelvis, Buttocks,
Genitals, Thighs,
Calves, and Feet
• The sacral plexus is
formed by the
ventral rami of L4-S3,
with parts of the L4
and S4 spinal nerves.
It is located on the
posterior wall of the
pelvic cavity.

13. 1.e.Coccygeal Plexus
• Coccygeal Plexus—
Serves a Small Region
over the Coccyx
• Originates from S4, S5,
and Co1 spinal nerves. It
is interconnected with
the lower part of sacral
plexus.

14. 2. Autonomic plexuses
• Autonomic plexus can contain both sympathetic and
parasympathetic neurons :
a) Celiac plexus (solar plexus)—Serves internal organs. The
solar plexus, or celiac plexus, is a large cluster of nerves that
relay messages from the major organs of the abdomen to the
brain. These visceral organs are important to metabolism and to
general life functioning.
b) Auerbach's plexus—Serves the gastrointestinal tract.
c) Meissner's plexus (submucosal plexus)—Serves the
gastrointestinal tract

16. Other plexuses
• Some other plexuses include the hypogastric plexus,
renal plexus, hepatic plexus, splenic plexus, gastric
plexus, pancreatic plexus, and testicular plexus /
ovarian plexus.
• choroid plexus infoldings of blood vessels of the pia
mater covered by a thin coat of ependymal cells that form
tufted projections into the third, fourth, and lateral
ventricles of the brain; they secrete the cerebrospinal fluid.
• cystic plexus a nerve plexus near the gallbladder.
• dental plexus either of two plexuses (inferior and
superior) of nerve fibers, one from the inferior alveolar
nerve, situated around the roots of the lower teeth, and the
other from the superior alveolar nerve, situated around the
roots of the upper teeth.

17. The Spinal Nerves
• 31 pairs of spinal nerves (1st cervical above C1)
– mixed nerves exiting at intervertebral foramen
• Proximal branches
– Dorsal (posterior) root is sensory input to spinal cord
– Ventral (anterior) root is motor output of spinal cord
• Distal branches
– dorsal ramus supplies dorsal body muscle and skin
– ventral ramus to ventral skin and muscles and limbs
– meningeal branch to meninges, vertebrae and
ligaments

18. Branches of a Spinal Nerve
• Spinal nerves: 8
cervical, 12
thoracic, 5
lumbar, 5 sacral
and 1 coccygeal.
• Each has dorsal
and ventral
ramus.

20. Spinal Nerve Roots and Plexuses

21. Cervical Plexus
• Formed by the anterior (ventral) rami of the
cervical nerves C1-C4 with contribution C5.
• Supplies the skin and muscles of the head,
neck and superior part of the shoulders and
chest.
• Phrenic nerve arises from the cervical plexus
& innervates the diaphragm.

22. The Cervical Plexus

24. Terminal
Branches
• Superficial branches
(Sensory)
1. Lesser occipital (C2) –
skin of scalp posterior
and superior to ear.
2. Great auricular (C2-C3) –
skin anterior, inferior,
and over ear and over
parotid gland.
3. Transverse cervical (C2-
C3) – skin over anterior
aspect of neck.
4. Supraclavicular (C3-C4) –
skin over superior
portion of chest and
shoulder.

25. CERVICAL PLEXUS BLOCK
• Two Types ---
• 1) SUPERFICIAL BLOCK
• 2) DEEP BLOCK
• INDICATIONS-
• 1) CAROTID ENDARTERECTOMY
• 2) SUPERFICIAL NECK SURGERY
• 3) THYROIDECTOMY
• 4) TRACHEOSTOMY

26. SUPERFICIAL CERVICAL PLEXUS BLOCK

27. Brachial Plexus
• The anterior (ventral) rami of spinal nerves C5-C8
and T1 form the brachial plexus.
• Extends inferiorly and laterally on either side of the
last four cervical and first thoracic vertebrae
through intervetebral foramen.
• Passes above the first rib posterior to the clavicle
and then enter the axilla (cervicoaxillary canal).
• The brachial plexus provide the entire nerve supply
of the shoulder and upper limbs.

29. • Five important nerves arise from brachial
plexus are:.
1. Axillary nerve
2. Musculocutaneous nerve
3. Radial nerve
4. Median nerve
5. Ulnar nerve

30. The brachial plexus is an arrangement of nerve
fibres, running from the spine, formed by the
ventral rami of the lower cervical and upper
thoracic nerve roots
it includes –
from above the fifth cervical vertebra to underneath
the first thoracic vertebra(C5-T1).
It proceeds through the neck, the axilla and into the
arm. The brachial plexus is responsible for
cutaneous and muscular innervation of the entire
upper limb.
ANATOMY

31. • The trunks pass laterally and lies around the
subclavian artery while passing over the first
rib to enter the axilla, between the clavicle and
the scapula.
• Behind the clavicle, each trunk splits into
anterior and posterior divisions. These
recombine to form the posterior , lateral and
medial cords around the axillary artery.
• The upper roots (C5–7) tend to stay lateral,
the lower roots (C8,T1) tend to stay medial
and All roots contribute to the posterior cord,
and therefore also to the radial nerve.

32. • In the neck, the brachial plexus lies in the
posterior triangle, being covered by the skin,
Platysma, and deep fascia;where it is crossed
by the supraclavicular nerves, the inferior belly
of the Omohyoid, the external jugular vein,
and the transverse cervical artery.
• When It emerges between the Scaleni
anterior and medius; its upper part lies above
the third part of the subclavian artery, while
the trunk formed by the union of the eighth
cervical and first thoracic is placed behind the
artery.
RELATIONS

35. FORMATION OF THE
BRACHIAL PLEXUS

36. • Roots
• The ventral rami of spinal nerves C5 to T1 are referred to as
the roots of the plexus.
• Trunks
• Shortly after emerging from the intervertebral foramina , these
5 roots unite to form three trunks.
–The ventral rami of C5 & C6 unite to form the Upper Trunk.
–The ventral ramus of C 7 continues as the Middle Trunk.
–The ventral rami of C 8 & T 1 unite to form the Lower
Trunk.

37. •Divisions
Each trunk splits into an anterior division and a posterior division.
–The anterior divisions usually supply flexor muscles
–The posterior divisions usually supply extensor muscles.
• Cords
• –The anterior divisions of the upper and middle trunks unite to
form the lateral cord.
• –The anterior division of the lower trunk forms the medial cord.
• –All 3 posterior divisions from each of the 3 cords unite to form
the posterior cord.
• –The cords are named according to their position relative to the
axillary artery

39. Schematic representation of brachial
plexus

40. Cutaneous distribution

41. From Nerve Roots Muscles Cutaneous
Roots
dorsal scapular
nerve
C5
rhomboid
muscles and
levator
scapulae
-
Roots
long thoracic
nerve
C5, C6, C7
serratus
anterior
-
Upper trunk
nerve to the
subclavius
C5, C6
subclavius
muscle
-
Upper trunk
suprascapular
nerve
C5, C6
supraspinatus
and
infraspinatus
-
NERVE SUPPLY

42. Lateral Cord
lateral pectoral
nerve
C5, C6, C7
pectoralis
major (by
communicating
with the medial
pectoral nerve)
-
Lateral Cord
musculocutane
ous nerve
C5, C6, C7
coracobrachiali
s, brachialis and
biceps brachii
becomes the
lateral
cutaneous
nerve of the
forearm
Lateral Cord
lateral root of
the median
nerve
C5, C6, C7
fibres to the
median nerve
-
From lateral cord

43. Posterior Cord
upper
subscapular
nerve
C5, C6 subscapularis (upper part) -
Posterior Cord
thoracodorsal
nerve (middle
subscapular
nerve)
C6, C7,
C8
latissimus dorsi -
Posterior Cord
lower
subscapular
nerve
C5, C6
subscapularis (lower part )
and teres major
-
POSTERIOR CORD BRANCHES

44. Posterior Cord Axillary Nerve C5, C6
Anterior Branch:
Deltoid And A
Small Area Of
Overlying Skin
Posterior Branch:
Teres Minor And
Deltoid Muscles
Posterior Branch
Becomes Upper
Lateral
Cutaneous Nerve
Of The Arm
Posterior Cord Radial Nerve C5, C6, C7, C8, T1
Triceps Brachii,
Supinator,
Anconeus, The
Extensor Muscles
Of The Forearm,
And
Brachioradialis
Skin Of The
Posterior Arm As
The Posterior
Cutaneous Nerve
Of The Arm
POSTERIOR CORD BRANCHES

45. Medial
cord
Medial pectoral
nerve
C8, t1
Pectoralis major and
pectoralis minor
-
Medial
cord
Medial root of
the median
nerve
C8, t1 Fibres to the median nerve
Portions of hand not
served by ulnar or radial
Medial
cord
Medial
cutaneous
nerve of the
arm
C8, t1 -
Front and medial skin of
the arm
MEDIAL CORD BRANCHES

46. Medial Cord
Medial
Cutaneous
Nerve Of
The
Forearm
C8, T1 -
Medial Skin Of The
Forearm
Medial Cord Ulnar Nerve C8, T1
Flexor Carpi Ulnaris, The
Medial 2 Bellies Of Flexor
Digitorum Profundus,
The Intrinsic Hand
Muscles Except The
Thenar Muscles And The
Two Most Lateral
Lumbricals
The skin of the medial
side of the hand
medial one and a half
fingers on the palmar
side
and
medial two and a half
fingers on the dorsal
side
MEDIAL CORD BRANCHES

47. • The plexus may include anterior rami from C4 or
T2 and these are designated as
• Pre fixed- C4 added
• Post fixed- T2 added.
• The connective tissue sheath that invests the
plexus especially in the axillary region has a
convoluted and septated structure that can lead to
non uniform distribution of local anaesthetics .
ANATOMIC VARIATIONS

48. Brachial
plexus
injury

49. • Named after augusta déjerine-
klumpke,
• klumpke's paralysis is a variety of
partial palsy of the lower roots of
the brachial plexus.
• Results from a brachial plexus injury
in which C8 and T1 nerves are
injured .
• Affects, principally, the intrinsic
muscles of the hand and the flexors of
the wrist and fingers.
• The classic presentation of klumpke's
palsy is the “claw hand” where the
forearm is supinated and the wrist
and fingers are hyperextended with
flexion at interphalangeal joints.
Klumpke s palsy

50. • Erb's palsy (Erb-Duchenne
Palsy) is a paralysis of the arm
caused by injury to the upper
trunk C5-C6.
• signs of Erb's Palsy
• include loss of sensation in the
arm and paralysis and atrophy of
the deltoid, biceps, and
brachialis muscles.
• the arm hangs by the side and is
rotated medially; the forearm is
extended and pronated.
commonly called "waiter's
tip hand."
Erb’s palsy

51. •Erb’s Palsy – Nerves Affected

52. • BRACHIAL PLEXUS BLOCK-
• Techniques-
• Interscalene Brachial Plexus Block
• Supraclavicular(Subclavian)Brachial Plexus Block
• Infraclavicular Brachial Plexus Block
• Axillary Brachial Plexus Block
Anesthetic implications

53. • Described by winnie in 1970.
• Indications-
• 1) Surgery in shoulder ,upper arm and forearm.
• 2) Post operative analgesia for total shoulder
arthroplasty
• Blockade occurs at the level of the upper and
middle trunks.
Interscalene block

56. • Positioning- supine position with the head turned
away from the side to be blocked.
• The posterior border of the sternocleidomastoid
muscle is palpated by having the patient briefly
lift the head.
• The interscalene groove can be palpated by
rolling the fingers posterolaterally from this
border over the belly of the anterior scalene
muscle into the groove.
• A line extended laterally from the cricoid
cartilage and intersecting the interscalene groove
indicates the level of the transverse process of
C6.
• The external jugular vein often overlies this point
of intersection.

58. • Complications
• Ipsilateral diaphragmatic paresis
• Severe hypotension and bradycardia (i.e., the
Bezold-Jarisch reflex)
• Inadvertent epidural or spinal block
• Nerve damage or neuritis
• intravascular injection with Seizure activity
• Horner’s syndrome with dyspnea and hoarseness
of voice.
• Puncture of the pleura may cause Pneumothorax.
• Hemothorax.
• Hematoma and Infection.

59. • Indications
• 1) operations on the elbow, forearm, and hand.
• Blockade occurs at the distal trunk–proximal
division level.
• Location-
• The three trunks are clustered vertically over
the first rib cephaloposterior to the subclavian
artery. The neurovascular bundle lies inferior
to the clavicle at about its midpoint.
Supraclavicular block

61. • Technique-
• in supine position with the head turned away from the
side to be blocked.
• The arm to be anesthetized is adducted, and the hand
should be extended along the side toward the ipsilateral
knee as far as possible.
• In the classic technique, the midpoint of the clavicle is
identified . The posterior border of the
sternocleidomastoid is felt. The palpating fingers can
then roll over the belly of the anterior scalene muscle
into the interscalene groove, where a mark should be
made approximately 1.5 to 2.0 cm posterior to the
midpoint of the clavicle. Palpation of the subclavian
artery at this site confirms the landmark.

62. • Indications- Hand, wrist, elbow and distal arm surgery
• Blockade occurs at the level of the cords of the
musculocutaneous and axillary nerves.
• Anatomical landmarks: The boundaries of the
infraclavicular fossa are
• pectoralis minor and major muscles anteriorly,
• ribs medially ,
• clavicle and the coracoid process superiorly,
• and humerus laterally.
Infraclavicular block

63. • Technique-
• Classic approach
• The needle is inserted 2 cm below the
midpoint of the inferior clavicular border,
advanced laterally and directed toward the
axillary artery
A coracoid technique consisting of insertion of
the needle 2 cm medial and 2 cm caudal to the
coracoid process has also been described

64. Infraclavicular approach

66. • Indications –
• include surgery on the forearm and hand.
Elbow procedures are also successfully
performed with the axillary approach.
• Blockade occurs at the level of the terminal
nerves. blockade of the musculocutaneous
nerve is not always produced with this
approach.
Axillary approach

67. Axillary block

68. • Landmark-
• The axillary artery is the most important
landmark; the nerves maintain a predictable
orientation to the artery.
• The median nerve is found superior to the artery,
the ulnar nerve is inferior, and the radial nerve is
posterior and somewhat lateral
• At this level, the musculocutaneous nerve has
already left the sheath and lies in the substance of
the coracobrachialis muscle.

69. • Technique-
• The patient should be in the supine position with
the arm to be blocked placed at a right angle to
the body and the elbow flexed to 90 degrees.
• A transarterial technique can be used
whereby the needle pierces the artery and 40 to
50 mL of solution is injected posterior to the
artery; alternatively, half of the solution can be
injected posterior and half injected anterior to the
artery.
• Field block of the brachial plexus with a fanlike
injection of 10 to 15 mL of local anesthetic
solution on each side of the artery is a variation of
the sheath technique.

70. Lumbosacral plexus
Lumbosacral plexus is basically combination of
two plexus,
Lumbar Plexus &
Sacral Plexus.
1. LUMBAR PLEXUS:
The lumbar plexus is formed by the ventral rami
of first four lumbar 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).
L.S Plexus by IM

71. Components of lumbosacral plexus
• Components of the lumbosacral plexus are as,
• 1. Lumbar plexus L1, L2, L3, L4
• 2. Lumbosacral Trunk L4, L5
• The above roots contribute in lumbar and sacral plexus
both.
• 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.
• Key to remember.
• Root →Branches→Divisions→Terminal Branches
• (RBDT)
L.S Plexus by IM

72. • 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
• 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
L.S Plexus by IM

73. 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.
• 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.
L.S Plexus by IM

74. L.S Plexus by IM

75. FEMORAL NERVE
• It is formed by the dorsal or posterior
division of the anterior rami of L2,L3, &
L4 roots.
• The femoral nerve is the largest branch
of the lumbar plexus. It mainly supplies
the extensors muscles of the knee
(quadriceps) (VL, VI, VM, RF).
• The Saphenous Nerve is a purely
sensory nerve which the largest and
longest cutaneous branch of the
femoral nerve.
• Lateral femoral cutaneous nerve of the
thigh
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.
L.S Plexus by IM

76. Sensory Distribution of the Lower Limb
L.S Plexus by. IM. 12-08-2014 76

77. L.S Plexus by IM

78. LUMBO-SACRAL TRUNK & 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 (R.D.T/B)
• 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.
L.S Plexus by IM

79. 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.
• 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.
• So both these nerves i.e. Tibial and peroneal 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.
•
L.S Plexus by IM

80. L.S Plexus by IM

81. 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 penis
L.S Plexus by IM

82. 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 gluteal 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

83. Sciatic Nerve
• Sciatic Nerve
descends along the
back of the thigh and
through the middle of
the popliteal fossa, to
the lower part of the
Popliteus muscle. It
divides just 5cm
above the politial
fossa into Common
Peroneal & Tibial
nerves to supply their
relative muscles.
L.S Plexus by IM

84. Sensory Distribution to the Legs:
• Superficial Peroneal: it’s the cutaneous branch
from the common peroneal nerve which supplies
to the antero-lateral aspect of leg upto dorsum of
the foot.
• Sural nerve formed by the junction of the medial
sural cutaneous (it is the sensory branch of tibial
nerve) with the peroneal anastomotic branch (its
branch of lateral sural cutaneous nerve), passes
downward near the lateral margin of the tendo-
calcaneous, lying close to the small saphenous
vein, to the interval between the lateral malleolus
and the calcaneous.
• It supplies to the postero-lateral aspect of the leg
upto lateral malleolus.
L.S Plexus by IM

85. Lat
femoral
obturator

87. LUMBAR PLEXUS BLOCK
• Approaches-
• 1) WINNIE’S approach- Lateral
• 2) CHAYEN’S approach- paravertebral, medial
• 3) CAPDEVILA’S approach

88. PSIS
TUFFIER’S LINE
SPINOUS PROCESSES
WINNIE’S APPROACH

89. SACRAL PLEXUS BLOCK
• Approaches-
• 1) MANSOUR’S approach
• 2) REAL SACRAL PLEXUS BLOCK- cr 1/3,cd 2/3
• 3) PARASACRAL approach
• 4) SCIATIC NERVE BLOCK-
• LABAT’S approach
• RAJ’s approach

91. COELIAC PLEXUS BLOCK
• Indications- for relief of
pain e.g
• 1) ACUTE PAIN- post
op pain
• 2) CHRONIC PAIN –
chronic pancreatitis
• 3) CANCER PAIN –
carcinoma pancreas

92. •THANK
YOU