Pocket comp periph nerve blocks.pdf

Page Contents
2 Preface
3 Review of the most important local anaesthetics
4 General technical and safety aspects
6 Systemic effects of local anaesthetic intoxication
7 Postoperative analgesia with Naropin®
polybag
8 Care of peripheral nerve catheters for p. o. analgesia
Upper extremities
10 Anatomy of the brachial plexus
12 Sensory supply of the upper extremities
13 Upper extremity motor response to nerve stimulation
14 Interscalene plexus block (acc. Meier)
16 Infraclavicular plexus block (acc. Kilka, Geiger, Mehrkens)
18 Infraclavicular plexus block, Raj technique (mod. by Borgeat)
20 Suprascapular nerve block (acc. Meier)
22 Axillary plexus block
24 Blocks in the upper arm region
– Multi-stimulation technique (mid-humeral, acc. Dupré)
26 – Radial nerve
28 Blocks in the elbow region
– Radial nerve
– Musculocutaneous nerve
30 – Median nerve
– Ulnar nerve
32 Block in the wrist region ("wrist block")
– Median nerve
– Ulnar nerve
34 – Radial nerve
Lower extremities
36 Anatomy of the lumbosacral plexus
40 Sensory supply of the lower extremities
41 Sensory supply of the bony structure
Motor response to stimulus
42 Psoas compartment block (acc. Chayen)
44 Femoral nerve block in the inguinal region (acc. Winnie, Rosenblatt)
46 Obturator nerve block
48 Transgluteal sciatic nerve block (acc. Labat)
50 Subgluteal sciatic nerve block (acc. Raj)
52 Proximal anterior/ventral sciatic nerve block (acc. Meier)
54 Proximal lateral sciatic nerve block
56 Distal lateral sciatic nerve block
58 Distal posterior sciatic nerve block (acc. Meier)
60 Saphenous nerve block
62 Common peroneal nerve block
64 Blocks for anaesthesia in the foot (ankle blocks)
– Superficial peroneal nerve
66 – Deep peroneal nerve
68 – Posterior tibial nerve
Contents

The development of anaesthesia is currently affected by the growing inter-
est in regional anaesthesia and analgesia. In particular, there is an
increasing interest in peripheral nerve blocks, and in many clinics the use
of this method is prefered to the central blocks whenever possible, thus
becoming increasingly more common. What is the reason of the growing
interest and what makes the greater educational and practical efforts
involved in the use of regional blocks worthwhile?
First of all, it is the implementation of a perioperative anaesthesia and
postoperative analgesia concept. A block initiated preoperatively and
used intraoperatively continued via a catheter to provide effective post-
operative regional analgesia with a low risk of complications. This con-
cept enables early mobilisation and quicker rehabilitation.
The effects of regional anaesthesia (mostly in the form of central neuraxial
blocks) on various outcome parameters were demonstrated in the CORTRA
meta-analysis (Rodgers et al., BMJ 2000; 321:1493) based on the eval-
uation of 141 clinical studies involving approximately 10,000 patients.
Patient groups who underwent surgery under general anaesthesia were
compared to those who either received regional anaesthesia or combined
general – regional anaesthesia. According to the results, regional anaes-
thesia reduced postoperative complications and the over-all postoperative
mortality rate by 30%. The authors concluded that the most likely reason
for the reduction of postoperative complications was the decreased intra-
operative stress response due to regional anaesthesia block.
Furthermore, we are well aware of the potential risk of severe pain devel-
oping into a chronic pain condition, a situation that can and should be
avoided. The most reliable way to prevent pain from becoming chronic
comprises regional anaesthesia techniques that block the pain stimulus
near its origin, both peri- and postoperatively, thereby eliminating acute
pain as a special postoperative risk factor.
The continuing development of regional anaesthesia and analgesia is
important when considering the aspects described above but there are
also ethical and economical points of view which call for a wider use of
regional anaesthesia. With this compendium of peripheral nerve blocks,
we present a brief review of the most commonly used techniques. Thereby
we hope to stimulate the interest and understanding among our colleagues
for the use of regional anaesthesia techniques.
Preface
2

3
Special features:
Ropivacaine ● Favourable effective dose/toxicity ratio
● Good differential block (analgesia >> motor block) at lower concentrations
used for analgesia
Lidocaine ● Local anaesthetic with medium action time and low toxicity
Mepivacaine ● Effectiveness comparable to lidocaine, but less toxic and slightly longer
duration
Overview of the most important local anaesthetics for peripheral nerve
blocks
Substance Concentration Dosage* Time until Analgesic
Anaesthesia Anaesthesia effective action time
Analgesia Analgesia
Ropivacaine 0.5% – 0.75% up to 300 mg 10 – 20 min 8 – 14 h
(Naropin) 0.2% – 0.375% up to 28 mg/h
Lidocaine 1% (– 2%) up to 600 mg 10 – 20 min 2 – 4 h
– –
Mepivacaine 1% (– 2%) up to 300 mg 10 – 20 min 3 – 4 h
– –
Anaesthetic Protein Distribution Elimination
potency (ratio binding (%) volume (L) half-life (h)
to procaine = 1) in plasma
Ropivacaine 16 94 59 1.9
Lidocaine 4 64 91 1.6
Mepivacaine 4 77.5 84 1.9
* (manufacturers' recommendations)
Review of the most important local anaesthetics
Action time of
regional anaesthetics:
Intraoperative and
postoperative anal-
gesia
* Start infusion before
onset of post operative
pain; otherwise start
with an initial bolus.
lidocaine 1%
lidocaine 1% + ropivacaine 0.75%
ropivacaine 0.75%
*ropivacaine 0.2% (– 0.375%)
2 4 6 8 10 12 14 hours

4
General technical aspects on peripheral nerve blocks
● Use aseptic technique.
● Resuscitation equipment and drugs should always be available
when regional anaesthesia is used.
● Local cutaneous infiltration anaesthesia.
● Skin incision with a lancet before insertion of a short-beveled needle
(e. g. 45° bevel).
● Nerve stimulation: Ascending from 0.1 – 1.0 mA, until visible muscle
contractions in the corresponding innervation area; then reduction to
between 0.3 – 0.5 mA/0.1 ms before injection of the local anaesthetic.
● Repeated aspiration attempts before and during injection of the local
anaesthetic. A negative aspiration test does not completely exclude an
intravascular needle position.
● With larger doses of a local anaesthetic, use fractional injection and
verbal patient monitoring for early recognition of accidental intravas-
cular injection.
● In poorly cooperative patients, patients under sedation or when
performing a block distal to an established central block (e. g. femoral
nerve block in the presence of spinal anaesthesia) a nerve stimulator
and unipolar needle should be used (no neuromuscular relaxation!).
Exception: Infiltration anaesthesia of purely sensory nerves.
● Catheter technique: Placement of the catheter tip 3 – 5 cm beyond the
tip of the introducing needle, to be inserted normally after injecting
the loading dose of the local anaesthetic.
● Monitoring: When performing blocks in the head and neck area and
when larger doses of local anaesthetic are used the patient should
have an i.v. cannula, ECG and pulse oximetry applied before the
block. Standard monitoring includes ECG, pulse oximetry, blood pres-
sure and the degree of consciousness.
● Catheter: Daily control of the catheter insertion site, written documen-
tation (see p. 9).
General technical and safety aspects

Side effects, complications/contraindications (general)
Side effects and complications
● Systemic toxicity of the local anaesthetic
Most common reason: Unintended intravascular injection
Minimize risk by
– Adhering to the recommended dosages
– Repeated aspiration and fractional injection
– Slow injection, observe and maintain verbal contact with the
patient (NB: negative aspiration does not entirely exclude
intravascular injection!)
● Nerve damage (extremely rare)
Minimize risk by
– Trying to avoid paresthesias when inserting the needle
– Correct use of a suitable nerve stimulator (≥ 0.3 – 0.5 mA/
0.1 ms)
– The use of atraumatic needles
● Hematoma
Minimize risk by
– No blocks in the presence of a clinically manifest coagulation
disorder or anticoagulation treatment
● Infection (especially when using continuous techniques)
Minimize risk by
– Aseptic needle insertion
– Regular planned checks of the catheter insertion site (at least
once a day)
– Most sensitive indicator: Tenderness at the point of catheter
entry (requires immediate removal of the catheter)
General contraindications to regional anaesthesia
● Rejection of the technique by the patient
● Clinically manifest coagulation disorders
● Infection or hematoma at the injection site
● Relative contraindication: Neurological deficits (previous documen-
tation necessary)
5
General technical and safety aspects

6
Systemic effects of local anaesthetic intoxication
Coma
Seizures
Muscular twitching
Confusion
Visual disurbances
Verbal/vocalization problems
Hyperacusis, tinnitus
Circumoral tingling,
Lightheadedness
Time
Dose
Symptoms and signs of local anaesthetic intoxication
CNS symptoms
Cardio-
vascular
symptoms
Treatment of local anaesthetic intoxication
Apnoea
Circulatory collapse/Cardiac arrest
Ventricular
fibrillation
Ventricular arrhythmia
QT-prolongation
Hypotension
Bradycardia
QRS-widening
Temporary hypertension
Tachycardia
Stop LA injection,
Give oxygen,
Support ventilation,
Avoid acidosis
Increasing CNS symptoms:
Stop seizures
with penthothal, propofol
or benzodiazepine.
If poor response:
rapid acting muscle relaxant,
intubate to control ventilation.
Cardiac symptoms:
Circulatory support
(Noradrenaline,
alternatively amiodarone or amrinone).
If persistent arrhythmia: electro-conversion,
CPR as long as needed.
Allergy for amide local anaesthetics is extremely rare and should be treated like any
allergic reaction.
A relative small dose of local anaesthetic, if accidentally injected intravasculary, may
lead directly to seizures with both respiratory and cardiovascular problems, depending
on drug and patient conditions.

7
Postoperative analgesia with Naropin®
Polybag
Naropin®
2 mg/ml, 200 ml Polybag
analgesically effective concentrations
*Real volume of Naropin®
ml
in 200 ml Polybag additional total total concentrations
is 210 ml volume mg volume ml* mg/ml
Reduce 80 420 290 1,4
concentration 60 420 270 1,6
by dilution 40 420 250 1,7
with NaCl 0.9 % 20 420 230 1,8
Polybag standard 420 210 2
Increase 10 520 220 2,4
concentration 20 620 230 2,7
by adding 40 820 250 3,3
Naropin®
10 mg/ml 60 1020 270 3,8
Mobile pump system (CADD-Legacy PCA)
for administration of Naropin®
Polybag
Pump and Polybag in a carrier bag for
mobile patient use

Check-up rounds
● At least once a day
– Check catheter insertion site
– Assess effectiveness
– Analyse indications critically
– Careful documentation (see p. 9)
● In case of insufficient effectiveness
– Catheter positioned correctly? Dislocated?
– In case of partial effectiveness: Injection of a bolus
(e. g. 20 ml ropivacaine 0.75%)
– Supplemental analgesics (NSAID, opiods orally) as needed
– Additional pain medication when removing catheter
● Duration of treatment
– Up to 4 – 5 days – depending on the indication. (For chronic
pain therapy a duration of more than 100 days has been
described.)
– Analgesic catheter can be used in out-patients, but the corre-
sponding prerequisites must be considered
Requirements for a nerve stimulator (acc. to Kaiser)
Electrical layout:
– Adjustable constant current in the presence of a load of
0.5 – 10 kOhm
– Monophasic square output impulse
– Selectable impulse width (0.1 – 1.0 ms)
– Impulse amplitude (0 – 5.0 mA) with precision adjustment and
digital display of the actual current
– Impulse frequency 1 – 2 Hz
Safety device:
– Alarm upon interruption of circuit
– Alarm when the max. impedance is exceeded
– Alarm when an error occurs inside the device
– Unmistakable assignment of outputs
– Adequate operating instructions for use, indicating the deviations
tolerated
Care of peripheral nerve catheters for p. o. analgesia in the medical ward
8

9
Care of peripheral nerve catheters for p. o. analgesia in the medical ward
ward
Documentation example

A + B: Sectional plane in the infraclavicular and axillary region. Please note the position
of the cords.
B
B
A
A
a
C4
C5
C6
C7
C4
C5
C6
C7
Th 1
Th 1
C8
d
1
2
3
4
5
6 8
7
9
10
11
12
e
f
b
c
Anatomy of the brachial plexus
a superior trunk
(rami ventrales C5 and C6)
b middle trunk
(ramus ventralis C7)
c inferior trunk
(rami ventrales C8 and Th1)
d lateral cord
e posterior cord
f medial cord
1 suprascapular n.
2 musculocutaneous n.
3 axillary n.
4 radial n.
5 median n.
6 ulnar n.
7 medial antebrachial cutaneous n.
8 medial brachial cutaneous n.
9 intercostobrachial n.
10 intercostal n. I
11 intercostal n. II
12 long thoracic n.
10

The brachial plexus is formed by the ventral rami of the C5 to Th1
(variably C4 and Th2) spinal nerves
Anaesthesia techniques for blockade of the upper
extremities
● Interscalene brachial plexus block (interscalene block, ISB) acc.
to Meier
● Vertical infraclavicular plexus block (vertical infraclavicular block, VIB)
● Suprascapular nerve block
● Axillary plexus block
● Blocks in the upper arm region (mid-humeral approach, radial n.)
● Blocks in the region of the elbow (radial, musculocutaneous,
median, ulnar nerves)
● Blocks in the wrist region (radial, median, ulnar nerves)
11
Upper extremities

Sensory supply
12
Sensory
supply of the
upper extremities
1 supraclavicular n.
2 axillary n.
(lat. cut. brachial)
3 intercosto-
brachial n.
4 medial brachial
cutaneous n.
5 antebrachial
cutaneous dorsal n.
(radial n.)
6 medial antebrachial
cutaneous n.
7 lateral antebrachial
cutaneous n.
(musculocutaneous n.)
8 radial n.
9 ulnar n.
10 median n.
1
C3
C4
C5 C5
C4
C6
C7
C7
C8 C8
T1
T1
T2
T2
C6
C6
1
2 2
3
4
5
10
10
9 9
8
8
7 7
6 6

13
Upper extremity motor response to nerve stimulation
a
b
d
c
Motor functions
of the peripheral
nerves in the
upper extremities
a radial n.: stretching elbow and fingers
b median n.: flexion of the fingers
c ulnar n.: flexion of the forth and fifth fingers with opposition of the first finger
d musculocutaneous n.: flexion (and supination) of the forearm

14
Side effects, complications: Horner s., ipsilateral phrenic block, recurrent block
Local anaesthetics:
Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropiva-
caine 0.75%
Continuous: Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5
mg/h bolus (alternatively): 10 – 20 ml ropivacaine 0.2 – 0.375%
(approx. every 6 hours)
Needle: Single shot: Short-bevel unipolar 22 G x 4 – 6 cm needle
Continuous: E. g. 19.5 G x 6 cm (Plexolong B-Set®
, Pajunk co., or Contiplex D®
, B. Braun)
with a 20 G catheter (advance catheter 4 cm beyond the tip of the cannula).
Patient position and method:
Patient supine
Guiding structures:
Lateral border of the sternocleidomastoid m., interscalenus groove
The insertion site is at the level of the thyroid notch (approx. 2 cm above
the level of the cricoid cartilage) at the posterior edge of the sternocleido-
mastoid muscle. The direction of insertion is along the interscalene groove
(in a caudal and lateral direction) at an angle of approx. 30° to the skin.
Stimulus response: Deltoid m., biceps m. Injection of the local anaesthetic
when an adequate stimulus response of 0.3 mA/0.1 ms is reached.
Comments on the technique:
● The aiming point is in the middle third of the clavicula
● The subclavian a. marks the caudal end of the interscalene groove.
It can be identified by palpation or with the aid of a vascular doppler.
Notice the difference to the classical interscalene approach acc. to Winnie;
the puncture site is 1 to 2 cm above (cranial) the puncture site of Winnies interscalene
block, the direction of the needle is lateral in contrast to Winnies technique (medial, dor-
sal, caudal). You will come in contact with the plexus at easily a more tangential angle
in contrast to the classical approach, where the needle approaches the plexus at a right
angle. Meier’s approach is suitable for continuous catheter techniques.
Indications:
● Anaesthesia and analgesia of the shoulder
and/or of the proximal upper arm region
● Mobilisation (e. g. frozen shoulder)
● Physiotherapy in the shoulder region
(e. g. postoperative, following mobilisation)
● Therapy for pain syndromes
● Sympathicolysis
Special contraindications:
● Contralateral phrenic paresis
● Contralateral recurrent paresis
● COPD (relative)
Interscalene plexus block
(acc. to Meier)

15
a sternocleidomastoid
m.
b interscalene groove
c subclavian a.
d cricoid cartilage
1 sternocleidomastoid
m.
2 phrenic n.
3 middle scalene m.
4 brachial plexus
(supraclavicular part)
5 anterior scalene m.
6 omohyoid m.
7 brachial plexus
(infraclavicular part)
8 subclavian a.
9 external jugular v.
10 internal jugular v.
11 cricoid cartilage
The direction of
insertion is caudally
and laterally along
the interscalene
groove, 30° angle
to the skin.
1
3
4 5 6
11 10 9
d
a b
c
2
7
8

16
Side effects, complications: Horner syndrome, pneumothorax, intravascular injection.
Local anaesthetics:
Initial:
30 – 40 ml lidocaine 1% or mepivacaine 1% or
30 ml ropivacaine 0.75%
Continuous:
Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/h
Bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours)
Needles:
Single shot: Short-bevel 22 G x 4 – max. 6 cm.
Continuous: E. g. Contiplex D®
18 G x 5.5 cm (B. Braun) alternatively Plexolong A®
19.5 G x 5
cm with catheter (Pajunk co.). The catheter is advanced 3 – 4 cm beyond the tip of the cannula.
Patient position:
Patient supine
Jugular notch, ventral acromial process of the scapula.
Guiding structures:
The distance between the jugular notch and the ventral acromial process
is bisected. The insertion site must be directly under the clavicula and
take place in a strictly vertical direction. The plexus is reached after
approx. 3 cm (max. 5 cm!). Flexion of the fingers at 0.3 mA/0.1 ms
form the desired stimulus response.
Risk of pneumothorax
Therefore, make absolutely sure to avoid:
● Insertions too far medially
● Deviation from the sagittal (plumb bob) direction of insertion
● Advancing the needle > 6 cm
When the index finger is placed to have contact with the coracoid
process laterally and the clavicle cranially (“Mohrenheim`s fossa”) the
medial border of the finger marks the injection point/”finger point”.
Always perform this block using a nerve stimulator. A stimulus response
only in the biceps m. yields poor results. Pull back the needle to a s.c.
position, shift it slightly laterally and advance it again in a strictly sagittal
direction. In comparison with the Raj/Borgeat technique (ref. to this) this
technique does not require abduction of the arm.
Indications and contraindications:
see infraclavicular plexus block, Raj technique (mod. by Borgeat)
Infraclavicular plexus block
VIB (= vertical infraclavicular block)
(acc. to Kilka, Geiger and Mehrkens)

1
3
4
5
6
7
8
2
17
a jugular notch
b ventral acromial
process
c 1/2 distance
from a – b
d “finger point”
e coracoid process
1 major pectoral m.
2 subclavian a.
3 pectoral n.
4 medial cord
5 posterior cord
6 lateral cord
7 deltoid m.
8 suprascapular n.
Strictly vertical
needle insertion
(perpendicular to
the underlying
surface)
a
d
e
b
c

Side effects, complications: intravascular injection, pneumothorax
Local anaesthetics:
Initial:
30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine
0.75%
Continuous:
bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6
hours)
Needle: Single shot: unipolar 22 G x 6 – 10 cm needle
Continuous: E. g. 19.5 G x 10 cm Plexolong with catheter (Pajunk co.). The catheter is
advanced 3 – 4 cm beyond the tip of the cannula.
Patient position:
Patient supine.
Guiding structures:
Jugular notch, ventral acromial process of the scapula. The needle inser-
tion site is located halfway between the anterior tip of the acromion and
the jugular notch approx. 1 cm below the clavicle. For injection, the arm
is abducted 90° and elevated 30°. The needle is directed laterally at an
angle of approx. 45° – 60° towards the most proximal point at which the
axillary artery can still be palpated in the axilla.
The risk of pneumothorax is low because of the lateral direction of the
needle. Intravascular injection (usually venous, cephalic vein) has been
observed. Between 3 – 8 cm there should be a motor response in the
hand or fingers. Because of the tangential approach to the plexus, a
catheter can be advanced readily.
Indications:
● Anaesthesia and analgesia for surgery
of the upper arm, lower arm and hand
● Treatment of pain syndromes
● Analgesia for physiotherapeutic
treatment
● Sympathicolysis
Contraindications:
● Thorax deformity
● Dislocated healed clavicular fracture
● Foreign bodies in the area of inser-
tion (e.g. pacemaker, port etc.)
● Untreated coagulation disorder
Infraclavicular plexus block
Raj technique (mod. by Borgeat)
18

1
3 4
5
6
2
19
a axillary a.,
anatomical land-
mark for establishing
the needle insertion
1 suprascapular n.
2 deltoid m.
3 brachial pl.
4 pectoral n.
5 subclavian a.
6 major pectoral m.
Needle insertion
site according to
VIB anatomical
landmarks (p. 16),
direction towards
the most proximal
point of the
axillary a., approx.
45° – 60° angle.

20
Side effects: Nothing specific
Local anaesthetics:
Initial:
10 – 15 ml lidocaine 1% or mepivacaine 1 % or ropivacaine 0.75%
Continuous:
hours)
Needles: Single shot: Unipolar needle 22 G x 6 – max. 8 cm long.
Continuous: E. g. Plexolong B®
19.5 G x 6 cm (Pajunk co.) or Contiplex (B. Braun). The
catheter is advanced approximately 3 cm beyond the tip of the cannula.
Patient position:
The patient is sitting.
Guiding structures:
Scapular spine, posterior portion of the acromion, medial end of the sca-
pular spine. The midpoint of the line between the lateral posterior portion
of the acromion and the medial end of the scapular spine is marked. The
insertion site is 2 cm cranial (above) and 2 cm medial of this point. The
unipolar needle is advanced 3 – 5 cm laterocaudally and only slightly
ventrally at an angle of approx. 30° (in the direction of the head of the
humerus) until a correct needle position is indicated by a stimulus re-
sponse in the infra- or the supraspinous muscles, or until the needle
shows a pain-free "knocking" sensation in the shoulder after 3 – 5 cm.
There is no risk of pneumothorax if these guidelines are followed.
Aspiration is necessary in order to avoid intravascular injection (supra-
scapular artery, extremely rare). The method can also be performed with-
out nerve stimulation (bone contact) and be used with a continuous tech-
nique.
Indications:
● Diagnostic: Shoulder pain of unclear origin
● Anaesthesia: Incomplete interscalene
plexus block
● Pain therapy: Adhesive capsulitis
(frozen shoulder), arthritis, rupture of
the rotator cuff, etc.
None
Suprascapular nerve block
(acc. to Meier)

a middle point of the
scapular spine
b needle insertion site:
2 cm medial
2 cm cranial to the
middle point
1 supraspinatus m.
2 infraspinatus m.
3 trapezius m.
4 suprascapular a.
5 transverse scapular
ligament
6 suprascapular n.
7 articular branches of
the suprascapular n.
8 deltoid m.
Direction of needle:
Laterocaudal,
approx. 30° angle
1
3
4 5 6 7
8
2
b
a
21

22
Side effects: No special ones
Local anaesthetics:
Initial:
Continuous:
Bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6
hours)
Needles: Single shot and/or continuous: Short-beveled needle through a plastic cannula
(e. g. 18 G, 45° bevel, Pajunk co. or B. Braun). A flexible catheter can well be inserted
through the 18 G cannula. The catheter is advanced 5 cm beyond the tip of the needle.
Alternatively: Single shot unipolar needle 22 G x 4 cm.
Patient position:
Patient supine, arm abducted 90°, externally rotated, elbow flexed
approx. 90°.
Guiding structures:
Axillary artery, coracobrachial muscle.
Palpate the gap between the axillary a. and the coracobrachial m.
Following pre-puncture of the skin, advance the needle parallel to and
above the artery in a proximal direction at an angle of 30° – 45° to the
skin ("click phenomenon" entering neurovascular sheath). Lower the distal
end of the needle and advance it further. Check position with a nerve sti-
mulator (not compulsary with this technique, but recommended).
A low-risk technique that can be performed without a nerve stimulator: A
"click" as the neurovascular sheath is penetrated and easy advancement
of the short bevel needle with cannula indicates a correct needle position.
Not infrequently, anaesthesia in the radial nerve’s area of distribution is
insufficient. Supplementary selective block may be needed (see below).
Indications:
● Operations in the arm (distal upper
arm, lower arm, hand)
● (Continuous) analgesia
● Physiotherapy
● Pain syndrome
● Sympathicolysis
None
Axillary plexus block

23
1
2
3 4 5 6
8
7
a coracobrachial m.
b axillary a.
1 coracobrachial m.
2 radial n.
3 medial antebrachial
cutaneous n.
4 ulnar n.
5 brachial a.
6 median n.
8 major pectoral m.
Direction of
insertion: medially,
above and parallel
to the artery,
30° – 45° angle to
the skin.
a
b

24
Side effects: No special ones
Local anaesthetics:
E. g. 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
for each individual nerve block
Needle: Unipolar, shortbevel 22 G x 4 – 6 cm
Patient position:
Patient supine, arm abducted approx. 80°, stretched out, externally rotat-
ed.
Guiding structures:
Junction of the proximal and middle thirds of the upper arm, brachial
artery.
Find the brachial artery in the medial aspect of the junction of the proxi-
mal and middle thirds of the upper arm. Insert the needle between the
two palpating fingers just above the brachial artery, and advance it pro-
ximally until a response of the median nerve is obtained.
Following injection of the local anaesthetic, the needle is withdrawn to a
subcutaneous position before the next nerve is located. Then advance it
perpendicular to the underlying surface (operating table, floor) medial
(below) the artery until a stimulus response of the ulnar nerve is found.
Next, block the radial nerve by redirecting the needle toward the lower
(posterior) edge of the underlying humerus. The musculocutaneous n. is
blocked after advancing the needle horizontally under the biceps muscle
until adequate stimulation response. It is recommended to raise the belly
of the biceps muscle slightly during the block of the musculocutaneous n..
Not suited for continuous blocks, time-consuming, generally needs a
nerve stimulator. Short onset, but relatively frequent problems with the
tourniquet. Well suited for selective supplementary block of individual
nerves with an incomplete brachial plexus block.
Blocks in the upper arm Multi-stimulation technique
(mid-humeral technique acc. Dupré)
Indications:
Anaesthesia of the distal arm, elbow and
hand
None

25
a: Needle
insertion for
median nerve
block
c: Needle
insertion for
radial nerve
block
2 median n.
3 ulnar n.
4 radial n.
All individual blocks
performed via one
single skin puncture.
b: Needle
insertion for
ulnar nerve
block
d: Needle
insertion for
musculo-
cutaneous
nerve
block
2
3
4
1

26
Local anaesthetics:
Initial:
10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: Unipolar 22 G x 4 – 6 cm
Patient position:
Patient supine.
Guiding structures:
Middle upper arm.
The arm is lying abducted and externally rotated (arm support). Insert the
needle in the space between the flexor muscles and the triceps muscles
on the medial side of the upper arm and direct it toward the lower
(posterior) edge of the underlying humerus. Following adequate nerve
stimulation-response, the local anaesthetic is injected.
Indications:
● Incomplete brachial plexus block
● Diagnostic block
● Pain therapy
Blocks in the upper arm Radial n.

27
Radial n. block at
the middle upper
arm:
site and direction
of needle insertion.
course of the
radial n. in
the upper arm

28
The following applies both for blocks of the radial and the
musculocutaneous nerves in the region of the elbow:
Local anaesthetics:
3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per
injection
Needle: 24 G short bevel, unipolar
Arm stretched out, externally rotated with the hand supinated.
Subcutaneous injection lateral (radial) to the biceps tendon toward the
lateral epicondyle of the humerus.
Combination with a radial block at the level of the elbow is possible (one
insertion, one needle). Injections that go too deep are the most frequent
cause of failure!
Arm stretched out laterally, externally rotated with the hand supinated.
Insert the needle approx. 1 – 2 cm laterally (radially) to the biceps ten-
don and advance it toward lateral epicondyle until it contacts the bone.
Inject the local anaesthetic when a stimulus response of the radial nerve
is obtained at 0.3 mA/0.1 ms or infiltrate the local anaesthetic in a fan-
shaped pattern while slowly withdrawing the needle.
When supplementing incomplete plexus block, the block must be perform-
ed using nerve stimulation. This block is also ideal to combine with a
s. c. musculocutaneous block in this same area.
Indications:
● Incomplete brachial plexus block
● Cimino shunt
Blocks in the elbow region Musculocutaneous n.
(Sensory supply of the radial side of the lower arm)
Blocks in the elbow region Radial nerve

29
2
3
4
5
6
7
1
Radial nerve block:
direction of needle
toward the lateral
epicondyle (2 – 3
cm).
1 lateral cutaneous
brachial n.
2 brachioradial m.
3 radial n.
4 biceps m.
5 median n.
6 ulnar n.
7 brachial a.
Musculocutaneous
block: subcutaneous
infiltration lateral
(radial) to the
biceps tendon.

30
The following applies for blocks in the region of the elbow
and for both the median and the ulnar nerves:
Local anaesthetics:
3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per
injection
Needle: 22 G 4 – 5 cm
Arm stretched out laterally, externally rotated with the hand supinated.
The site of insertion is approx. 1 cm medial (ulnar) of the brachial artery
tangential to the nerve using a unipolar 22 G needle of 4 cm length. A
stimulus response of the median nerve expected at a depth of 1 – 2 cm.
Please note: Mm = Median nerve medial to the artery.
The arm is abducted, with elbow flexed 30°. The site of insertion is
approx. 1 cm proximal to the sulcus of the ulnar nerve (between the
medial epicondyle of the humerus and the olecranon). The needle is
directed tangentially along the ulnar nerve, and 3 – 5 ml local anaesthet-
ic is injected close to (but not into!) the nerve.
The ulnar n. is found in the sulcus of the ulnar nerve when the elbow is
flexed. Avoid pressure and paresthesias, the nerve is very sensitive! It is
recommended to use a unipolar needle (22 G, 5 cm) and nerve stimula-
tion.
Indications:
● Incomplete plexus block
● Pain therapy
Blocks in the elbow region Median nerve
Blocks in the elbow region Ulnar nerve

31
Median nerve block:
approx. 1 cm
medial to the
brachial artery.
Ulnar n.
1 ulnar n.
2 medial condyle of
the humerus
3 olecranon process
Ulnar nerve block:
approx. 1 cm
proximal to the
ulnar nerve sulcus.
2 1
3

32
Local anaesthetics:
3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Local anaesthetics:
Needle: 22 or 24 G
Guiding structures and method:
The injection is made on the flexor side between the tendons of the radial
flexor carpi muscle of the wrist and the long palmar muscle (occasionally
missing). After eliciting paresthesias, withdraw the 25 G needle slightly
and apply 5 ml of the local anaesthetic.
The arm is stretched out laterally and externally rotated with the hand
supinated. Insert the needle approx. 3 – 4 cm proximal to the hand be-
tween the tendon of the ulnar flexor carpi muscle and the ulnar artery.
After eliciting a light paresthesia, withdraw the needle slightly and inject
3 – 5 ml of the local anaesthetic.
Block in the wrist region Median nerve
("wrist block")
Block in the wrist region Ulnar nerve
("wrist block")

33
2 3 4
5 6 7 8
1
Median nerve block
at the wrist
1 pisiform bone
2 ulnar n.
3 ulnar a.
4 flexor carpi ulnaris
tendon
5 palmaris longus
tendon
6 flexor carpi radialis
tendon
7 median n.
8 radial a.
Ulnar nerve block
at the wrist

34
Local anaesthetics:
Needle: 22 or 24 G
The arm is stretched out laterally with the hand supinated. Subcutaneous
infiltration is performed on the radial side of the wrist 3 – 5 cm proximal
to the joint.
Block in the wrist region Radial nerve
("wrist block")

35
1 2
Radial nerve block
at the wrist:
subcutaneous
infiltration.
1 superficial branches
of the radial n.
2 radial a.

36
1 iliohypogastric n.
2 ilioinguinal n.
3 genitofemoral n.
4 lateral femoral
cutaneous n.
5 femoral n.
6 obturator n.
7 sciatic n.
8 pudendal n.
1
XI
XII L1
L1
L2
L2
L3
L3
L4
L4
L5
L5
Th 12
2
3
4
5
6
6
7
8
Lumbosacral plexus

37
Lower extremities
Lumbar plexus
The lumbar plexus is formed by the ventral rami of the L1 – L4 spinal
nerves.
Nerves of the lower extremities relevant for anaesthesia:
Femoral nerve with terminal saphenous nerve, lateral femoral cutaneous
nerve, obturator nerve.
Anaesthesia techniques:
● Psoas compartment block
● Femoral block in the inguinal region ("3-in-1 block")
● Block of the lateral femoral cutaneous nerve
● Obturator nerve block

2
1
3
4
5
6
7
8
38
Lumbosacral plexus
1 posterior femoral
cutaneous n.
2 sciatic n.
3 iliohypogastric n.
4 ilioinguinal n.
5 lateral femoral
cutaneous n.
6 genitofemoral n.
7 obturator n.
8 femoral n.

39
Sacral plexus
The sacral plexus is formed by the ventral rami of the L4 and L5 spinal
nerves (lumbosacral trunk) and S1 – S3.
Nerves of the lower extremities relevant to anaesthesia:
Sciatic n. (common peroneal nerve, tibial nerve), posterior femoral
cutaneous nerve
Anaesthesia techniques:
● Proximal sciatic nerve block (transgluteal, dorsal, anterior)
● Distal sciatic nerve block
● Lateral sciatic block (proximal, distal)
● Selective blocks (of the peroneal and tibial nerves)
● Ankle block
Lower extremities

40
Sensory supply of the lower extremities
1
2
3
4
4
9
5
6
7
7
3
4
8
9
10
12 13
10
11
1 lateral femoral
cutaneous n.
2 femoral n.
3 peroneal n.
4 saphenous n.
5 sciatic n.
Areas of sensory distribution:
Blue: Femoral nerve and its branches. Yellow: Sciatic n. and its branches.
Grey: The lateral femoral cutaneous nerve. Green: Obturator nerve.
6 posterior femoral
cutaneous n.
7 obturator n.
8 posterior tibial n.
9 superficial peroneal n.
10 sural n.
11 deep peroneal n.
12 medial plantar n.
13 lateral plantar n.
(tibial n.)

41
Sensory supply of the bony structure
3
5
1 tibial nerve: plantar
flexion, foot inversion
2 peroneal nerve:
dorsiflexion, foot
eversion
The correct response for
all proximal sciatic nerve
blocks should be in the
foot. Either the (medially
situated) tibial branch
(plantar flexion) or the
(laterally situated) pero-
neal/fibular branch (dor-
siflexion) is stimulated.
With the Labat and
Mansour techniques, a
response in the ischio-
crural muscles (flexion of
the thigh) can also be
regarded as a correct
motor response.
Areas of distribution:
Blue: Femoral nerve and
its branches.
Yellow: Sciatic nerve and
its branches.
Green: Obturator nerve
(variable innervation).
1 sciatic n.
2 obturator n.
3 tibial n.
4 femoral n.
5 common peroneal n.
Motor response
1
2
1
2
4

42
Side effects/complications: Spinal anaesthesia, epidural-like block due to spread to the
epidural space, hematoma
Local anaesthetics:
Initial: 40 – 50 ml lidocaine 1% or mepivacaine 1% or
Continuous: 6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or
bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours)
Patient position and method
Patient in a lateral position with legs flexed, the back kyphotic and the
leg to be blocked uppermost.
Guiding structures:
L4 vertebral spinous process.
A mark is made 3 cm caudal from the L4 vertebral spinous process in
the interspinal line. From this point at a right angle to the interspinal line
draw a line at a right angle to the midline and mark its lateral end after
5 cm. Check by palpating the posterior iliac spine, which should be in
the immediate vicinity. After local infiltration, insert a 10 – 12 cm 22 G
needle in the marked point in a sagittal direction. After bony contact
(transverse process of the L5), withdraw the needle a few cm and redi-
rect it more cranially. Advance it until stimulation contractions of the qua-
driceps muscle appear at 0.3 mA/0.1 ms at a depth of 7 – 11 cm, indi-
cating that the tip of the needle is in the immediate vicinity of the femo-
ral nerve. Inject a test dose of the local anaesthetic to preclude an intra-
spinal needle position.
● The most effective method of lumbar plexus blockade
● Injecting at the L3 level does not improve the quality of anaesthesia,
but carries a risk of causing a subcapsular haematoma of the kidney
● Injection into the peritoneal cavity may appear with an injection
depth of > 12 cm
● Complete block of the sacral plexus (sciatic n.) is not possible, even
with higher volumes of local anaesthetic
Psoas compartment block
(acc. to Chayen)
Indications:
● In combination with proximal sciatic nerve
block, all types of leg surgery (including
endoprosthesis)
● Wound treatment in the ventral and lateral
thigh regions, skin grafts in the upper thigh
● Physiotherapy
● Pain therapy (e. g. postop. after hip
or knee surgery)
Anticoagulation therapy, same
recommendations as for patients
with neuroaxial block

43
2 3 4 5
1
a iliac crest
b L4 vertebral spinous
process
c sup. post. iliac
spine
d needle insertion
site:
3 cm caudal and
5 cm lateral of the
L4 vertebral spinous
process
1 lumbar plexus
2 psoas major m.
3 iliac fascia
4 transverse process
(costal process)
5 erector spinae m.
b
a
c
d
Needles:
E. g. 22 G, 12 cm needle
Continuous: E. g. Plexolong B®
19.5 G, 12 cm (Pajunk co.), UP 18 G/22 G, 11 cm
(B. Braun)
Continuous: The catheter is advanced 5 cm beyond the tip of the cannula, preferably in a
caudal direction
ventral
Body of L5
dorsal
direction
of needle
insertion

44
Local anaesthetics:
Initial:
Continuous:
6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/ml or
hours)
Needle: E. g. a combination needle Plastic cannula set‚ 18 G, 5 cm (Pajunk co.) or
5.5 cm Contiplex D®
(B. Braun)
Continuous: The catheter is advanced 5 cm beyond the end of the cannula
Patient supine with the leg abducted and externally rotated.
Guiding structures:
The inguinal fold, femoral artery with vein medial, nerve lateral.
The insertion site is 2 cm below the inguinal fold, 1.5 cm lateral of the
artery. The stimulation cannula is advanced at a 30° angle in a cranial
direction until occurence of a double-click, indicating passage through
the fascia lata femoris and the fascia iliaca. A motor stimulus response in
the quadriceps muscle with a "dancing" kneecap at 0.3 mA/0.1 ms indi-
cates that the needle tip is in the immediate vicinity of the femoral nerve.
Direct stimulus response in the sartorius muscle may mimic a quadriceps
response but leads to "anaesthesia failure" so make sure that the patella
dances! Avoid intraneural needle insertion (nerve stimulation).
Indications:
● When used in combination with a
proximal sciatic block, most types of leg
surgery
● Wound treatment, skin grafts in the
ventral thigh, mobilisation, physiotherapy
● Pain therapy (fractures of the shaft
of the femur, postop. after knee joint
surgery, e. g. synovectomy, anterior
cruciate ligament reconstruction; pain
alleviation in fractures of the neck of the
femur)
None
Relative contraindications:
After e. g. fem. popliteal bypass (useful
devices: Doppler, sono), lymphomas in
the groin
Femoral nerve block in the inguinal region
("3-in-1" technique acc. to Winnie, continuous technique acc. to Rosenblatt)

45
1
4
3
2
5
a femoral artery
b needle insertion
site
1 lateral femoral
cutaneous n.
2 psoas major m.
3 femoral n.
4 obturator n.
5 femoral a.
cranially at
30° angle,
lateral to and
parallel with
the femoral artery.
a
a
b

46
Local anaesthetics:
Needle: 20 G, 10 cm short bevel, insulated unipolar needle
The anterior branch (superficial n.) innervates the anterior adductors,
the hip joint and, to a varying extent, a section of skin on the inner sur-
face of the thigh.
The posterior branch (profound n.) innervates the deep adductors and
(variably) medial portions of the knee joint.
Patient supine with the leg abducted.
Guiding structures:
Palpate the tendon of the long adductor m.
Insert the stimulation needle immediately ventral of the tendon's proximal
attachment point. Advance the unipolar needle cranially at an angle of
approx. 45° to the body's longitudinal axis (toward the sup. ant. iliac
spine) and in a slightly dorsal direction. After approx. 4 – 8 cm at 0.3
mA/0.1 ms, contractions of the adductors indicate the proximity of the
obturator nerve.
A catheter technique can be used for continuous block. The catheter is
advanced approx. 3 – 4 cm beyond the tip of the needle in a cranial
direction.
Indications:
● TUR of tumors of the ipsilateral
wall of the bladder
● Supplementary to incomplete
lumbar plexus (3-in-1) block
● Diagnosis and therapy of pain
syndromes in the region of the
hip joint
● Adductor spasm
None
Obturator nerve block

1
4
7
3
2
5
6
47
a femoral artery
b tendon of the
long adductor m.
1 obturator n., anterior
(superficial) branch
2 obturator n.,
posterior (deep)
branch
3 adductor longus m.
4 adductor brevis m.
5 adductor magnus m.
6 gracilis m.
7 needle insertion site
Needle insertion:
ventral of the
tendon attachment
in a cranial-dorsal
direction (the
obturator nerve is
at 4 – 8 cm depth).
a
b

48
Local anaesthetics:
Needle: E. g. 20 G 10 or 15 cm long, insulated unipolar needle with 30° or 15° bevel
Patient in a lateral position with the side to be blocked uppermost. The
lower leg is stretched, the leg that is to be blocked is flexed in hip and
knee-joint.
Guiding structures:
Greater trochanter, superior posterior iliac spine.
Draw a line between the sup. post. iliac spine and the greater trochanter,
from its midpoint a perpendicular line is drawn caudomedially. The nee-
dle insertion point is 4 – 5 cm from the first line. A confirming line can
be drawn from the trochanter to the sacral hiatus, the insertion point is
where the last two lines cross each other. The stimulation needle is advan-
ced perpendicularly to the skin. After 5 – 10 cm, contractions of the
dorsiflexors of the foot (common peroneal nerve) or of the plantar flexors
of the foot (tibial nerve) at 0.3 mA/0.1 ms indicate the correct position
of the needle in the immediate vicinity of the sciatic nerve.
● Occasional vascular puncture (inferior gluteal artery)
● Direct stimulation of the major gluteal muscle must not be mistaken for
the sciatic nerve stimulation response (inject local anaesthetic only
at a stimulus response in the lower leg/foot)
● Local LA infiltration recommended
Indications:
● All leg surgery when combined with a
lumbar plexus block
● Pain therapy (knee joint on the
flexor side, lower leg)
● Sympathicolysis
None
Relative contraindications:
Coagulation disorder (Risk of puncturing
inferior gluteal artery)
Transgluteal sciatic nerve block
(acc. to Labat)

49
1 2
a greater trochanter
b superior posterior
iliac spine
c site of insertion:
direction of needle
perpendicular to
the skin, 5 – 10 cm
deep
1 piriformis m.
2 sciatic n.
a
b c

50
Local anaesthetics:
Initial:
30 ml lidocaine 1% or mepivacaine 1% or
20 – 30 ml ropivacaine 0.75%
Continuous:
6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or
hours)
Needles: 10 cm, 20 G, 30° or 15° bevel unipolar needle
Continuous: E. g. 19.5 G, 10 cm bevel, Plexolong set®
(Pajunk co.), Contiplex®
(B. Braun)
The catheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction
The patient is supine with the leg to be blocked flexed at hip and knee
approx. 90° and held by an assistant.
Guiding structures:
Greater trochanter, ischial tuberosity.
Draw a line between the greater trochanter and the ischial tuberosity and
mark its midpoint. This point marks the site for needle insertion. The sti-
mulation needle is advanced perpendicular to the skin surface in a cra-
nial direction. After 5 – 10 cm, contractions of the dorsiflexors of the foot
(peroneal n.) or of the plantar flexors (tibial n.) at 0.3 mA/0.1 ms indi-
cate the correct position of the needle.
Advantage: The patient can remain supine. The technique is easy to
learn. The leg can also be placed in a leg support. A continuous tech-
nique can be used.
Indications:
● Most types of surgery on the leg when
used in combination with a lumbar
plexus block
● Pain therapy
● Sympathicolysis
None
Subgluteal sciatic nerve block
(acc. to Raj)

51
1
2
3
a
b
c
a site of insertion:
midpoint of line
between the
greater trochanter
and the ischial
tuberosity
b greater trochanter
c ischial tuberosity
1 sciatic n.
2 greater trochanter
3 ischial tuberosity

52
Local anaesthetics:
Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 20 – 30 ml
ropivacaine 0.75%
Continuous: 6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5
mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx.
every 6 hours)
Needles: 20 G, 15 cm, 30° or 15° bevel, insulated unipolar needle
Continuous: E. g. 19.5 G, 15 cm, facet tip, Plexolong set®
(Pajunk co.) or Contiplex®
set
(B. Braun) 20 G catheter. The catheter is advanced approx. 4 cm beyond the tip of the
cannula
Patient supine with the leg in a neutral position.
Guiding structures:
Superior anterior iliac spine, middle of the symphysis, greater trochanter,
the intermuscular space between the sartorius m. and the rectus femoris m.
The connecting line between the anterior iliac spine and the middle of
the symphysis is divided into three equal segments. Draw a line parallel
to this line through the middle section of the greater trochanter. Then
draw a perpendicular line from the junction of the medial and middle
segments in a caudal direction. The point where the lines cross each
other marks the needle insertion site. Palpate the intermuscular space be-
tween the sartorius m. and the rectus femoris m. in this region. Advance
the needle at a 60° angle approx. 8 – max. 15 cm in a cranial direc-
tion. Avoid bone contact. A motor stimulus response in the foot (dorsi- or
plantar flexion at 0.3 mA/0.1 ms) indicates that the needle tip is in the
immediate vicinity of the sciatic nerve.
The palpation of the space between the sartorius and rectus femoris
muscles is very important, because the femoral vessels are displaced
medially and the distance to the injection site is shortened as a result of
the vertical pressure ("two-finger grasp").
Indications:
● Most surgery on the leg when combined
with a lumbar plexus block
● Pain therapy (also as a continuous
technique)
● Sympathicolysis
None
Proximal anterior/ventral sciatic nerve block
(acc. to Meier)

53
a c
b
a the connecting line
between the sup.
ant. iliac spine and
the middle of the
symphysis
b greater trochanter
c needle insertion
site
1 rectus femoris m.
2 sartorius m.
3 femoral n.
4 femoral a.
5 femoral v.
6 sciatic n.
Direction of needle
insertion
Note:
"two-finger grasp"
into the intermuscu-
lar space, sciatic
nerve at a depth
of 8 – 15 cm.
3
2
1 4 5
6
lateral medial
right
thigh

Local anaesthetics:
Initial:
30 ml lidocaine 1% or mepivacaine 1% or 20 – 30 ml ropivacaine 0.75%
Continuous:
6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or
hours)
Needles: 20 G, 10 cm, 30° or 15° unipolar needle
Continuous: E. g. 19.5 G, 10 cm, facetted tip, Plexolong set®
(Pajunk co.). The catheter
is advanced 4 – 5 cm beyond the needle tip in a cranial direction.
Patient position:
Patient supine. The leg lies in neutral position. A small pad or pillow is
placed under the foreleg.
Guiding structures:
Greater trochanter, femur shaft.
A line is drawn distally from the prominent part of the greater trochanter
parallel to the femur. The injection site is approx. 3 cm below this line at
5 cm distal to the greater trochanter. The needle enters at the level of the
dorsal border of the femur and the needle is directed dorsally (approx.
30°) and cranially (approx. 30 – 45°). The sciatic nerve is reached after
8 – 10 cm.
Muscular contractions in the posterior thigh are frequent. The correct
position of the needle tip in the vicinity of the nerve is confirmed by a
motor response in the foot (dorsiflexion or plantar flexion) with a pulse
amplitude of 0.3 mA and a pulse width of 0.1 ms. The peroneal nerve is
in front of the tibial nerve. Dorsiflexion of the foot is therefore usually the
initial motor response. If no motor response is produced, the needle
should be withdrawn and its direction should be corrected anteriorly
when it is advanced again.
Indications:
● All operations on the leg in combination
with a lumbar plexus block
● Pain therapy
● Sympathicolysis
None
Proximal lateral sciatic nerve block
54

2
1
a
55
a greater trochanter
with a line parallel
to the femur
b needle insertion site
5 cm distal to the
greater trochanter
and 3 cm below
line a (just behind
the femur)
1 greater trochanter
2 sciatic n.
approx. 30°
dorsally and
cranially
b

Local anaesthetics:
Initial:
30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine
0.75%
Continuous:
6 ml/h (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or
hours)
Needles: 22 G, 10 – 12 cm unipolar needle
Continuous: E. g. 19.5 G, 10 – 12 cm, catheter 20 G (Plexolong set®
, Pajunk co.). The
catheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction.
Patient position:
Patient supine. The leg is supported at the foot so that the thigh sags
freely.
Guiding structures:
Upper border of patella, biceps femoris (long head), vastus lateralis.
The needle insertion site is located approx. 12 cm proximal to the upper
border of the patella between the upper border of the biceps femoris and
the lower border of the vastus lateralis. The needle is directed approx.
20° – 30° dorsally and approx. 45° cranially. A motor response in the
foot after 6 – 9 cm (peroneal nerve – dorsiflexion, tibial nerve – plantar
flexion) at 0.3 mA/0.1 ms indicates that the nerve is immediately nearby.
To make it easier to palpate the tendon and belly of the biceps femoris
muscle, brief elevation and flexion the patient’s leg is recommended. An
additional saphenous nerve block is required for complete anaesthesia of
the lower leg and foot (see page 60). Suitable as a continuous technique
(distal sciatic catheter, DSC). The advantage compared to distal (dorsal)
sciatic block (see page 58) is that the patient can remain in supine position.
Indications:
● Anaesthesia for operation on the foot/ankle
● Anaesthesia/pain therapy distal to the knee
● Postop. pain therapy (foot/ankle)
● Pain therapy/sympathetic block
(achillodynia, diabetic gangrene, circulatory
or wound healing disorders, CRPS)
None
Distal lateral sciatic nerve block
56

57
1 vastus lateralis m.
2 iliotibial tract
3 level for anatomical
cross section
4 patella
5 biceps femoris m.
(long head) with
tendon
6 biceps femoris m.
(short head)
7 sciatic n. with
peroneal division
(thinner, lateral) and
tibial division
(thicker, medial)
a biceps femoris m.
(long head)
b tendon of biceps
femoris m. (l. h.)
c biceps femoris m.
(short head)
d vastus lateralis m.
e patella
20° – 30° dorsally,
45° cranially
d
a
e
c b
lateral medial
right
thigh
1
1 3 2 4
5
7
5
2
6
5
6

58
Local anaesthetics:
Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or
Patient in the lateral position with the lower leg semi-flexed in hip and
knee. The leg to be blocked is uppermost and stretched, a pillow placed
between the knees as a comforting support. Alternatively: Patient supine
with the leg to be blocked flexed in the hip and knee (leg support neces-
sary).
Guiding structures:
Flexion fold ("wrinkle") of the popliteal fossa. Laterally: biceps femoris
m.; medially: semimembranous m., semitendinous m., popliteal artery.
The thumb and the middle finger are placed on the epicondyles and a
symmetric triangle is formed cranially with the index finger. This triangle
corresponds closely to the boundaries of the upper popliteal fossa, with
its cranial angle approx. 8 – 12 cm proximal to the flexion fold. The in-
sertion site is 1 – 2 cm lateral of the tip of the triangle immediately
medial to the tendon of the biceps femoris muscle. The needle
is advanced in a cranial direction at a 30° – 45° angle to the skin and
slightly medially. A stimulus-response in the foot can be expected after
4 – 6 cm, (peroneal n.: dorsiflexion; tibial n.: plantar flexion) at 0.3
m/0.1 ms and indicates the immediate vicinity of these nerves.
The sciatic nerve runs parallel to the popliteal artery. Anatomic arrange-
ment in the fossa poplitea, from lateral to medial: biceps femoris muscle,
common peroneal nerve, tibial nerve, popliteal artery. In case of a tourni-
quet below the knee, it is recommendable to add a saphenous nerve
block (see p. 60). This block is particularly well suited for a continuous
technique (distal sciatic n. catheter).
Note: A large proportion of the sciatic n. consists of sympathetic fibres.
Sympathicolysis can be used therapeutically.
Indications:
● Anaesthesia for foot/ankle joint surgery
● Anaesthesia/analgesia distal of the
knee
● Postoperative analgesia (foot/ankle joint)
● Analgesia/sympathicolysis (CRPS I or II)
achillodynia, diabetic gangrene, blood
circulation disorders or leg ulcer
None
Distal posterior sciatic nerve block
(acc. to Meier)

59
1
3
4
lateral
5
6
7
2
Continuous: 6 ml/h (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5
mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx.
every 6 hours)
Needles and catheters: Shortbevel, unipolar needle 22 G, 5 – 10 cm
Continuous: E. g. 19.5 G, 6 or 10 cm long, 20 G catheter (Plexolong set®
, Pajunk co.).
The catheter is advanced 4 – 5 cm beyond the tip of the needle
a tendon of the
biceps m. of the
thigh
b popliteal a.
c needle insertion
site approx. 8 – 10
cm proximal to the
flexion fold of the
popliteal fossa 45°
angle cranially,
sciatic nerve at a
depth of approx.
4 – 6 cm
1 semimembranosus
m.
2 semitendinosus m.
3 popliteal a.
4 biceps femoris m.
5 sciatic n.
6 tibial n.
7 peroneal n.
a
b
c

60
Local anaesthetics:
Needle: 24 G, 6 cm
Sensory terminal branch of the femoral nerve.
Patient supine
Guiding structures:
Tuberosity of tibia, medial head of the gastrocnemius muscle.
The tuberosity of tibia is palpated and subcutaneous infiltration is carried
out with a 6 cm long 24 G needle in the direction of the medial head of
the gastrocnemius m.
Accidental puncture of the saphenous vein (rare) can be excluded by
repeated aspirations.
Indications:
● Incomplete lumbar plexus or femoral
nerve block (medial lower leg)
● Combination with a distal sciatic block
when tourniquet below the knee is used
None
Saphenous nerve block

61
1
3
2
medial
a tuberosity of tibial
b medial head of
gastrocnemius m.
c needle insertion
site: subcutaneous
injection
direction of
insertion toward the
medial head of the
gastrocnemius m.
1 infrapatellar branches
of the saphenous n.
2 sartorius m.
3 saphenous n.
a
b
c

62
Local anaesthetics:
5 ml lidocaine 1% or mepivacaine 1% or 5 ml ropivacaine 0.75%
Needle: unipolar 22 G, 5 cm
Patient position and methods:
Patient supine, palpation of the head of the fibula.
The needle insertion point lies 2 cm distal and dorsal. The direction of
the unipolar needle is perpendicular to the skin, stimulus-response in the
foot (dorsiflexion of the foot) at 1 – 3 cm. Injection of the local anaesthet-
ic at 0.3 mA/0.1 ms.
Nerve stimulation strongly recommended, as the peroneal nerve is very
sensitive.
Indications:
● Incomplete anaesthesia following sciatic
block
● Pain therapy
None
Common peroneal nerve block

63
1 2 3
a head of the fibula
b site of insertion
needle perpendicu-
lar to the skin
nerve 1 – 3 cm
deep
1 biceps femoris m.
2 common peroneal n.
3 head of fibular bone
lateral
a
b

64
The foot is supplied by 5 nerves, 4 of which originate in the sciatic n.
(superficial and deep peroneal nerves, tibial and sural nerves). The fifth
(saphenous n.) is the terminal branch of the femoral nerve.
Patient supine
Superficial peroneal nerve:
A subcutaneous infiltration is performed between the anterior edge of the
tibia and the upper edge of the lateral malleolus with 5 – 10 ml local
anaesthetic: (Anaesthesia distribution: Skin on the back of the foot and
the toes, except an area between the greater and second toes.)
Sural nerve:
The sural n. is blocked by subcutaneous infiltration of 5 ml local anaes-
thetic between the Achilles tendon and the lateral malleolus. (Anaesthesia
distribution: Lateral edge of the foot, variable up to the 5th toe.)
Saphenous nerve:
Subcutaneous infiltration of 5 – 10 ml local anaesthetic from the anterior
edge of the tibia to the Achilles tendon, approximately a hand-width
above the medial malleolus. (Anaesthesia distribution: skin medially from
the inner ankle variable up to the great toe.)
Comments:
If this subcutaneous block is initially performed as a ring-shaped infiltra-
tion, subsequent needle-sticks will be pain-free.
Blocks for anaesthesia in the foot (ankle blocks)
(acc. to Löfström)

65
1
2 3
Subcutaneous ring
infiltration above
the ankle to block
the
– superficial pero-
neal and sural
nerves (lateral)
– saphenous n.
(medial)
1 sural n.
3 deep peroneal n.

66
Block of the deep peroneal nerve
The needle is inserted between the tendon of the long extensor pollicis
muscle and the dorsalis pedis artery on the back of the foot. The needle
is inserted perpendicularly to the skin and advanced slightly under the
artery. Following negative aspiration, injection of 5 ml local anaesthetic.
Anaesthesia distribution: Skin of the medial side of the great toe and the
lateral side of the 2nd toe.
Local anaesthetics:
Needle: 24 G, 3 – 5 cm
Ankle block Deep peroneal nerve

67
1
2
3
4
4
a tendon of the long
extensor pollicis
muscle
b dorsalis pedis a.
2 saphenous n.
3 dorsalis pedis a.
4 deep peroneal n.
a
b

68
The following applies to ankle blocks:
Local anaesthetics:
per injection
Needles: 22 – 24 G, 4 – 6 cm
Tibial nerve block:
The needle insertion point lies directly dorsal to the posterior tibial artery
on the medial side of the joint, or alternatively, directly anterior of the
Achilles tendon at the level of the medial malleolus. The needle is insert-
ed perpendicular to the skin. 5 – 8 ml local anaesthetic are injected
using intermittent aspirations.
Warning: In case of paresthesias, withdraw the needle to avoid injury to
the nerve. (Anaesthesia distribution: Sole of the foot with the exception of
its extreme lateral and proximal segments.)
Comments (recommendation):
Nerve stimulation and a unipolar 5 cm 22 G or 24 G, needle is recom-
mended (stimulus-response: Plantar flexion of the toes).
Ankle block Posterior tibial nerve
Indications:
● Incomplete plexus lumbosacral block
● Foot surgery
● Pain therapie
● Diagnostic blocks
None. In case of neurological deficits,
check diagnosis before initiating the
block

69
1
2
3
a posterior tibial a.
needle insertion
dorsal of the artery,
direction perpen-
dicular to the skin
1 saphenus n.
2 posterior tibial a.
3 tibial n.
a

Notes – own experience – phone numbers – pain service, etc.
Notes

Notes
Notes – own experience – phone numbers – pain service, etc.

Authors' addresses:
Dr. Gisela Meier, M.D.
Head of the Department of Anaesthesia and Pain Therapy
Rheumazentrum, Waldburg-Zeil Kliniken
Hubertusstraße 40
D-82487 Oberammergau, Germany
Dr. Johannes Büttner, M.D.
Head of the Department of Anaesthesia
Berufsgenossenschaftliche Unfallklinik Murnau
Professor-Küntscher-Straße 8
D-82418 Murnau, Germany
The English version was revised by:
Dag Selander, MD, PhD,
c/o Selmedic HB
Betzensgatan 1
S-414 55 Göteborg, Sweden

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