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Lower limb blocks
- 1. Lower limb blocks Abraham Tarekegn Universityof Gondar Department of Anesthesia 1/4/2018 1
- 2. Spinal cord • Lumbarand sacral enlargement The sites where the nerves serving the lower limbs, emerge. • Conus Medullaris: The terminal portion of the spinal cord • Cauda equina: The collection of nerve roots at eh inferior end of the vertebral canal. • Spinal cord ends at the level of L2 vertebrae (adults). L.S Plexus by IM
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- 5. Nerve supply tothe lower extremity Composed of the lumbar and sacral plexuses. The lumbar plexus is formed in the psoas muscle by the first four lumbar nerves, including, frequently, a branch from the 12th thoracic nerve and occasionally one from the 5th lumbar nerve. The sacral plexus is derived from the anterior rami of the 4th and 5th lumbar and the first two or three sacral nerves.1/4/2018 5
- 6. The five majornerves to the lower extremity The lumbar plexus: 1. The femoral nerve 2. The lateral femoral cutaneous nerve 3. The obturator nerve Minor contributions Iliohypogastric innervate to the skin of the buttock and the muscles of the abdominal wall ilioinguinal supplies the skin of the perineum and adjoining portion of the inner thigh, Genitofemoral nerves It supplies filaments to the genital area and adjacent parts of the thigh.1/4/2018 6
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- 8. The five majornerves to the lower extremity…. 4. The posterior cutaneous nerve - the "small sciatic" nerve - from the first, second, and third sacral nerves 5. The larger sciatic nerve, which also receives branches of the anterior rami of the fourth and fifth lumbar nerves. The two nerves course through the pelvis together and out through the greater sciatic foramen, they are considered together when techniques for blocking the sciatic nerve are discussed. 1/4/2018 8
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- 10. Sensory Distribution of the Lower Limb L.SPlexus by. IM. 12-08-2014 10
- 11. Lumbar plexus Thelumbar plexus is formed by the ventral rami of first four lumber nerve roots (L1, L2, L3 (major) & part of L4). In 50% of cases it receives a contribution from the ventral rami of last thoracic root (T12). It lies within the substance of the posterior part of psoas major muscle, anterior to the transverse processes of the lumbar vertebrae. The branches emerge to both lateral and medial side of psoas major muscles.1/4/2018 11
- 12. Components of lumbosacralplexus Components of the lumbosacral plexus are as, 1. Lumbar plexus = L1, L2, L3, L4 2. Lumbosacral Trunk = L4, L5 3. Sacral Plexus = S1, S2, S3, S4 Smaller branches of the lumber plexus innervate the posterior abdominal wall and psoas muscles (psoas major, iliacus). Main branches innervate the anterior thigh and their relative muscles. L.S Plexus by IM
- 14. Lumbar plexus Root: Theseare constituted by the anterior primary rami of L1, L2, L3, L4 (T12). Branches: L1 root gives an upper and lower branch L2 Root gives and upper and lower branch L3 does not give any branch L4 gives an upper and lower branch 1/4/2018 14
- 15. Division: Lower branch ofL2, upper branch of L4 and ventral rami of L3 nerve roots divide into small anterior and large posterior division. From L2 and L3 each gives two and L4 one posterior divisions, with single anterior division from all branches (L2, L3, L4). Lower branch of L4 and L5 unite to form lumbosacral trunk 1/4/2018 15
- 16. Terminal Branches ofLumbar Plexus L1 unites with a small branch from T12 and splits into an upper and lower branches. The upper larger branch divides into two: Iliohypogastric (T12, L1) and Ilioinguinal nerves (L1). The lower smaller branch of L1 unites with a branch from L2 to form the genitofemoral nerve. The remainders of L2, L3 and L4 divide into ventral and dorsal branches. Ventral (Anterior) divisions of L2, L3, L4 unite to form obturator nerve. 1/4/2018 16
- 17. Branches… The dorsal(posterior) divisions of L2 and L3 divide into small and larger parts. Smaller parts of dorsal divisions of L2 and L3 unite to form the lateral femoral cutaneous nerve. Larger parts of dorsal divisions of L2 and L3 unite with L4 to form femoral nerve. 1/4/2018 17
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- 22. Sacral plexus Thesacral plexus is formed by the lumbosacral trunk (L4 ,L5 ), & ventral rami of S1, S2, S3, S4 . Contribution of the fourth sacral ventral rami is partial & the remainder of the last (S5 ) joins the coccygeal plexus. Key to remember sacral plexus: Root Divisions Terminal Branches 1/4/2018 22
- 23. Sacral plexus…. Roots:These are constituted by the anterior primary rami of L4 , L5, S1, S2, S3, & S4 Divisions: The lower branch of L4 ventral rami & ventral rami of L5 , S1 & S2 give anterior and posterior divisions. While S3 forms & shares only anterior division. Terminal Branches: These anterior and posterior divisions unite to form the terminal nerve branches.1/4/2018 23
- 24. Terminal Branches Theposterior division of L4 ,L5 & S1 joins to form Superior Gluteal Nerve . The posterior divisions of L5,S1 & S2 unites to form the Inferior Gluteal Nerve. The posterior divisions of L4 ,L5 ,S1 & S2 joins to form Common fibular or Peroneal Nerve. It’s the about one-half the size of the tibial nerve. L.S Plexus by IM
- 25. Terminal Branches… Theanterior divisions of L4 ,L5 ,S1,S2 & S3 unites to form Poterior Tibial Nerve. The anterior divisions of S2,S3& S4 unites to form Pudendal Nerve. Both Tibial and peroneal nerves run in a single covering of sheath and called as Sciatic Nerve (L4 ,L5,S1,S2 &S3) . Which is the largest nerve of the body. 1/4/2018 25
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- 28. Nerve Name OriginSupplies Iliohypogastric T12,L1 Motor supply to internal oblique, transverses muscles, sensation over lower anterior abdominal wall Ilioinguinal L1 Sensation over anterior pubis (mons) and anterior scrotum or labia Genitofemoral L1, L2 Genital branch: motor supply to cremastor muscle, sensation to anterior scrotum; femoral branch: sensation to anterior thigh Femoral L2, L3, L4 Motor supply to extensors of the knee, sensation to anterior thigh Obturator L2, L3, L4 Motor supply to adductors of the thigh, sensation to medial thigh Lumbosacral trunk L4, L5 Joins the sacral nerves to form the lumbosacral plexus that supplies motor and sensory innervations to the lower extremities Posterior femoral cutaneous S2, S3 Sensation to perineum, posterior scrotum, and posterior thigh Pudendal S2, S3, S4 Motor to levator ani, muscles of the urogenital diaphragm, anal and striated urethral sphincter, sensation to the perineum, scrotum, and penisL.S Plexus by IM
- 29. 12/08/2014 Nerve Name OriginSupplies Nerve to quadratus femoris L4,L5,S1 quadratus femoris, inferior gemellus Superior gluteal L4,L5,S1 gluteus medius & minimus, tensor fasciae latae Inferior gluatel L5,S1,S2 Gluteus maximus Nerve to obturator internus L5,S1,S2 obturator internus, superior gemellus sciatic sacral plexus (ventral primary rami of L4-L5, S1- S3) (via its tibial & common peroneal branches) semitendinosus, semimembranosus, biceps femoris, part of adductor magnus, muscles of leg & foot skin of leg & foot (excluding medial side of leg & foot) L.S Plexus by IM
- 30. Lumbar plexus block The lumbar plexus is located in a virtual space inside the Psoas major muscle. This space is limited medially by Psoas major insertions on the bodies of the vertebrae and their transverse processes and by the lumbar spine itself. The aponeurosis surrounding the plexus inside the Psoas major constitutes the anterior, posterior and lateral limits of this space.1/4/2018 30
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- 32. Lumbar plexus block… Formed from the ventral rami of L1– L3 and the major part of the L4 nerve. It gives rise to the: Iliohypogastric nerve (L1&T12) Ilioinguinal nerve (L1) Genitofemoral nerve (L1–L2) Lateral femoral cutaneous nerve (L2– L3) Femoral nerve (L2–L4) Obturator nerve (L2–L4). 1/4/2018 32
- 33. Lumbar plexus block… The depth at which the plexus is located varies. To reach it, the needle goes through skin, subcutaneous fat, Erector spinae, Quadratus lumborum, and Psoas major muscles. During its progression, the needle may come into contact with the transverse process of L4, providing an excellent landmark. 1/4/2018 33
- 34. Blocked nerves Upper thigh Ilio-inguinal nerve Iliohypogastric nerve Genitofemoral nerve Lower limb Femoral nerve Lateral femoral cutaneous nerve Obturator nerve 1/4/2018 34
- 35. Indications Analgesia forfractured neck of femur and femoral shaft. It can be used for hip, knee and femoral shaft surgery. In combination with sciatic nerve block it can be used for all operations on the knee, ankle, and foot. 1/4/2018 35
- 36. Landmarks Midline(spinous process) Posterior superior iliac spine (PSIS), Line joining the iliac crests (Tuffier's line) intercristine line. 1/4/2018 36
- 37. Technique Position thepatient laterally and operative side uppermost. Horizontal line joining the top of the iliac crests at the L4-L5 level. A line joining the spinous processes of L3, L4 and L5. A line parallel to the line joining the spinous processes and passing over the posterior superior iliac spine. A line starting at the spinous process of L4 and reaching perpendicularly the line passing by the posterior superior iliac spine. 1/4/2018 37 Posterior superior iliac spine Iliac crest
- 38. Technique… The puncturesite is located at the union of the lateral 1/3 and medial 2/3 of the line joining the spinous process of L4 to the line passing through the posterior superior iliac spine (approximately 40 mm lateral the spinous process of L4). 22G 100 mm insulated needle perpendicular to the skin with a slight caudal angle needle is inserted slowly through the muscles until it reaches the transverse process of L4. This contact is expected and provides a real safeguard. 1/4/2018 38
- 39. Technique… If thereis bony contact redirect the needle to pass beneath the transverse process or quadriceps stimulation is encountered approximately 8–10 cm. The needle is inserted more deeply until the required stimulation of the femoral nerve (ascension of the patella) can be observed. Inject at the site and aspiration test is then carried out to avoid vascular or spinal injection. nerve block vedio 1/4/2018 39
- 40. Doses Approximately 0.5ml/kgof LA. For a single injection, a volume of 20- 30 ml of anesthetic solution is required. Injection must be slow and divided. 1% Prilocaine, 1% Lidocaine 0.25%-0.5% Levobupivacaine. 1/4/2018 40
- 41. Complications Kidney puncture: The needle is inserted too deep and too cephalic. Avoid puncture at the L3 level, particularly on the right side. Ureter puncture: Needle tip is too deep. Spinal or epidural puncture: The puncture site or the direction of the needle are too medial. Always aspirate before injecting slowly small quantities of anesthetic solution. Epidural extension of anesthesia : In this case, whether the catheter is located in the paravertebral space or in the Psoas compartment, the anesthetic solution reaches the epidural space. Analgesia is effective. The catheter can be left in place but it should then be treated as an epidural. 1/4/2018 41
- 42. Femoral Nerve: Anatomy The femoral nerve is the largest branch of the lumbar plexus. Femoral nerve is created from contributions from L2, L3, and L4. The femoral nerve enters into the thigh under the inguinal ligament, between the psoas and iliacus muscle.
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- 44. Anatomy Pectineous muscle Iliopsoas muscle Fascia iliaca Fascia lata Skin FemoralVein Femoral Artery Femoral Nerve
- 45. Femoral nerve block The femoral nerve (L2 - L4) arises from the lumbar plexus and runs under the psoas major and iliacus muscles, covered by illopsoas fascia. The psoas fascia separates the nerve from the femoral artery. The femoral nerves lie lateral to the artery deep to the inguinal ligament. 45
- 46. Femoral nerve…. Thefemoral nerve is the largest branch of the lumbar plexus. It mainly supplies the extensors muscles of the knee (quadriceps). About one inch below the inguinal ligament the nerve divides in to branches: ◦ The deep branch that innervate the muscles of the front of the thigh. ◦ Cutaneous branches that innervate the lateral of thigh. 1/4/2018 46
- 47. Femoral nerve block… The saphenous nerve which innervates the medial side of the leg up to the middle of the medial border of the foot. It is formed by the dorsal or posterior division of the anterior rami of L2,L3, & L4 roots. The Saphenous Nerve is a purely sensory nerve which the largest and longest cutaneous branch of the femoral nerve. 1/4/2018 47
- 48. Femoral nerve block… The lateral femoral cutaneous nerve of the thigh emerges from the lateral border of psoas major which is formed by the posterior divisions of L2 and L3. It gives cutaneous supply to the lateral part of the thigh. 1/4/2018 48
- 49. Femoral nerve block A femoral block results in anesthesia of the entire anterior thigh and most of the femur and knee joint. The block also confers anesthesia of the skin on the medial aspect of the leg below the knee joint (saphenous 1/4/2018 49
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- 51. Indication of femoralnerve block The femoral block is primarily used in combined with other peripheral blocks. However, it can be used alone for muscle biopsies of the quadriceps muscle or other surgical procedures limited to the anterior thigh such as skin graft It is reported effective for anesthetic management of knee arthroscopy and surgical repair of mid femoral shaft fractures. 1/4/2018 51
- 52. Land marks forfemoral nerve block Inguinal ligament: A line drowns between the anterior posterior iliac spine and the pubic tubercle Femoral crease (oblique skin fold positioned a few centimeters below the inguinal ligament) The femoral artery is palpated as it passes behind the midpoint of the ligament. The needle is inserted just below the ligament, 1 cm. lateral to the artery, parallel with the course of the nerve. 1/4/2018 52
- 53. Identify the landmarks. The femoral nerve is located just below the inguinal ligament. Locate the anterior superior iliac spine and the pubic tubercle. A line between these two structures is where the inguinal ligament is located. Next locate the pulsation of the femoral artery. The site for needle insertion is approximately 2 cm lateral to the pulsation. From medial to lateral the structures are femoral vein, femoral artery, and femoral nerve. 1/4/2018 53
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- 55. Techniques Thepatient is placed in the supine position. A line is drawn between the anterior superior iliac spine and the pubic tubercle, identifying the inguinal ligament. Palpate and mark the femoral artery at the level of the inguinal ligament. Mark a point 1 cm lateral to the pulsation and 1–2 cm distal to the ligament. Insert a 22G 50 cm needle at 45° to the skin in a cephalad direction. Two distinct ‘pops’ may be felt as the needle passes through fascia lata then the fascia iliaca respectively. nerve block vedio 55
- 56. Techniques Paraesthesia inthe knee or stimulation of quadratus femoris ‘dancing patella’ indicates correct location of the needle. Inject 10–30 ml of solution fanwise lateral to the artery. 1% Prilocaine, 1% Lidocaine. 0.25%-0.5% Levobupivacaine. 1/4/2018 56
- 57. Complications Intravascular injectionand hematoma are possible because of the close proximity of the femoral artery. Nerve damage Vascular puncture 1/4/2018 57
- 58. Obturator nerve block The obturator nerve, which originates from the ventral rami of L2, L3, L4, is the most anterior and medial branch of the lumbar plexus. It emerges from posterior and medial border of the psoas muscle, piercing the iliaca fascia between L5 and S1. It runs on the lateral side of the pelvis over the obturator muscle. It crosses the obturator foramen with the obturator vessels and gives two divisions, anterior and posterior, for the medial side of the thigh. 1/4/2018 58
- 59. Indications Indicated foradductor spasm and knee surgery (optional). For TUR of tumors located on the lateral and inferolateral bladder combined with SA or GA. For the diagnosis and treatment of adductor muscle spasticity and in chronic pain conditions (hip pain, pelvic tumor). Postoperative analgesia after total knee arthroplasty. 1/4/2018 59
- 60. Landmarks The landmarkfor the classic approach to obturator nerve block is the pubic tubercle. Insertion of adductor tendons. Inguinal ligament and the femoral artery. 1/4/2018 60
- 61. Techniques The patientis first asked to flex his/her hip and a line marked the inguinal crease. The adductor longus tendon is identified as the most superficial palpable tendon in the medial part of the thigh. A mark on the skin is made in the inguinal crease at the midpoint of the line drawn between the inner border of the adductor longus tendon and the femoral arterial pulse. This point corresponds to the center of an easily palpable groove between the vascular bundle and the adductor longus muscle. 1/4/2018 61
- 62. Technique …. 1. Superioranterior iliac spine 2. Pubic tubercle 3. Inguinal crease 4. Femoral pulse 5. Insertion point of the needle in the inguinal approach 6. Insertion point of needle in the pubic approach 1/4/2018 62
- 63. Technique …. At apoint between the tendons, 1 cm inferior to the pubis, insert a 22G 80 mm insulated needle in the horizontal plane aiming at the ipsilateral anterior superior iliac spine. At a depth of 5–6 cm resistance of the obturator membrane may be felt. 10 mL of LA is injected for an adult patient. A volume of 0.3 ml/kg is suggested for children. video 1/4/2018 63
- 64. Lateral cutaneous nerveblock Block of this nerve is indicated for analgesia of lateral femoral incisions (hip surgery and surgery for fractured neck of femur). It is commonly blocked by a femoral nerve block or femoral 3:1 block. 1/4/2018 64
- 65. Landmarks &Technique Landmarks: Anteriorsuperior iliac spine, inguinal ligament. Technique: At a point 2 cm medial and 2 cm inferior to the anterior superior iliac spine, below the inguinal ligament. Insert a 22G 25–50 cm short-bevelled needle perpendicular to the skin. 10 -15ml of solution is injected beneath the fascia lata after appreciation of the “pop” sensation. video 1/4/2018 65
- 66. 1/4/2018 66 Landmarks &Technique…. 2cm 2 cm Landmarks for lateral femoral cutaneous nerve block. Needle entry site (indicated by the cross) is 2 cm medial and 2 cm caudad to the anterior superior iliac spine.
- 67. The three -in - one block The aim is to block the femoral, the lateral cutaneous and obturator nerves with a single injection. The principle upon which the block is based is that all three nerves are branches of the lumbar plexus and lie sandwiched between the same muscles and fascia. Femoral and/or 3-in-1 nerve blocks are used for surgical procedures on the front portion of the thigh down to the knee and postoperative analgesia. 1/4/2018 67
- 68. Indications for Femoral/3-in-1 NerveBlock Femoral Nerve Block Operations on the anterior thigh (i.e. lacerations, skin graft, muscle biopsy) Pin or plate insertion/removal (femur) Femur fractures Analgesia 3-in-1 Nerve Block Same indications as femoral nerve block Analgesia and anesthesia of the hip (dislocations, femoral neck fractures) Analgesia of the knee 1/4/2018 68
- 69. Innervations of theFemoral, Lateral Femoral Cutaneous, and Obturator Nerves Femoral Nerve- Anterior and medial portion of the thigh and knee. Cutaneous innervations of the medial and lateral portion of the thigh. Periosteum of the femur. Lateral Femoral Cutaneous Nerve- Sensory nerve to the lateral buttock, thigh, and knee joint. Obturator Nerve- sensory to the medial thigh, hip joint, and adductor muscle. 1/4/2018 69
- 70. Technique Technique of3-in -1 nerve blocks are basically the same with femoral nerve block, with some minor alterations. vedio 1/4/2018 70
- 71. Differences between FemoralNerve Block and 3-in-1 Nerve Block There are two main differences. 1. Volume of local anesthetic. For femoral nerve blocks, the volume of local anesthetic is generally 20 ml or less. For 3-in-1 nerve blocks, the volume of local anesthetic is 25-30 ml. This allows the local anesthetic to spread further in the tissue plane resulting in blockade of the femoral, lateral femoral cutaneous, and obturator nerve. 1/4/2018 71
- 72. Technique… 2. Slight alterationin technique. Once the needle has been placed in the correct area, pressure should be applied 2-4 cm below the injection site. Next, administer the local anesthetic. Applying distal pressure helps spread the local anesthetic to the obturator and lateral femoral cutaneous nerve, in addition to the femoral nerve. 1/4/2018 72
- 73. Sciatic nerve Thelargest nerve in the body (1.5 - 2 cm. in width and 0.3 to 0.9 cm. in thickness as it leaves the pelvis). Leaving the pelvis it passes through a tunnel between the greater trochanter and the ischial tuberosity. It lies on the muscles around the hip joint and is covered by gluteus Maximus. 1/4/2018 73
- 74. Sciatic Nerve Itthen runs vertically down wards in the hamstring compartment of the thigh to reach the popliteal fossa where it divides in to common peroneal and tibial branches. Occasionally this division occurs much higher in the thigh. The tibial nerve passes vertically down wards through the calf to supply the heel and sole of the foot. The common peroneal nerve winds diagonally across the popliteal fossa to the lateral part of the calf before descending to the foot where its branches innervate the dorsal structures. 1/4/2018 74
- 75. Indications of sciaticnerve block Produce anesthesia in the back of the thigh. Ankle and foot with saphenous nerve block. Surgery of the knee with the block of femoral. Surgery of the leg with saphenous block 1/4/2018 75
- 76. Lateral/Posterior Approaches Thepatient in the Sims position. Lie with the side to be blocked upper most. The posterior superior iliac spine and the greater trochanter are identified and a line is drown between the two points. A perpendicular line is dropped at its mid point The point of entry is 1 to 11/2 inches from the midpoint along this line. This point should meet the line drawn from the sacral hiatus to the greater trochanter. 1/4/2018 76
- 77. Skin cleansingand local anesthetic is in filtrated in the skin and muscle. A 22-gauge, 10–12-cm needle is advanced until a paresthesia or nerve stimulator response is elicited or bone is contacted. If bone is encountered, the needle is redirected systematically in a lateral or medial direction. A 9 spinal needle can be used (6-8 cm. deep) Dosage = 20-30 ml. 1% lignocaine or prilocaine or 0.5% bupivacaine. vedio 1/4/2018 77 Lateral/Posterior Approaches…
- 78. Anterior Approaches ofsciatic nerve Supine position Identify inguinal ligament line. This line is divided in to three equal parts and a perpendicular dropped from the junction of the medial and middle thirds. The anterior approach requires a fairly long needle 1/4/2018 78
- 79. Anterior approach Aline is drawn then from the top of the grater trochanter parallel to the line of the inguinal ligament and the point where it meets the perpendicular is the point of needle insertion. This over lies the lesser trochanter on the inner aspect of the femur and at this level the sciatic nerve lies close behind the acetabulum and the lead of the femur. Vedio 1/4/2018 79
- 80. Side Effects/Complications Technicallydifficult to perform and can be quite painful. Hematoma formation is possible The risk of nerve damage is also reported Self limited persistent paresthesia A minimal degree of vasodilatation 1/4/2018 80
- 81. Sciatica Is aterm used to describe the symptoms of low back pain that spreads (radiates) through the hip, to the back of the thigh, and down the inside of back the leg via the sciatic nerve, characterized by pain, tingling, numbness, or weakness. Sciatica (sometimes known as radiculopathy) is a description of symptoms of inflammation or compression of the sciatic nerve , not a diagnosis. A herniated disc, spinal stenosis, degenerative disc disease, and spondylolisthesis, can all cause sciatica. 81
- 84. Symptoms of Sciatica Cramping sensation in the thigh Radiating pain from the buttock down the back of the leg Tingling in the legs Numbness in the legs Burning sensation in legs or thigh area Severe cases present with muscle weakness Literally a pain in the butt! Thursday, January 4, 2018 TAKE CARE OF YOUR LIFE 84
- 85. Symptoms of Sciatica… In Severe cases lower extremity weakness, numbness in the upper thighs, and/or loss of bladder or bowel control. Loss of knee flexion due to weakness of hamstring group of muscles.
- 88. Popliteal block Poplitealnerve block provides sciatic nerve anesthesia near the point where the sciatic nerve divides into its common peroneal and tibial nerve components in the popliteal fossa. 1/4/2018 88
- 89. Popliteal block Poplitealfossa block is preferable to ankle block for surgical procedures requiring the use of a calf tourniquet. The components of the sciatic nerve may be blocked at the level of the popliteal fossa through posterior or lateral approaches. Supplemental block of the saphenous nerve is required for surgical 1/4/2018 89
- 90. Technique of poplitealblock The patient positioned prone. However, access may also occur with the patient in the lateral (operative side nondependent) or supine (with leg flexed at the hip and knee) positions. The borders of the popliteal fossa are identified by flexing the knee joint. A triangle is constructed, with the base consisting of the skin crease behind the knee, and the two sides composed of the semimembranosus 1/4/2018 90
- 91. A bisectingline is drawn from the apex to the base of the triangle, and a 5-cm needle is inserted at a site 7–10 cm above the skin fold and 0.5–1 cm lateral to the bisecting line. The needle is advanced at a 45° angle until either a paresthesia or nerve stimulator response is elicited. Injection of approximately 30- mL of local anesthetic solution is sufficient. Success rate is typically 90– 95%. Identification of both tibial and peroneal components decreases onset time and improves success rate. vedio 1/4/2018 91
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- 93. Side Effects/Complications Neuropathyas with other block, is the most common complication. Intravascular injection may occur as a result of the presence of vascular structures within the popliteal fossa. 1/4/2018 93
- 94. Ankle block: anatomy 5 Nerves: 4 Sciatic branches: ◦ Deep peroneal ◦ Superficial peroneal ◦ Posterior tibial ◦ Sural nerve 1 Femoral branch: ◦ Saphenous nerve 1/4/2018 94
- 95. Nerves of footand ankle The ankle and the foot are innervated by five nerves. The Saphenous nerve, is a branch of the femoral nerve The Saphenous nerves provides sensory innervation to the medial aspect of the ankle and the foot. The remaining four, the tibial, sural, deep peroneal and superficial peroneal, are branches of the sciatic nerve. 1/4/2018 95
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- 98. Common peroneal nerve Before entering the longus muscle, the common peroneal nerve divides into the deep and superficial peroneal nerves. 1/4/2018 98
- 99. Common peroneal nerve The Deep Peroneal Nerve provide sensory innervation to the tarsal and metatarsal joint as well as the first interdigital space. The Superficial Peroneal Nerve: provides sensory innervation to the dorsum of the foot and toes. 1/4/2018 99 Deep Peroneal Nerve
- 100. Tibial nerve Thetibial nerve divides into the posterior tibial nerve and the sural nerve. 1/4/2018 100
- 101. Tibial nerve Thetibial nerve provides motor and sensory innervation to the heel and medial side of the foot below the territory innervated by the Saphenous nerve and above the sural nerve. The sural nerve provides sensory innervation to the lateral aspect of the foot above the territory innervated by the calcaneal nerve. 1/4/2018 101
- 102. Ankle block Thedeep peroneal, superficial peroneal, and saphenous nerves can be blocked through a single needle entry site. A line is drawn across the dorsum of the foot connecting the malleoli. 1/4/2018 102
- 103. Deep peroneal, superficialperoneal and saphenous nerve block The extensor hallucis longus tendon is identified by having the patient dorsiflex the big toe. The anterior tibial artery lies between this structure and the tendon of the extensor digitorum longus muscle and is palpable at this level. 1/4/2018 103
- 104. Deep peroneal nerveblock A skin wheal is raised just lateral to the pulsation between the two tendons on the intermalleolar line. A 25-gauge, 3-cm needle is advanced perpendicular to skin entry site, and 3–5 mL of local anesthetic injected deep to the extensor retinaculum to block the deep peroneal nerve. This technique anesthetizes the skin between the first and second toes and the short extensors of the toes. 1/4/2018 104
- 105. Superficial peroneal and saphenousnerve block The needle is now directed laterally through the same skin wheal while injecting 3–5 mL of solution subcutaneously, thus blocking the superficial peroneal nerve and resulting in anesthesia of the dorsum of the foot, excluding the first interdigital cleft. The same maneuver can now be performed in the medial direction, thereby anesthetizing the saphenous nerve, a terminal branch of the femoral nerve that supplies a strip along the medial aspect of the foot. nerve block vedioankle 1/4/2018 105
- 106. Sural Nerve Itis located superficially between the lateral malleolus and the Achilles tendon. A 25-gauge, 3-cm needle is inserted lateral to the tendon and is directed toward the malleolus as 5– 10 mL of solution is injected subcutaneously. This block provides anesthesia of the lateral foot and the lateral aspects of the proximal sole of the 1/4/2018 106
- 107. Regional anesthesia inchildren 1/4/2018 107
- 108. Advantages Intra &postoperative prolonged pain relief. Regional anesthesia suppress undesirable reflex such as laryngospasm. Spontaneously breathing patient decrease physiologic dead space. Earlier ambulation & discharge from hospital. Modify stress response. For G. A contraindicated patient i.e., chronic respiratory disease.1/4/2018 108
- 109. Disadvantages Require extratime to perform the block. The need of G.A to perform the block- one may risk the child to possible complications of both G.A & L.A 1/4/2018 109
- 110. Anatomic & physiologicconsideration The tip of the canal cord is at L-3 at birth & L1- L2 at one Year. Infants weighing 15 kg have relatively high volume of CSF 4ml/kg body weight, compared with adult values of 2ml/kg body weight. The content of epidural space have spongy gelatinous lobules with distinct spaces permitting the wide longitudinal spread of injected solution. The more extensive spread of caudal injection in children is attributed to the lower density of their epidural fat. 1/4/2018 110
- 111. Caudal block Itcan be used analgesia for surgery up to and including the umbilicus. A short bevel 21-gauge needle. 0.25 % bupivacaine o.5 ml/kg for lumbo sacral procedure. 1ml/kg for thoracolumbar procedure. 1.25 ml/kg for mid thoracic procedure. Lidocaine 1% may be used instead of .25% bupivacaine 1/4/2018 111
- 112. Epidural block Generalanesthesia is almost always required. Children have narrow epidural space. The distance between the epidural space & skin depend on the age of the child. Resistance to air technique is used. Tuohy needle. Dose- 0.5% bupivacaine 0.25 - .5 ml/kg for subsequent tip up. 1/4/2018 112
- 113. Spinal block Performedbelow L3 Lateral position, to avoid neck flexion & hypoxia. A small gauge, 3.5cm. styleted lumbar puncture needle. Mid line approach preferred. 1/4/2018 113
Editor's Notes
- #82 Sciatica may also occur during pregnancy as a result of the weight of the fetus pressing on the sciatic nerve during sitting or during leg spasms. An infection in the spine An injury to the spine, or the surrounding muscles and ligaments A growth within the spine, such as a tumour
- #85 Risk factors - age,,ocupation ,,obesity,,diabetus,,prolonged sitting,,