Transcript Femoral Nerve Block - Professor Dr Ghaleb

Lower Extremity Block
A.Ghaleb,M.D.
Associate professor
Medical director
Acute and chronic Pain management
Dept. of Anesthesiology
UAMS
Lumbar plexus
• The lumbar plexus is formed by the ventral rami of the first
three lumbar nerves and the greater part of the fourth
• Two major anastomosis involving the lumbar plexus
one with a branch of the last thoracic nerve
and another between the fourth and fifth lumbar nerves
give birth respectively to the :
Infracostal nerve
Lumbosacral trunk which contributes to the sacral plexus.
A.Ghaleb,M.D.
Lumbar plexus(T12,L1-4)
Lumbar plexus
**Ilioinguinal
**Iliohypogastric
**Genito femoral
**Lateral fem.cut.
Supply lat. Thigh + buttocks
**Obturator
**Femoral
Supply adductors ms.
Supply ant thigh+hip+knee
Saphenous
A.Ghaleb,M.D.
A.Ghaleb,M.D.
A.Ghaleb,M.D.
Plexus location
• 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. A.Ghaleb,M.D.
From skin to plexus
A.Ghaleb,M.D.
A.Ghaleb,M.D.
Blocked nerves
• Upper thigh Ilio-inguinal nerve,
•
Iliohypogastric nerve, Genitofemoral
nerve.
Lower limb Femoral nerve, Lateral
femoral cutaneous nerve, Obturator
nerve.
A.Ghaleb,M.D.
Frequency of anesthesia in the three
major nerves' territories
Femor Obtur
al
ator
nerve nerve
Lateral
femoral
cutaneous
nerve
Piffaut, 1996
(single injection)
100%
100%
96%
Rickwaert, 2000
(catheter)
97.5%
88%
92%
Indications Of L.P.B.
• Alone:
It can be used for hip or knee surgery
• Combined with a sciatic nerve block:
The lumbar plexus block can be used for
most surgeries involving the lower limb
Contraindications
• Vertebromeningeal infections.
• Lumbar vertebral trauma.
• Associated trauma or disorders making
lateral positioning impossible (Femoral
neck fracture is no contraindication to the
lateral position).
• Coagulation abnormalities,
• In patients exhibiting severe lumbar
scoliosis, the landmarks may be modified
The patient lays on the side opposite to the block (thigh flexion: 30°; knee flexion: 9
while the physician stands behind. An assistant facing the patient with hands on the
upper thorax and thigh will help maintain correct position and identify thigh
movements during neurostimulation.
Landmarks
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An 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
Puncture site
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The puncture site 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).
This site differs from the classic
one located at the junction of the
line passing through the posterior
superior iliac spine and the line
joining the top of the iliac crests.
Anatomical studies suggest that the
location of the classic site is in fact
too lateral. See the scanners above
where we can see the puncture site
and the anatomical cut .
Puncture
• A septic Technique
• The needle is introduced perpendicularly to the skin
• Stimulation intensity is adjusted between 1 and 2 ma for a 0.1-ms
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period of stimulation.
The needle is inserted slowly through the muscles until it reaches the
transverse process of L4. This contact is expected and provides a real
safeguard.
Anatomical studies have shown that the distance between the
posterior edge of the costal process and the lumbar plexus is 15-20
mm . The insertion depth of the needle is then noted. After adding 20
mm to the depth indicator, the needle is withdrawn and reoriented with
a 5° angle in cephalic or caudal direction, thus avoiding the transverse
process.
The needle is inserted more deeply (without exceeding the additional
20 mm) until the required stimulation of the femoral nerve (ascension
of the patella) can be observed. The intensity of the stimulation is then
gradually reduced until the motor response disappears (0.5 ma).
An aspiration test is then carried out to avoid vascular or spinal
injection.
Suitable responses
• Stimulation of Erector spinae or
Quadratus lumborum muscles:
This is a usual response to initial needle
insertion. Poorly defined contractions are
observed around the puncture site.
Progression must continue.
Stimulation of the femoral nerve:
Contraction of the Quadriceps femoris
muscle is noted. This is the ideal and
sought-after response
Unsuitable responses
• Stimulation of the obturator nerve: Contraction of the adductors, felt by
palpation of the internal portion of the thigh, reveals that the needle is
located too medially. The needle is withdrawn and reoriented laterally with a
5° angle.
• Stimulation causing thigh adduction and patella ascension. It may
correspond to a stimulation of nerve near the spinal canal. This reveals that
the needle is located too medially. The needle should then be withdrawn
and reoriented with a 5° angle laterally.
• Thigh flexion on the pelvis is caused by stimulation of a motor branch
to the Psoas major. Needle reorientation with a 5° angle toward cephalic
or caudal direction should allow for stimulation of the femoral nerve at
approximately the same depth.
• Sciatic nerve stimulation may happens if the puncture site is either too
caudal or too medial (stimulation of the lumbosacral trunk). The needle must
be reoriented with a 5° angle in both, cephalic and lateral direction
Vertical paravertebral opacity from L2 to L5.
Bundle-shaped, which parallels the Psoas major location
Complications
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Venous puncture:
The lumbar vein may be punctured. The needle is then located too medially and
must be reoriented with a 5° angle laterally.
Ureter puncture:
Needle tip is too deep.
Kidney puncture :
The needle is inserted too deep and too cephalic. Avoid puncture at the L3 level,
particularly on the right side.
Peritoneal 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
Intravascular injection:
Intravascular injection can be prevented with a proper test dose and divided
injections.
Fascia Iliaca Block
Identify
*ASIS
*Pubic tubercle
Connect & divide into thirds
Junction of lateral 1/3rd & medial 2/3rd
1 cm inferior to mark
Technique
• Insert the needle at right angles to the skin until two clearly
identifiable losses of resistance are felt, respectively at the
crossing of the fascia lata then the fascia iliaca
Single shot technique: inject the local anaesthetic through the
lumen of the needle according the usual safety rules, then
massage the swelling produced in order to favour the upward
spread of the local anaesthetic
Continuous infusion or iterative injection technique: when the
tip of the needle is below the fascia iliaca, remove the obturator
and introduce the catheter through the lumen in order to insert
2-3 cm of catheter at the inner aspect of the fascia iliaca. Set
the connecting device and interpose an antibacterial filter
before carefully dressing and fixing the catheter on the skin.
Ilio inguinal block
• ASIS
• 2 cm inferior, 2 cm medial
• perpendicular
• advance needle through skin
• discern a 'pop' or click as external oblique aponeurosis penetrated
• inject 5 - 7 ml LA to block iliohypogastric nerve
• advance needle a further 1 - 2 cm to penetrate softer resistance of
internal oblique muscle
• inject 5 - 7 ml LA to block ilioinguinal nerve
Femoral Nerve Block
provides sensory anesthesia of :
the anterior thigh
knee
medial aspect of the calf, ankle and foot
Indications
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foot and ankle surgery
femoral neck fractures
total hip arthroplasty
foot and ankle surgery
femoral shaft fractures
saphenous vein stripping
outpatient knee arthroscopy etc..
Contraindications
• prosthetic femoral artery graft
• dense sensory block could mask the
onset of lower extremity compartment
syndrome (e.g., fresh fractures of the
tibia and fibula)
The point of needle insertion is marked 1.5 cm
lateral and 1.5 cm distal to the intersection of
the inguinal ligament and the femoral artery
Techniques
• NERVE STIMULATOR
• PARESTHESIAE
• LOSS OF RESISTANCE lies below two facial
planes: the fascia lata and the fascia iliacus
• FIELD BLOCK
"Three-in-One" Block
• INGUINAL PARAVASCULAR THREE-IN-ONE BLOCK
• A single injection of large volume within the neural "sheath"
with the needle directed cephalad + pressure applied distal to
the femoral nerve sheath
• Block obturator and lateral femoral cutaneous nerves as well
as the femoral nerve
Sacral plexus ( L4-5,S1-2-3)
Sciatic
Common peroneal
Tibial
Supply medial foot
planter flexion
*Super. Peroneal
Supply ant foot
arround head of fibula
Sural
Tibial+ comm.per.
Deep peroneal
Supply web space 1st & 2nd toe
Dorsi flexion
Sciatic Nerve Block
• Anatomy
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The largest single nerve trunk of the body (a
diameter about as large as the thumb (16-20 mm).
It arises from the L4, L5, S1, S2, S3 spinal roots and
exits the pelvis posteriorly through the greater
sciatic foramen and runs laterally along the posterior
surface of the ischium anterior to the piriformis
muscle.
The posterior cutaneous nerve of the thigh
accompanies the sciatic nerve as it exits the greater
sciatic foramen. The sciatic nerve has medial and
lateral components which separate into the tibial and
the common peroneal nerves in the superior aspect
of the popliteal fossa.
Classic Posterior Approach
• lateral (Sim's) position, with the operative side
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nondependent. The operative extremity is flexed
45 degrees at the hip and 90 degrees at the
knee and rests against the dependent lower
extremity
The posterior superior iliac spine (PSIS), greater
trochanter, and sacral hiatus are identified and
marked
A line is drawn between the greater trochanter
and PSIS . This line is bisected. A perpendicular
is dropped 3-5 cm from the midpoint of this line
to the point of needle insertion.
Classic Posterior Approach
• The point of needle insertion should lie along a
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third line drawn between the greater trochanter
and the sacral hiatus .
6 inch nerve stimulator needle is advanced
perpendicular to the skin. The nerve lies about
6-8 cm deep
motor response . Plantar flexion (downgoing
toes) at less than 0.5 mA is the desired motor
response and indicates placement of the needle
near the medial part (tibial component) of the
nerve
Parasacral approch
• lateral recumbent position
• thigh slightly folded forming an angle of 135 •
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140° with the trunk.
The knee flexed at 90°.
A line is drawn between the postero-superior
iliac spine and the ischial tuberosity
puncture point is situated at 6 cm from the
postero-superior iliac spine following this
line
PROCEDURE
• The needle is inserted perpendicularly and
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progressed slowly,
at approximately 6 cm-8 cm a motor response is
obtained rarely more than 8 cm
A bone contact may be the sacral ala or the iliac
bone, superior and near the greater sciatic foramen.
In this case needle should be withdrawn and
reinserted inferior to the first point.
Moreover this bone contact can be used as a depth
test. Needle depth should be noted and it is
recommended not to go more than 2 cm beyond this
depth
Popliteal Block
• Prone position
• Tendons of biceps femoris (lateral) and
semitendinosus (medial)
• Popliteal crease
• Midpoint between tendons at a point 7 10 cm superior to popliteal crease .
Lateral popliteal
Anatomy
• In the mid thigh, the sciatic nerve more
superficial lies medial to the biceps
femoris
• It is also distant from the femoral
vessels
• The sciatic nerve is reached at a depth
averaging 6 cm
Position :
• The patient lies in supine. The ankle is posed
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on a pillow to raise the lower limb from the
table.
places one hand on the knee to move the leg
to zero rotation for better exposure. With
other hand insert the needle at the puncture
site
Landmarks : A line is drawn from the
posterior aspect of the great trochanter
towards the knee, parallel to the femur. The
puncture site is situated along this line, at
mid thigh, from the knee to the great
Pearls
• Anaesthetic injection after stimulation of the
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common peroneal nerve provides blockade of the
latter within 10-20 min followed by the blockade of
the tibial nerve being effective within 40-60 min.
Anaesthetic injection after stimulation of the tibial
nerve provides blockade of the two nerves in much
less time.
If no stimulation is obtained, it is recommended to
re-insert a centimetre above or below the initial
puncture site, instead of probing in vain.
Hamstring Contractions indicate that the needle is
beneath the sciatic nerve. Try and insert the needle
one centimetre above
Motor response
Stimulation of
tibial (plantar flexion +Inversion )
common peroneal (dorsiflexion + eversion)
Saphenous block
• Sartorious muscle on medial aspect of
thigh
• Grip muscle between index finger &
thumb at distal end of thigh. Midpoint
of muscle belly between fingers
Lateral Popliteal Block
• Lateral femoral condyle
• Groove between biceps femoris (posterior)
and vastus lateralis (anterior)
• Horizontal plane to contact femur (approx
5 cm)
• Re-direct needle posteriorly at 30° angle
Ankle Block
• medial malleolus Saphenous nerve
1cm anterior to malleolus, 1cm proximal to
inter-malleolus line (skin crease) 5ml LA
Tibial nerve Posterior to
posterior tibial artery Contact bone and
withdraw needle by 1mm 5ml LA
Hip
Lumbar plexus
Except
Ilio ing.
Ilio hypo
Best Psoas Block
Major thigh operation
L.F.C, Obturator
Femoral
Combined
Sciatic & psoas block
Sciatic
three in one +sciatic
Tourniquet pain
L.F.C
Femoral
Sciatic
Open Knee
L.F.C
Femoral
Obturator
Sciatic
Thigh operation
Combined
Sciatic
+ psoas block
Quadriceps Plasty
Patellar surgery
Femoral block
Distal to the Knee
Sciatic
popliteal
Saphenous