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Lower Extremity
Peripheral NerveBlock
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Lower ExtremityPeripheral Nerve Block
Lower Extremity Peripheral Nerve BlockTechniques Psoas compartment block
Femoral nerve block Lat Femoral cutaneous nerve block !aphenous nerve block Parasacral block !ciatic nerve block "nkle an# $oot block
Pharmacolo%ic &onsi#eration&omplications o$ Lower Extremity
Peripheral Nerve Blocks
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!ensory !upply "reas o$the Lumbosacral Plexus
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soas ompar menBlock'Lumbar plexus
block("nesthesia $or thi%h sur%ery) an# hip
$racture repair in combination with apara sacral nerve block
"nal%esia $ollowin% T*") T+" an# inthe treatment o$ chronic hip pain
&onsistent anesthesia in the#istributions o$ the $emoral)latcutaneous n o$ the thi%h) an# theobturator nn
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soas ompar menBlock'Lumbar plexus
block(
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Femoral Nerve Block
"nesthesia $or knee arthroscopy in
combination with intra,articular local
anesthesia"nal%esia $or $emoral sha$t $ractures)
ant cruciate li% reconstruction'"&L()
an# T+" in multimo#al re%imens
-,in,. block '$emoral) LF&) obturator n(
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Femoral Nerve Block
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Lateral Femoral&utaneous Nerve Block
"nesthesia #urin%
#ia%nostic muscle
biopsy an#
harvestin% o$ split
thickness skin
%ra$ts
Blin# /$an0technique with a
variable success
rate
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!aphenous Nerve Block
!upplies
the cutaneous
area o$ theme#ial aspect o$
the cal$ an# $oot
to the level o$the mi#$oot
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Parasacral Block 'P!NB(
1t has been use# to provi#e anal%esia$ollowin% ma2or $oot an# anklereconstruction
&onsistently block both components o$ thesciatic nerve an# the post cutaneous nerve o$the thi%h
The sympathetic n supply to the bla##er isalso in close promixity but problems withvoi#in% an# the nee# $or bla##ercatheteri3ation a$ter P!NB have not beenreporte#
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c a c erve oc the level o$ the 5luteus
6aximus
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!ub%luteal "pproachesto the !ciatic Nerve
!upine approach to the sciatic nerve in
the 7exe# hip position initiatin% the block
at the mi#point between the %reater
trochanter o$ the $emur an# the ischial
tuberosity
1#enti$yin% bony lan#marks in very obese
patients is sometimes #i8cult an# the
patient position requires a##itional
personnel to maintain
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c a c erve oc athe level o$ the Popliteal
Fossa
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"nkle an# Foot Block
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Pharmacolo%ic&onsi#erations
&omplete unilat blocka#e involves
multiple nerve blocks an# a lar%er
volume o$ local anesthetic solution
"ttention must be %iven to total local
anesthetic #ose
The concentration must also take intoaccount the #e%ree o$ sensory an#9or
motor block #esire#
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Epinephrine
Epi prolon%s the #uration an# quality o$
most local anesthetics use# $or lower
extremity peripheral block
:asoconstriction o$ the perineural vessels ;ecreases uptake an# increases the neural
exposure to the local anesthetics
Li#ocaine vs Ropivacaine
The #ecision to a## Epi an# the #ose o$ Epi &ar#iac or neural ischemia vs the ability to #iscern
an intravascular in2ection
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Epinephrine
The nearly equivalent e
vs >? 9ml) su%%est that the lowerconcentration is su8cient
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Bicarbonate
There was little reason to a## so#ium
bicarbonate with plain local anesthetics
or those with $reshly a##e# epinephrine
No #i@ bupivacaine
with alkalini3ation compare# to thosewho receive# a non,alkalini3e# solution
&omplications o$ Lower
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&omplications o$ LowerExtremity Peripheral Nerve
Blocks
!erious &x $ollowin% =.)=A PNBs in a >,
month perio#
ByAuroy et al. France
Per .?)??? PNBs) ?,=C #eath) ?-,4. car#iac arrests) ?>,4
neurolo%ic in2uries) an# -D,..= sei3ures
There is a paucity o$ reports o$ complications
specically associate# with lower extremityPNBs compare# to upper extremity PNBs Less common application rather than to inherent
sa$ety o$ the techniques
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Toxicity&omplications o$ Lower Extremity Peripheral
Nerve Blocks The apparent mar%in o$ sa$ety seems to vary
with in#ivi#ual block techniques The #i
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Toxicity&omplications o$ Lower Extremity Peripheral
Nerve Blocks Prevention
se o$ Epi as an intravascular marker
!low) metho#ical in2ection while avoi#in% hi%h,
in2ection pressure
Frequent aspiration
&onstant assessment o$ the pts an# vital si%ns
Pru#ent selection o$ local anesthetic
concentration an# volume
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Block(&omplications o$ Lower Extremity Peripheral
Nerve Blocks 1ntra$ascicular sprea# o$ the local anesthetic
proximally towar# the spinal cor#) resultin%
in central neuronal blocka#e
Nee#le placement at the level o$ the nerve roots orspinal nerves
Force$ul) $ast in2ections un#er hi%h pressure into
#ural cu
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&omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks !everal approaches $or PNBs o$ lower
extremity
Psoas compartment approach to the lumbar
plexus) the obturator nerve block) parasacral
an# classical approaches to the sciatic n
This block is less suitable in the settin% o$
anticoa%ulation as compare# to other)more sup$ lower extremity nerve blocks
1 $ ti & li ti
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1n$ectious &omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks
The inci#ence o$ bacterial complicationsassociate# with the use o$ continuous $emoralnerve blocks By Cuvillon et al.
1n their cohort o$ =? pts) >A@ ha# positive bacterialcoloni3ation o$ the catheter at 4 hrs postoperatively
There were no lon%,term sequelae relate# tothese positive catheter cultures
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&omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks ?4,.@ o$ all nerve block proce#ures
The symptoms o$ nerve in2ury a$ter PNB usuallymani$est shortly a$ter block resolution
1ntraneural in2ection is a well,knownmechansm o$ neurolo%ic in2ury associate#with PNBs There is no consensus on the techniques or metho#s
that can re#uce the risk o$ intraneural in2ection
6etho#s o$ nerve locali3ation 'ie) paresthesia vsnerve stimulation(
The a#vanta%es o$ short,bevel over sharper) lon%,bevel nee#les remain controversial
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&omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks Lancinatin% pain an# hi%h in2ection pr may
porten# intraneural in2ection o$ local
anesthetic) thus increasin% the potential $or
n in2ury Pain is not a reliable warnin% si%n o$ impen#in%
nerve in2ury
*i%h in2ection pr'G=? psi( with intraneural nee#le
placement lea# to nerve in2ury &linical perception o$ an abnormally hi%h resistance
an# pressure require# to in2ect is impossible to
veri$y
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&omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks Neuronal ischemia can occur $rom a variety
o$ sources ;isruption o$ the neuronal microvasculature
*i%h,en#oneurial pressures "##ition o$ vasoconstrictin% a%ents
Exo%enous compression $rom tourniquets
The potential $or neurotoxicity with a localanesthetics Function o$ its potency) concentration) the len%th
o$ exposure o$ the neuronal tissue to the a%ent
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&omplications&omplications o$ Lower Extremity Peripheral
Nerve Blocks Local anesthetics are use# in concentrations
that) un#er normal clinical con#itions) #o not
cause irreversible nerve #ama%e
Exposure o$ the en#oneurium to hi%h concentrationo$ local anesthetics
Hhile neurolo%ic &x o$ PNBs are uncommon)
they can an# #o occur even in the han#s o$
experience# practitioners an# may result insi%nicant pts su
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!ummary
Recent #evelopments in the el# o$ re%ional
anesthesia have lea# to an increase# interest in
lower extremity PNBs Transient neurolo%ic symptoms associate# with spinal
anesthesia 1ncrease# risk o$ epi#ural hematoma with the
intro#uction o$ new anti,thromboembolic prophylaxis
re%imens
Evi#ence o$ improve# rehabilitation outcome with
continuous lower extremity PNBs
!tan#ar#i3e# an# repro#ucible practice with
more clearly #ene# in#ications , both to
improve their clinical utility an# to re#uce the
risk o$ complications
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