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Lower Ext Blocks
Lower Extremity Nerve Blocks
| Question | Answer |
|---|---|
| Major nerve supply to lower extremities | Lumabar plexus and lumbarsacral plexus |
| What spinal nerve roots is the lumbar plexus derived from | Ventral rami of L1-L4 and occasional contribution from T12 and L5. Primarily L2-L4 |
| Three nerves originating from the lumbar plexus | Lateral Femoral cutaneous, femoral, obturator. Cephelad nerves are the iliohypogastric, ilioinguinal, and genitofemoral |
| Lumbosacral plexus forms from what spinal nerve roots? | L4-L5 and S1-S3 |
| What nerves originate from the lumbosacral plexus? | The sciatic nerve and the posterior cutaneous nerve of the thigh |
| What nerves arise from the sciatic nerve | The common peroneal and the tibeal nerves. |
| The femoral nerve comes from what spinal nerve roots? | L2-L4 |
| The obturator nerve comes from what spinal nerve roots? | L2-L4 |
| The sciatic nerve comes from what spinal nerve roots? | L4-S3 |
| The lateral femoral cutaneous nerve comes from what spinal nerve roots? | L1-L3 |
| The tibial nerve arises from what spinal nerve roots | Ventral branches of anterior rami of L4-5 and S1-3 |
| The peroneal nerve arises from what spinal nerve roots | Drosal branches of anterior rami of L4-5 and S1-3 |
| Lumbar plexus cutaneous and muscle innervation | Motor and sensory innervation to the anterior surface of the lower extremity and cutaneous sensory to the medial aspect of the lower leg |
| Femoral nerve block provides anesthesia to what areas? | Anterior thigh, knee, and a small portion of the medial foot. |
| Describe how landmarks are used to locat the injection site for a femoral nerve block. | A line is drawn from the anterior superior iliac spine to the superior lateral corner of the pubic tubercle. Palpate the mid point of this line until the femoral pulse is located. The insertion point is 2cm distal from line & 2cm lateral from pulsation. |
| What size needle for femoral block | 22 guage 2 inch needle |
| What twitch response will be elicited from the femoral | You should see a twitch of the quadriceps muscle, lifting the patella in a cephalad direction. A twitch of the sartorius muscle is not reliable because its nerve branches may be outside the femoral sheath. |
| No response to stimulating needle during femoral nerve block | The needle is too medial or too lateral. Usually r/t improper localization of femoral artery. Withdraw needle and reassess landmarks and insertion point. |
| Bone contact when performing a femoral nerve block. | The needle has been inserted too deeply and should be withdrawn and inserted in another direction. |
| Local twitch elicited during femoral nerve block stimulating needle. | R/T direct stimulation of the iliopsoas muscle or pectineus muscle. This indicates that the needle is inserted too deeply. Withdraw and redirect. |
| Sartorius muscle twitch during femoral nerve block. | Needle is inserted slightly anterior and medial to the main trunk of the femoral nerve, redirect needle laterally and advance deeper 1-3 mm. |
| Areas innervated by sciatic nerve | Sensation to posterior hip capsule, the knee, all the muscles distal to the knee and 90% of the sensory innervation below the knee (all but the medial component of the lower leg) |
| Indications for sciatic nerve block | BKA, ankle/foot surgery (along with saphenous nerve block if indicated), analgesia following foot surgery, to avoid hemodynamic consequences of BLE sympathectomy a/w neuraxial blockade. |
| Localization of needle insertion site for sciatic nerve block. | Line between posterior superior iliac spine and greater trochanter and sacral hiatus and greater trochanter. Line drawn from midpoint of upper line 5cm...should intersect lower line and is the insersion point. Needle inserted perpendicular to the skin. |
| Twitch response during sciatic nerve block that indicated correct needle placement. | Motor response in the distal ankle, foot, and toes |
| Size of neele for femoral nerve block | 21-22 guage 4 inch insulated needle |
| Injection of LA for sciatic nerve block | Inject 2-3 cc and witness the sttenuation of the twitch and thin inject the remainder of the LA in 5cc increments to a total of 20-25c. |
| Local twtich of gluteus muscle during sciatic nerve block. | Needle is too shallow...continue advancing |
| How to respond when during a sciatic nerve block the needle contacts bone but does not elicit local twitch of gluteus muscle | Needle is placed too superior near where the gluteus muscle attaches to the iliac bone. Stop and reassess landmarks. |
| Action to take when during sciatic nerve block needle encounters bone after eliciting sciatic twitches | Needle has missed the plane of the sciatic nerve and has been stopped by the hip joint of ischial bone. Withdraw needle and redirect medially or laterally by 5-10 degrees |
| Action to take during sciatic nerve block when needle is placed deep, no bone is contacted, and twitches were not elicited. | Needle has passe through the sciatic notch, indicating too inferior needle placement. Withdraw and redirect medially, laterally, or superiorly |
| Vascular puncture during sciatic nerve block | Not likely, however deep needle insertions should be avoided (pelvic vessels) |
| Nerve injury r/t sciatic nerve block | High incidence of nerve injury with this block. When stimulation is obtained with less than 0.2mAmps the needle should be withdrawn slightly to obtain the same response with a intensity of greater than 0.2mAmps |
| Popliteal block landmarks | Popliteal fossa crease, tendon of semitendinous muscle (medial), and tendon of biceps femoris muscle (lateral) |
| Needle insertion site for popliteal block | Midway between the tendon of the semitendinous muscle and tendon of the bicepts femoris muscle, 7 cm above to popliteal fossa. |
| Nerves blocked with popliteal block | Popliteal block, blocks the sciatic at its division into the tibial and common peroneal nerves |
| Area of lower extremity not blocked by popliteal block | The anteromedial aspect of lower leg is not blocked by a popliteal block as this portios is served by the saphenous vein, a division of the femoral nerve |
| What is the popliteal block used for? | It is used for postop analgesia for foot and ankle surgery |
| Common peroneal nerve motor movements | Eversion and dorsiflexion of the foot |
| Tibial nerve motor movements | Inversion and plantar flexion of the foot |
| Vascular puncture with popliteal block | Avoid medial redirection of the needle as the vascular bundle is located medially in the popliteal fossa |
| Five nerves blocked by an ankle block | Tibial nerve, Sural nerve, Superficial Peronial Nerve, Deep peroneal nerve, Saphenous nerve |
| Anatomy to locate injection site for deep peroneal nerve, needle size, and amount of LA | Groove formed by extensor hallicus longus and extensor digitorum longus tend @ IML. Remain lateral to anterior tibial art which is lateral to EHL. 25g needle, 5-8cc of LA advance perpindicular to skin until periosteom encountered & inject 5-8cc more LA |
| Superficial Peroneal Nerve Block | After deep peroneal nerve block is preformed, needle is pulled back to point just under skin and redirected laterally toward the lateral malleolus, as it is advanced, 5-8cc of LA is injected |
| Saphenous Nerve Block | Performed after the deep and superficial peroneal nerves are blocked. The needle is again withdrawn to point just under the skin and the needle is redirected toward the medial malleolus, as it is advanced, 5-8cc of LA are injected. |
| Tibial Nerve block | Identify tibial art posterior to medial malleolus & inject posterorlateral to the art pulse. If pulse can't be located inject posterior to medial malleolus. Make sure to aspirate r/t close proximity to art. Use 25 gauge needle & inject 5-8cc of LA. |
| Sural Nerve Block | Sural nerve is blocked by inserting a 25 gauge needle posterior to lateral malleolus and injecting 5-8cc of LA after aspirating. |
| Lower extremity digit block | Insert 1inch 25 gauge needle just lateral and medial to the base of the metatarsal. Start injecting just below the skin and gradually go deeper until you pass the metatarsal, injecting as you progress deeper. |
| IVRA for lower extrmity | For short procedures of LE of less than 45-60 minutes |
Created by:
mandyrosern
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