Lower Extremity

Peripheral Nerve
Block
R4

Lower Extremity
Peripheral Nerve Block
Lower

Extremity Peripheral Nerve Block

Techniques

Psoas compartment block

Femoral nerve block
Lat. Femoral cutaneous nerve block
Saphenous nerve block
Parasacral block
Sciatic nerve block
Ankle and foot block

Pharmacologic

Consideration
Complications of Lower Extremity
Peripheral Nerve Blocks

Sensory Supply Areas of

the Lumbosacral Plexus

Psoas Compartment
Block(Lumbar plexus
block)
Anesthesia

for thigh surgery, and hip

fracture repair in combination with a
para sacral nerve block

Analgesia

following THA, TKA and in

the treatment of chronic hip pain.

Consistent

anesthesia in the
distributions of the femoral,
lat.cutaneous n. of the thigh, and the
obturator nn.

Psoas Compartment
Block(Lumbar plexus
block)

Femoral Nerve Block

Anesthesia for knee arthroscopy in

combination with intra-articular local
anesthesia

Analgesia for femoral shaft fractures,

ant. cruciate lig. reconstruction(ACL),
and TKA in multimodal regimens.

3-in-1 block (femoral, LFC, obturator n.)

Femoral Nerve Block

Lateral Femoral
Cutaneous Nerve Block

Anesthesia during
diagnostic muscle
biopsy and
harvesting of split
thickness skin
grafts.

Blind fan
technique with a
variable success
rate.

Saphenous Nerve Block

Supplies

the cutaneous
area of the
medial aspect of
the calf and foot
to the level of
the midfoot.

Parasacral Block (PSNB)

It

has been used to provide analgesia

following major foot and ankle
reconstruction.

Consistently block both components of the

sciatic nerve and the post. cutaneous nerve of
the thigh.

The sympathetic n. supply to the bladder is

also in close promixity but problems with
voiding and the need for bladder
catheterization after PSNB have not been
reported.

Sciatic Nerve Block: At

the level of the Gluteus
Maximus

Subgluteal Approaches
to the Sciatic Nerve

Supine approach to the sciatic nerve in

the flexed hip position initiating the block
at the midpoint between the greater
trochanter of the femur and the ischial
tuberosity.

Identifying bony landmarks in very obese

patients is sometimes difficult and the
patient position requires additional
personnel to maintain.

Sciatic Nerve Block at

the level of the Popliteal
Fossa

Ankle and Foot Block

Pharmacologic
Considerations

Complete unilat. blockade involves

multiple nerve blocks and a larger
volume of local anesthetic solution.

Attention must be given to total local

anesthetic dose.

The concentration must also take into

account the degree of sensory and/or
motor block desired.

Epinephrine

Epi. prolongs the duration and quality of

most local anesthetics used for lower
extremity peripheral block.

Vasoconstriction of the perineural vessels

Decreases uptake and increases the neural

exposure to the local anesthetics

Lidocaine vs Ropivacaine

The decision to add Epi. and the dose of Epi.

Cardiac or neural ischemia vs the ability to discern

an intravascular injection

Epinephrine

The nearly equivalent effects on block

quality and duration reported with Epi. 2.5
vs 5.0. /ml, suggest that the lower
concentration is sufficient.

Bicarbonate
There

was little reason to add sodium

bicarbonate with plain local anesthetics
or those with freshly added epinephrine.

No

difference in the onset or duration of

combined lumbar plexus-sciatic block in
pts. that received 0.5% bupivacaine
with alkalinization compared to those
who received a non-alkalinized solution.

Complications of Lower
Extremity Peripheral Nerve
Blocks
Serious Cx. following 21,278 PNBs in a 5month period

By Auroy et al. France

Per 10,000 PNBs,

0-2.6 death, 0.3-4.1 cardiac arrests, 0.5-4.8

neurologic injuries, and 3.9-11.2 seizures

There is a paucity of reports of complications

specifically associated with lower extremity
PNBs compared to upper extremity PNBs.

Less common application rather than to inherent

safety of the techniques.

Local Anesthetic Systemic

Toxicity
Complications of Lower Extremity Peripheral
Nerve Blocks

The apparent margin of safety seems to vary

with individual block techniques.

The difference in the anatomy, primarily in the

vascularity and presence of deep muscle beds in the
area of blockade

The severe toxic reactions typically occur during

the injection or immediately upon the injection.

An unintentional intravascular injection of local

anesthetic into the circulation, rather than absorption.
A forceful, rapid injection of local anesthetic carries a
much higher risk of local anesthetic toxicity than a slow,
gentle injection.

Local Anesthetic Systemic

Toxicity
Complications of Lower Extremity Peripheral
Nerve Blocks

Prevention

Use of Epi. as an intravascular marker

Slow, methodical injection while avoiding highinjection pressure

Frequent aspiration

Constant assessment of the pts. and vital signs

Prudent selection of local anesthetic

concentration and volume

Proximal Spread (Neuraxial

Block)
Complications of Lower Extremity Peripheral
Nerve Blocks

Intrafascicular spread of the local anesthetic

proximally toward the spinal cord, resulting
in central neuronal blockade.

Needle placement at the level of the nerve roots or

spinal nerves

Forceful, fast injections under high pressure into

dural cuffs or perineurium

Post. approach to the lumbar plexus have

the highest incidence of complications of the
lower extremity PNBs.

Hemorrhagic
Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

Several approaches for PNBs of lower

extremity.

Psoas compartment approach to the lumbar

plexus, the obturator nerve block, parasacral
and classical approaches to the sciatic n.

This block is less suitable in the setting of

anticoagulation as compared to other,
more supf. lower extremity nerve blocks.

Infectious Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

The incidence of bacterial complications

associated with the use of continuous femoral
nerve blocks.
By Cuvillon et al.

In their cohort of 208 pts, 57% had positive bacterial

colonization of the catheter at 48 hrs. postoperatively.

There were no long-term sequelae related to

these positive catheter cultures.

Neurologic
Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

0.4-18% of all nerve block procedures.

The symptoms of nerve injury after PNB usually

manifest shortly after block resolution.

Intraneural injection is a well-known

mechansm of neurologic injury associated
with PNBs.

There is no consensus on the techniques or methods

that can reduce the risk of intraneural injection.
Methods of nerve localization (i.e., paresthesia vs.
nerve stimulation)
The advantages of short-bevel over sharper, longbevel needles remain controversial.

Neurologic
Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

Lancinating pain and high injection pr. may

portend intraneural injection of local
anesthetic, thus increasing the potential for
n. injury.

Pain is not a reliable warning sign of impending

nerve injury.

High injection pr.(>20 psi) with intraneural needle

placement lead to nerve injury

Clinical perception of an abnormally high resistance

and pressure required to inject is impossible to
verify.

Neurologic
Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

Neuronal ischemia can occur from a variety

of sources.

Disruption of the neuronal microvasculature

High-endoneurial pressures

Addition of vasoconstricting agents

Exogenous compression from tourniquets

The potential for neurotoxicity with a local

anesthetics

Function of its potency, concentration, the length

of exposure of the neuronal tissue to the agent.

Neurologic
Complications
Complications of Lower Extremity Peripheral
Nerve Blocks

Local anesthetics are used in concentrations

that, under normal clinical conditions, do not
cause irreversible nerve damage.

Exposure of the endoneurium to high concentration

of local anesthetics

While neurologic Cx. of PNBs are uncommon,

they can and do occur even in the hands of
experienced practitioners and may result in
significant pts. suffering, distress to the
practitioner, and medico-legal consequences.

Summary

Recent developments in the field of regional

anesthesia have lead to an increased interest in
lower extremity PNBs.

Transient neurologic symptoms associated with spinal

anesthesia

Increased risk of epidural hematoma with the

introduction of new anti-thromboembolic prophylaxis
regimens

Evidence of improved rehabilitation outcome with

continuous lower extremity PNBs.

Standardized and reproducible practice with

more clearly defined indications - both to
improve their clinical utility and to reduce the
risk of complications.