LOWER LIMB NERVE

BLOCKS

Presented By:
Dr. Muhammad Asim

INTRODUCTION
American surgeons Halsted and Hall described the
injection of cocaine into peripheral sites in 1880s.
Peripheral blockade remains a well accepted
component of comprehensive anesthetic care.
Its role has expanded from the operating suite into the
arena of the post-op and chronic pain management.

 Lower limb blocks are safe and have certain advanatages

Post-op pain relief.
Lack of complete sympathectomy.
They are less popular than upper limb blocks because
Wide spread acceptance and safety of central
neuraxial blockade
Unlike the brachial plexus, nerves supplying the
lower extremity are not anatomically clustered
where they can be blocked.
Technically more difficult and require more
training and practice.

Lower extremity nerve blocks can be divided into:

A)Lumbar Plexus Nerve Blocks:
1. Femoral N. block
2. Obturator N. block
3. Lateral Femoral Cutaneous N. block
4. 3 in 1 block (Inguinal Paravascular Block)
B) Sacral Plexus Nerve Blocks:
1. Sciatic N. Block
2. Popliteal N. Block
3. Ankle Block

ANATOMY OF LUMBAR PLEXUS

Formed by the ventral primary divisions of the first 4
lumbar nerve roots.
Situated in front of the transverse processes of the
lumbar vertebrae posterior to the Psoas major muscle.
Derivatives of this plexus are:

Ilio-hypogastric
Ilio-inguinal
Genito femoral
Lateral femoral cutaneous
Femoral
Obturator

LATERAL FEMORAL CUTANEOUS NERVE

BLOCK
Anatomy:
Arises from the dorsal divisions of second and third
lumbar nerves.
Emerges behind the Psoas major muscle while
lying on the Iliacus muscle crosses pelvis
reach anterior superior iliac spine passes under
the inguinal ligament to enter thigh.
Divides into 2 branches, which are distributed to the
anterior & lateral aspects of thigh as far as the knee.

LATERAL FEMORAL CUTANEOUS NERVE

BLOCK
Technique:
Supine position
Anterior Superior Iliac spine and inguinal ligament
identified.
Skin wheal is raised on the skin 2 to 3cms medial to the
iliac spine and just superior to the inguinal ligament.
2inch, 22guage needle is inserted perpendicular to skin
until contact is made with the iliac bone. 10ml of anesthetic
solution injected while the needle being advanced.

LATERAL FEMORAL CUTANEOUS NERVE

BLOCK
Needle is re-introduced 2-3cm medial to spine but 23cms inferior to inguinal ligament. 5-10ml of anesthetic
solution injected.
Indications:
1. In combination with other nerve blocks for surgery of
thigh.
2. Neuralgia of thigh.
3. Fascia Lata Pain syndrome

FEMORAL NERVE BLOCK

Anatomy:
Largest branch of lumbar plexus.
Arises from the dorsal portion of the anterior primary
divisions of the 2nd , 3rd & 4th lumbar nerves.
Descends through the psoas major emerge in its lateral
border passes along the pelvic wall on the iliacus
muscle reaches superior pubic ramus & crosses over
passes beneath the inguinal ligament divides into
anterior and posterior divisions.

FEMORAL NERVE BLOCK

It supplies:
Four parts of quadriceps femoris.
Skin of medial and anterior parts of thigh.
Skin of the front and medial side of the leg below
patella (Saphenous nerve)

FEMORAL NERVE BLOCK

Technique:
Mark the inguinal ligament.
Palpate the femoral artery about 2 to 3cms below the
ligament.
Insert a 22 gauge, 3 inch needle perpendicular to skin
until it is just lateral to femoral artery and elicit
paresthesias.
Inject 10ml of anesthetic solution.

FEMORAL NERVE BLOCK

Indications:
In combination with the Lateral Femoral cutaneous nerve
block, it provides anesthesia for many orthopaedic &
plastic surgical procedures.
Very useful in case of Burns, Split Thickness Grafting &
Other procedure as far down as the knee.
Paediatric practice for post-operative pain relief.

OBTURATOR NERVE BLOCK

Anatomy:
Arises from the ventral divisions of the 2nd , 3rd & 4th
lumbar nerves (chief contribution L3)
Descends through the psoas major muscle brim of
pelvis enters lesser pelvis along the lateral wall
reaches upper part of the obturator foramen
enters the thigh through obturator foramen.
It divides into two branches: Anterior & Posterior

OBTURATOR NERVE BLOCK

Anterior division supplies:
Adductor longus
Adductor brevis
Gracilis
Hip joint
Posterior division supplies:
Obturator externus
Adductor magnus
Adductor brevis
Knee joint

OBTURATOR NERVE BLOCK

Technique:
Supine position
Make a skin wheal at a point 2 cm lateral & 2 cm
inferior from pubic tubercle.
Insert a 22 gauge, 3 inch needle perpendicular and
advance until contact is made with bone (Inferior or
Horizontal ramus of pubic bone).
Withdraw the needle and redirect laterally so that the
needle slides off the pubis into the obturator foramen.
Aspirate and then inject 10 ml of anesthetic solution.

OBTURATOR NERVE BLOCK

Indications:
Painful hip joints.
Adductor muscle spasm especially in paraplegics.

THE INGUINAL PARAVASCULAR TECHNIQUE

OF LUMBAR PLEXUS ANESTHESIA (3 IN 1
BLOCK)
Introduction:
Blocking of three nerves Femoral, Obturator & Lateral
cutaneous with injection of local anesthetic into the
sheath of the femoral nerve in the thigh.
When these nerves emerge from the lumbar plexus,
they are sandwiched between the fascial covering of
Posteriorly

Quadratus lumborum

Anteriorly

Psoas major

THE INGUINAL PARAVASCULAR

TECHNIQUE OF LUMBAR PLEXUS
ANESTHESIA (3 IN 1 BLOCK)
The compartment continues with Femoral nerve and
extends below the inguinal ligament.
Just above the inguinal ligament, Femoral nerve lies in a
groove bounded
Medially
Posterolateraly

by Psoas Fascia

Anteriorly

by Transversalis Fascia

by Iliac Fascia

Hence drugs injected into the Femoral sheath will travel

upwards provided
Enough volume is given
Pressure is applied below the site of injection.

THE INGUINAL PARAVASCULAR TECHNIQUE

OF LUMBAR PLEXUS ANESTHESIA (3 IN 1
BLOCK)
Technique:
Supine position with anesthesiologist standing opposite the
site of operation.
Femoral artery palpated below the inguinal ligament and
retracted medially.
Immobile needle (a short bevel needle with translucent hub
connected by an extension tube to a syringe) inserted lateral
to Femoral artery and angulated cephalad.
The needle is advanced until paresthesia of the femoral
nerve obtained ( response is quadriceps contracture)

THE INGUINAL PARAVASCULAR

TECHNIQUE OF LUMBAR PLEXUS
ANESTHESIA (3 IN 1 BLOCK)
The finger palpating Femoral artery is removed and
placed firmly below the needle which facilitates cephalad
movement of anesthetic.
20 to 25 ml of anesthetic solution used.
Simultaneous block of lateral Femoral cutaneous nerve is
recommended.

THE INGUINAL PARAVASCULAR

TECHNIQUE OF LUMBAR PLEXUS
ANESTHESIA (3 IN 1 BLOCK)
Indication:
For operation on the thigh.
For management of fracture of Femur shaft.
For acute knee injuries (Along with sciatic N. block)
For knee arthroscopy.
Advantages:
One Injection used.
Less local anesthetic needed.
High success rate.