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2 Preface3 Review of the most important local anaesthetics4 General technical and safety aspects6 Systemic effects of local anaesthetic intoxication7 Postoperative analgesia with Naropin® polybag8 Care of peripheral nerve catheters for p. o. analgesia
Upper extremities10 Anatomy of the brachial plexus12 Sensory supply of the upper extremities13 Upper extremity motor response to nerve stimulation
14 Interscalene plexus block (acc. Meier)16 Infraclavicular plexus block (acc. Kilka, Geiger, Mehrkens)18 Infraclavicular plexus block, Raj technique (mod. by Borgeat)20 Suprascapular nerve block (acc. Meier)22 Axillary plexus block
24 Blocks in the upper arm region– Multi-stimulation technique (mid-humeral, acc. Dupré)
26 – Radial nerve
28 Blocks in the elbow region– Radial nerve– Musculocutaneous nerve
30 – Median nerve– Ulnar nerve
32 Block in the wrist region ("wrist block")– Median nerve– Ulnar nerve
34 – Radial nerve
Lower extremities36 Anatomy of the lumbosacral plexus40 Sensory supply of the lower extremities41 Sensory supply of the bony structure
Motor response to stimulus42 Psoas compartment block (acc. Chayen) 44 Femoral nerve block in the inguinal region (acc. Winnie, Rosenblatt)46 Obturator nerve block48 Transgluteal sciatic nerve block (acc. Labat)50 Subgluteal sciatic nerve block (acc. Raj)52 Proximal anterior/ventral sciatic nerve block (acc. Meier)54 Proximal lateral sciatic nerve block56 Distal lateral sciatic nerve block58 Distal posterior sciatic nerve block (acc. Meier)60 Saphenous nerve block62 Common peroneal nerve block64 Blocks for anaesthesia in the foot (ankle blocks)
– Superficial peroneal nerve66 – Deep peroneal nerve68 – Posterior tibial nerve
Contents
The development of anaesthesia is currently affected by the growing inter-est in regional anaesthesia and analgesia. In particular, there is anincreasing interest in peripheral nerve blocks, and in many clinics the useof this method is prefered to the central blocks whenever possible, thusbecoming increasingly more common. What is the reason of the growinginterest and what makes the greater educational and practical effortsinvolved in the use of regional blocks worthwhile?
First of all, it is the implementation of a perioperative anaesthesia andpostoperative analgesia concept. A block initiated preoperatively andused intraoperatively continued via a catheter to provide effective post-operative regional analgesia with a low risk of complications. This con-cept enables early mobilisation and quicker rehabilitation.
The effects of regional anaesthesia (mostly in the form of central neuraxialblocks) on various outcome parameters were demonstrated in the CORTRAmeta-analysis (Rodgers et al., BMJ 2000; 321:1493) based on the eval-uation of 141 clinical studies involving approximately 10,000 patients.Patient groups who underwent surgery under general anaesthesia werecompared to those who either received regional anaesthesia or combinedgeneral – regional anaesthesia. According to the results, regional anaes-thesia reduced postoperative complications and the over-all postoperativemortality rate by 30%. The authors concluded that the most likely reasonfor the reduction of postoperative complications was the decreased intra-operative stress response due to regional anaesthesia block.
Furthermore, we are well aware of the potential risk of severe pain devel-oping into a chronic pain condition, a situation that can and should beavoided. The most reliable way to prevent pain from becoming chroniccomprises regional anaesthesia techniques that block the pain stimulusnear its origin, both peri- and postoperatively, thereby eliminating acutepain as a special postoperative risk factor.
The continuing development of regional anaesthesia and analgesia isimportant when considering the aspects described above but there arealso ethical and economical points of view which call for a wider use ofregional anaesthesia. With this compendium of peripheral nerve blocks,we present a brief review of the most commonly used techniques. Therebywe hope to stimulate the interest and understanding among our colleaguesfor the use of regional anaesthesia techniques.
Preface
2
3
Special features:Ropivacaine ● Favourable effective dose/toxicity ratio
● Good differential block (analgesia >> motor block) at lower concentrations used for analgesia
Lidocaine ● Local anaesthetic with medium action time and low toxicityMepivacaine ● Effectiveness comparable to lidocaine, but less toxic and slightly longer
duration
Overview of the most important local anaesthetics for peripheral nerveblocks
Substance Concentration Dosage* Time until Analgesic Anaesthesia Anaesthesia effective action timeAnalgesia Analgesia
Ropivacaine 0.5% – 0.75% up to 300 mg 10 – 20 min 8 – 14 h
(Naropin) 0.2% – 0.375% up to 28 mg/h
Lidocaine 1% (– 2%) up to 600 mg 10 – 20 min 2 – 4 h– –
Mepivacaine 1% (– 2%) up to 300 mg 10 – 20 min 3 – 4 h– –
Anaesthetic Protein Distribution Eliminationpotency (ratio binding (%) volume (L) half-life (h)
to procaine = 1) in plasma
Ropivacaine 16 94 59 1.9
Lidocaine 4 64 91 1.6
Mepivacaine 4 77.5 84 1.9
* (manufacturers' recommendations)
Review of the most important local anaesthetics
Action time ofregional anaesthetics:
Intraoperative andpostoperative anal-gesia
* Start infusion before onset of post operativepain; otherwise start with an initial bolus.
lidocaine 1%
lidocaine 1% + ropivacaine 0.75%
ropivacaine 0.75%
*ropivacaine 0.2% (– 0.375%)
2 4 6 8 10 12 14 hours
4
General technical aspects on peripheral nerve blocks
● Use aseptic technique.
● Resuscitation equipment and drugs should always be available when regional anaesthesia is used.
● Local cutaneous infiltration anaesthesia.
● Skin incision with a lancet before insertion of a short-beveled needle (e. g. 45° bevel).
● Nerve stimulation: Ascending from 0.1 – 1.0 mA, until visible muscle contractions in the corresponding innervation area; then reduction to between 0.3 – 0.5 mA/0.1 ms before injection of the local anaesthetic.
● Repeated aspiration attempts before and during injection of the local anaesthetic. A negative aspiration test does not completely exclude an intravascular needle position.
● With larger doses of a local anaesthetic, use fractional injection and verbal patient monitoring for early recognition of accidental intravas-cular injection.
● In poorly cooperative patients, patients under sedation or when performing a block distal to an established central block (e. g. femoral nerve block in the presence of spinal anaesthesia) a nerve stimulator and unipolar needle should be used (no neuromuscular relaxation!). Exception: Infiltration anaesthesia of purely sensory nerves.
● Catheter technique: Placement of the catheter tip 3 – 5 cm beyond the tip of the introducing needle, to be inserted normally after injecting the loading dose of the local anaesthetic.
● Monitoring: When performing blocks in the head and neck area and when larger doses of local anaesthetic are used the patient should have an i.v. cannula, ECG and pulse oximetry applied before the block. Standard monitoring includes ECG, pulse oximetry, blood pres-sure and the degree of consciousness.
● Catheter: Daily control of the catheter insertion site, written documen-tation (see p. 9).
General technical and safety aspects
Side effects, complications/contraindications (general)
Side effects and complications● Systemic toxicity of the local anaesthetic
Most common reason: Unintended intravascular injectionMinimize risk by
– Adhering to the recommended dosages– Repeated aspiration and fractional injection– Slow injection, observe and maintain verbal contact with the
patient (NB: negative aspiration does not entirely exclude intravascular injection!)
● Nerve damage (extremely rare)Minimize risk by
– Trying to avoid paresthesias when inserting the needle– Correct use of a suitable nerve stimulator (≥ 0.3 – 0.5 mA/
0.1 ms)– The use of atraumatic needles
● HematomaMinimize risk by
– No blocks in the presence of a clinically manifest coagulation disorder or anticoagulation treatment
● Infection (especially when using continuous techniques)Minimize risk by
– Aseptic needle insertion– Regular planned checks of the catheter insertion site (at least
once a day)– Most sensitive indicator: Tenderness at the point of catheter
entry (requires immediate removal of the catheter)
General contraindications to regional anaesthesia
● Rejection of the technique by the patient● Clinically manifest coagulation disorders● Infection or hematoma at the injection site● Relative contraindication: Neurological deficits (previous documen-
tation necessary)
5
General technical and safety aspects
6
Systemic effects of local anaesthetic intoxication
Coma
Seizures
Muscular twitching
Confusion
Visual disurbances
Verbal/vocalization problems
Hyperacusis, tinnitus
Circumoral tingling,
Lightheadedness
Time
Dose
Symptoms and signs of local anaesthetic intoxication
CNS symptoms
Cardio-vascular
symptoms
Treatment of local anaesthetic intoxication
Apnoea
Circulatory collapse/Cardiac arrest
Ventricular fibrillation
Ventricular arrhythmia
QT-prolongation
Hypotension
Bradycardia
QRS-widening
Temporary hypertension
Tachycardia
Stop LA injection,Give oxygen,
Support ventilation,Avoid acidosis
Increasing CNS symptoms:Stop seizures
with penthothal, propofolor benzodiazepine.If poor response:
rapid acting muscle relaxant,intubate to control ventilation.
Cardiac symptoms:Circulatory support
(Noradrenaline,alternatively amiodarone or amrinone).
If persistent arrhythmia: electro-conversion,CPR as long as needed.
Allergy for amide local anaesthetics is extremely rare and should be treated like any allergic reaction.
A relative small dose of local anaesthetic, if accidentally injected intravasculary, maylead directly to seizures with both respiratory and cardiovascular problems, dependingon drug and patient conditions.
7
Postoperative analgesia with Naropin® Polybag
Naropin® 2 mg/ml, 200 ml Polybaganalgesically effective concentrations
*Real volume of Naropin® mlin 200 ml Polybag additional total total concentrations
is 210 ml volume mg volume ml* mg/ml
Reduce 80 420 290 1,4
concentration 60 420 270 1,6
by dilution 40 420 250 1,7
with NaCl 0.9 % 20 420 230 1,8
Polybag standard 420 210 2
Increase 10 520 220 2,4
concentration 20 620 230 2,7
by adding 40 820 250 3,3
Naropin® 10 mg/ml 60 1020 270 3,8
Mobile pump system (CADD-Legacy PCA)for administration of Naropin® Polybag
Pump and Polybag in a carrier bag formobile patient use
Check-up rounds
● At least once a day– Check catheter insertion site– Assess effectiveness– Analyse indications critically– Careful documentation (see p. 9)
● In case of insufficient effectiveness– Catheter positioned correctly? Dislocated?– In case of partial effectiveness: Injection of a bolus
(e. g. 20 ml ropivacaine 0.75%)– Supplemental analgesics (NSAID, opiods orally) as needed– Additional pain medication when removing catheter
● Duration of treatment– Up to 4 – 5 days – depending on the indication. (For chronic
pain therapy a duration of more than 100 days has been described.)
– Analgesic catheter can be used in out-patients, but the corre-sponding prerequisites must be considered
Requirements for a nerve stimulator (acc. to Kaiser)Electrical layout:
– Adjustable constant current in the presence of a load of 0.5 – 10 kOhm
– Monophasic square output impulse– Selectable impulse width (0.1 – 1.0 ms)– Impulse amplitude (0 – 5.0 mA) with precision adjustment and
digital display of the actual current– Impulse frequency 1 – 2 Hz
Safety device:– Alarm upon interruption of circuit– Alarm when the max. impedance is exceeded– Alarm when an error occurs inside the device– Unmistakable assignment of outputs– Adequate operating instructions for use, indicating the deviations
tolerated
Care of peripheral nerve catheters for p. o. analgesia in the medical ward
8
9
Care of peripheral nerve catheters for p. o. analgesia in the medical wardward
Documentation example
A + B: Sectional plane in the infraclavicular and axillary region. Please note the positionof the cords.
B
B
A
A
a
C4
C5
C6
C7
C4
C5
C6
C7
Th 1Th 1
C8
d1
2
3
4
5
6 87
910
11
12
ef
bc
Anatomy of the brachial plexus
a superior trunk (rami ventrales C5 and C6)
b middle trunk(ramus ventralis C7)
c inferior trunk(rami ventrales C8 and Th1)
d lateral corde posterior cordf medial cord
1 suprascapular n.2 musculocutaneous n.3 axillary n.4 radial n.5 median n.6 ulnar n.
7 medial antebrachial cutaneous n.8 medial brachial cutaneous n.9 intercostobrachial n.
10 intercostal n. I11 intercostal n. II12 long thoracic n.
10
The brachial plexus is formed by the ventral rami of the C5 to Th1 (variably C4 and Th2) spinal nerves
Anaesthesia techniques for blockade of the upper extremities
● Interscalene brachial plexus block (interscalene block, ISB) acc.to Meier
● Vertical infraclavicular plexus block (vertical infraclavicular block, VIB)● Suprascapular nerve block● Axillary plexus block● Blocks in the upper arm region (mid-humeral approach, radial n.)● Blocks in the region of the elbow (radial, musculocutaneous,
median, ulnar nerves)● Blocks in the wrist region (radial, median, ulnar nerves)
11
Upper extremities
Sensory supply
12
Sensorysupply of theupper extremities
1 supraclavicular n.2 axillary n.
(lat. cut. brachial)3 intercosto-
brachial n.4 medial brachial
cutaneous n.5 antebrachial
cutaneous dorsal n.(radial n.)
6 medial antebrachialcutaneous n.
7 lateral antebrachialcutaneous n. (musculocutaneous n.)
8 radial n.9 ulnar n.
10 median n.
1C3
C4
C5 C5
C4
C6
C7C7
C8 C8
T1
T1
T2
T2
C6
C6
1
2 23
4
5
10
10
9 9
8
8
7 76 6
13
Upper extremity motor response to nerve stimulation
a
b
d
c
Motor functions of the peripheral nerves in the upper extremities
a radial n.: stretching elbow and fingersb median n.: flexion of the fingers c ulnar n.: flexion of the forth and fifth fingers with opposition of the first fingerd musculocutaneous n.: flexion (and supination) of the forearm
14
Side effects, complications: Horner s., ipsilateral phrenic block, recurrent block
Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropiva-caine 0.75% Continuous: Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5mg/h bolus (alternatively): 10 – 20 ml ropivacaine 0.2 – 0.375%(approx. every 6 hours)Needle: Single shot: Short-bevel unipolar 22 G x 4 – 6 cm needleContinuous: E. g. 19.5 G x 6 cm (Plexolong B-Set®, Pajunk co., or Contiplex D®, B. Braun)with a 20 G catheter (advance catheter 4 cm beyond the tip of the cannula).
Patient position and method:Patient supine
Guiding structures: Lateral border of the sternocleidomastoid m., interscalenus grooveThe insertion site is at the level of the thyroid notch (approx. 2 cm abovethe level of the cricoid cartilage) at the posterior edge of the sternocleido-mastoid muscle. The direction of insertion is along the interscalene groove(in a caudal and lateral direction) at an angle of approx. 30° to the skin.Stimulus response: Deltoid m., biceps m. Injection of the local anaestheticwhen an adequate stimulus response of 0.3 mA/0.1 ms is reached.
Comments on the technique:● The aiming point is in the middle third of the clavicula● The subclavian a. marks the caudal end of the interscalene groove.
It can be identified by palpation or with the aid of a vascular doppler.Notice the difference to the classical interscalene approach acc. to Winnie;the puncture site is 1 to 2 cm above (cranial) the puncture site of Winnies interscaleneblock, the direction of the needle is lateral in contrast to Winnies technique (medial, dor-sal, caudal). You will come in contact with the plexus at easily a more tangential anglein contrast to the classical approach, where the needle approaches the plexus at a rightangle. Meier’s approach is suitable for continuous catheter techniques.
Indications:● Anaesthesia and analgesia of the shoulder
and/or of the proximal upper arm region● Mobilisation (e. g. frozen shoulder)● Physiotherapy in the shoulder region
(e. g. postoperative, following mobilisation)● Therapy for pain syndromes● Sympathicolysis
Special contraindications:● Contralateral phrenic paresis● Contralateral recurrent paresis● COPD (relative)
Interscalene plexus block(acc. to Meier)
15
a sternocleidomastoidm.
b interscalene groovec subclavian a.d cricoid cartilage
1 sternocleidomastoid m.
2 phrenic n.3 middle scalene m.4 brachial plexus
(supraclavicular part)5 anterior scalene m.6 omohyoid m.7 brachial plexus
(infraclavicular part)8 subclavian a.9 external jugular v.
10 internal jugular v.11 cricoid cartilage
The direction of insertion is caudally and laterally along the interscalene groove, 30° angle to the skin.
1
34 5 6
11 10 9
d
a b
c
2
7
8
16
Side effects, complications: Horner syndrome, pneumothorax, intravascular injection.
Local anaesthetics:Initial:30 – 40 ml lidocaine 1% or mepivacaine 1% or30 ml ropivacaine 0.75%Continuous:Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/hBolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours)Needles: Single shot: Short-bevel 22 G x 4 – max. 6 cm. Continuous: E. g. Contiplex D® 18 G x 5.5 cm (B. Braun) alternatively Plexolong A® 19.5 G x 5cm with catheter (Pajunk co.). The catheter is advanced 3 – 4 cm beyond the tip of the cannula.
Patient position: Patient supineJugular notch, ventral acromial process of the scapula.
Guiding structures:The distance between the jugular notch and the ventral acromial processis bisected. The insertion site must be directly under the clavicula andtake place in a strictly vertical direction. The plexus is reached afterapprox. 3 cm (max. 5 cm!). Flexion of the fingers at 0.3 mA/0.1 msform the desired stimulus response.
Comments on the technique:Risk of pneumothorax Therefore, make absolutely sure to avoid:● Insertions too far medially● Deviation from the sagittal (plumb bob) direction of insertion● Advancing the needle > 6 cmWhen the index finger is placed to have contact with the coracoid process laterally and the clavicle cranially (“Mohrenheim`s fossa”) themedial border of the finger marks the injection point/”finger point”.Always perform this block using a nerve stimulator. A stimulus responseonly in the biceps m. yields poor results. Pull back the needle to a s.c. position, shift it slightly laterally and advance it again in a strictly sagittaldirection. In comparison with the Raj/Borgeat technique (ref. to this) thistechnique does not require abduction of the arm.
Indications and contraindications:see infraclavicular plexus block, Raj technique (mod. by Borgeat)
Infraclavicular plexus blockVIB (= vertical infraclavicular block)
(acc. to Kilka, Geiger and Mehrkens)
1
3
4
5
6
7
8
2
17
a jugular notchb ventral acromial
processc 1/2 distance
from a – bd “finger point”e coracoid process
1 major pectoral m.2 subclavian a.3 pectoral n.4 medial cord5 posterior cord6 lateral cord7 deltoid m.8 suprascapular n.
Strictly vertical needle insertion (perpendicular to the underlying surface)
a
de
b
c
Side effects, complications: intravascular injection, pneumothorax
Local anaesthetics: Initial:30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine0.75% Continuous:Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/h bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)Needle: Single shot: unipolar 22 G x 6 – 10 cm needleContinuous: E. g. 19.5 G x 10 cm Plexolong with catheter (Pajunk co.). The catheter isadvanced 3 – 4 cm beyond the tip of the cannula.
Patient position: Patient supine.
Guiding structures:Jugular notch, ventral acromial process of the scapula. The needle inser-tion site is located halfway between the anterior tip of the acromion andthe jugular notch approx. 1 cm below the clavicle. For injection, the armis abducted 90° and elevated 30°. The needle is directed laterally at anangle of approx. 45° – 60° towards the most proximal point at which theaxillary artery can still be palpated in the axilla.
Comments on the technique:The risk of pneumothorax is low because of the lateral direction of theneedle. Intravascular injection (usually venous, cephalic vein) has beenobserved. Between 3 – 8 cm there should be a motor response in thehand or fingers. Because of the tangential approach to the plexus, acatheter can be advanced readily.
Indications:● Anaesthesia and analgesia for surgery
of the upper arm, lower arm and hand● Treatment of pain syndromes● Analgesia for physiotherapeutic
treatment● Sympathicolysis
Contraindications:● Thorax deformity● Dislocated healed clavicular fracture● Foreign bodies in the area of inser-
tion (e.g. pacemaker, port etc.)● Untreated coagulation disorder
Infraclavicular plexus blockRaj technique (mod. by Borgeat)
18
1
3 4
5
6
2
19
a axillary a.,anatomical land-mark for establishingthe needle insertion
1 suprascapular n.2 deltoid m.3 brachial pl.4 pectoral n.5 subclavian a.6 major pectoral m.
Needle insertion site according to VIB anatomical landmarks (p. 16), direction towards the most proximal point of theaxillary a., approx.45° – 60° angle.
20
Side effects: Nothing specific
Local anaesthetics:Initial:10 – 15 ml lidocaine 1% or mepivacaine 1 % or ropivacaine 0.75%Continuous:Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/hbolus (alternatively): 10 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needles: Single shot: Unipolar needle 22 G x 6 – max. 8 cm long. Continuous: E. g. Plexolong B® 19.5 G x 6 cm (Pajunk co.) or Contiplex (B. Braun). Thecatheter is advanced approximately 3 cm beyond the tip of the cannula.
Patient position:The patient is sitting.
Guiding structures: Scapular spine, posterior portion of the acromion, medial end of the sca-pular spine. The midpoint of the line between the lateral posterior portionof the acromion and the medial end of the scapular spine is marked. Theinsertion site is 2 cm cranial (above) and 2 cm medial of this point. Theunipolar needle is advanced 3 – 5 cm laterocaudally and only slightlyventrally at an angle of approx. 30° (in the direction of the head of thehumerus) until a correct needle position is indicated by a stimulus re-sponse in the infra- or the supraspinous muscles, or until the needleshows a pain-free "knocking" sensation in the shoulder after 3 – 5 cm.
Comments on the technique:There is no risk of pneumothorax if these guidelines are followed.Aspiration is necessary in order to avoid intravascular injection (supra-scapular artery, extremely rare). The method can also be performed with-out nerve stimulation (bone contact) and be used with a continuous tech-nique.
Indications:● Diagnostic: Shoulder pain of unclear origin● Anaesthesia: Incomplete interscalene
plexus block● Pain therapy: Adhesive capsulitis
(frozen shoulder), arthritis, rupture of the rotator cuff, etc.
Special contraindications:None
Suprascapular nerve block(acc. to Meier)
a middle point of the scapular spine
b needle insertion site:2 cm medial 2 cm cranial to themiddle point
1 supraspinatus m.2 infraspinatus m.3 trapezius m.4 suprascapular a.5 transverse scapular
ligament6 suprascapular n.7 articular branches of
the suprascapular n.8 deltoid m.
Direction of needle:Laterocaudal,approx. 30° angle
1
34 5 6 7
8
2
b
a
21
22
Side effects: No special ones
Local anaesthetics:Initial:30 – 50 ml lidocaine 1% or mepivacaine 1% or40 ml ropivacaine 0.75%Continuous:Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/hBolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needles: Single shot and/or continuous: Short-beveled needle through a plastic cannula(e. g. 18 G, 45° bevel, Pajunk co. or B. Braun). A flexible catheter can well be insertedthrough the 18 G cannula. The catheter is advanced 5 cm beyond the tip of the needle.Alternatively: Single shot unipolar needle 22 G x 4 cm.
Patient position:Patient supine, arm abducted 90°, externally rotated, elbow flexedapprox. 90°.
Guiding structures:Axillary artery, coracobrachial muscle.Palpate the gap between the axillary a. and the coracobrachial m.Following pre-puncture of the skin, advance the needle parallel to andabove the artery in a proximal direction at an angle of 30° – 45° to theskin ("click phenomenon" entering neurovascular sheath). Lower the distalend of the needle and advance it further. Check position with a nerve sti-mulator (not compulsary with this technique, but recommended).
Comments on the technique:A low-risk technique that can be performed without a nerve stimulator: A"click" as the neurovascular sheath is penetrated and easy advancementof the short bevel needle with cannula indicates a correct needle position.Not infrequently, anaesthesia in the radial nerve’s area of distribution isinsufficient. Supplementary selective block may be needed (see below).
Indications:● Operations in the arm (distal upper
arm, lower arm, hand)● (Continuous) analgesia● Physiotherapy● Pain syndrome● Sympathicolysis
Special contraindications:None
Axillary plexus block
23
1
2
3 4 5 6
8
7
a coracobrachial m.b axillary a.
1 coracobrachial m.2 radial n.3 medial antebrachial
cutaneous n.4 ulnar n.5 brachial a.6 median n.7 musculocutaneous n.8 major pectoral m.
Direction of insertion: medially,above and parallel to the artery,30° – 45° angle to the skin.
a
b
24
Side effects: No special ones
Local anaesthetics:E. g. 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%for each individual nerve block
Needle: Unipolar, shortbevel 22 G x 4 – 6 cm
Patient position:Patient supine, arm abducted approx. 80°, stretched out, externally rotat-ed.
Guiding structures: Junction of the proximal and middle thirds of the upper arm, brachialartery.Find the brachial artery in the medial aspect of the junction of the proxi-mal and middle thirds of the upper arm. Insert the needle between thetwo palpating fingers just above the brachial artery, and advance it pro-ximally until a response of the median nerve is obtained. Following injection of the local anaesthetic, the needle is withdrawn to asubcutaneous position before the next nerve is located. Then advance itperpendicular to the underlying surface (operating table, floor) medial(below) the artery until a stimulus response of the ulnar nerve is found.Next, block the radial nerve by redirecting the needle toward the lower(posterior) edge of the underlying humerus. The musculocutaneous n. isblocked after advancing the needle horizontally under the biceps muscleuntil adequate stimulation response. It is recommended to raise the bellyof the biceps muscle slightly during the block of the musculocutaneous n..
Comments on the technique:Not suited for continuous blocks, time-consuming, generally needs anerve stimulator. Short onset, but relatively frequent problems with thetourniquet. Well suited for selective supplementary block of individualnerves with an incomplete brachial plexus block.
Blocks in the upper arm Multi-stimulation technique(mid-humeral technique acc. Dupré)
Indications:Anaesthesia of the distal arm, elbow andhand
Special contraindications:None
25
a: Needle insertion for median nerve block
c: Needle insertion for radial nerve block
1 musculocutaneous n.2 median n.3 ulnar n.4 radial n.
All individual blocksperformed via onesingle skin puncture.
b: Needle insertion for ulnar nerve block
d: Needle insertion for musculo-cutaneous nerve block
2
3
4
1
26
Local anaesthetics:Initial:10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: Unipolar 22 G x 4 – 6 cm
Patient position:Patient supine.
Guiding structures: Middle upper arm.The arm is lying abducted and externally rotated (arm support). Insert theneedle in the space between the flexor muscles and the triceps muscleson the medial side of the upper arm and direct it toward the lower(posterior) edge of the underlying humerus. Following adequate nerve stimulation-response, the local anaesthetic is injected.
Indications:● Incomplete brachial plexus block ● Diagnostic block● Pain therapy
Blocks in the upper arm Radial n.
27
Radial n. block at the middle upperarm:site and direction of needle insertion.
course of theradial n. inthe upper arm
28
The following applies both for blocks of the radial and themusculocutaneous nerves in the region of the elbow:
Local anaesthetics:3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% perinjection
Needle: 24 G short bevel, unipolar
Patient position and method:Arm stretched out, externally rotated with the hand supinated.Subcutaneous injection lateral (radial) to the biceps tendon toward thelateral epicondyle of the humerus.
Comments on the technique:Combination with a radial block at the level of the elbow is possible (oneinsertion, one needle). Injections that go too deep are the most frequentcause of failure!
Patient position and method:Arm stretched out laterally, externally rotated with the hand supinated. Insert the needle approx. 1 – 2 cm laterally (radially) to the biceps ten-don and advance it toward lateral epicondyle until it contacts the bone.Inject the local anaesthetic when a stimulus response of the radial nerveis obtained at 0.3 mA/0.1 ms or infiltrate the local anaesthetic in a fan-shaped pattern while slowly withdrawing the needle.
Comments on the technique:When supplementing incomplete plexus block, the block must be perform-ed using nerve stimulation. This block is also ideal to combine with a s. c. musculocutaneous block in this same area.
Indications:● Incomplete brachial plexus block● Cimino shunt
Blocks in the elbow region Musculocutaneous n.(Sensory supply of the radial side of the lower arm)
Blocks in the elbow region Radial nerve
29
23
4567
1
Radial nerve block:direction of needle toward the lateral epicondyle (2 – 3 cm).
1 lateral cutaneous brachial n.
2 brachioradial m.3 radial n.4 biceps m.5 median n.6 ulnar n.7 brachial a.
Musculocutaneous block: subcutaneousinfiltration lateral (radial) to the biceps tendon.
30
The following applies for blocks in the region of the elbowand for both the median and the ulnar nerves:
Local anaesthetics:3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% perinjection
Needle: 22 G 4 – 5 cm
Patient position and method:Arm stretched out laterally, externally rotated with the hand supinated.
The site of insertion is approx. 1 cm medial (ulnar) of the brachial arterytangential to the nerve using a unipolar 22 G needle of 4 cm length. Astimulus response of the median nerve expected at a depth of 1 – 2 cm.Please note: Mm = Median nerve medial to the artery.
Patient position and method:The arm is abducted, with elbow flexed 30°. The site of insertion isapprox. 1 cm proximal to the sulcus of the ulnar nerve (between themedial epicondyle of the humerus and the olecranon). The needle isdirected tangentially along the ulnar nerve, and 3 – 5 ml local anaesthet-ic is injected close to (but not into!) the nerve.
Comments on the technique:The ulnar n. is found in the sulcus of the ulnar nerve when the elbow isflexed. Avoid pressure and paresthesias, the nerve is very sensitive! It isrecommended to use a unipolar needle (22 G, 5 cm) and nerve stimula-tion.
Indications:● Incomplete plexus block● Diagnostic block● Pain therapy
Blocks in the elbow region Median nerve
Blocks in the elbow region Ulnar nerve
31
Median nerve block:approx. 1 cm medial to the brachial artery.
Ulnar n.
1 ulnar n.2 medial condyle of
the humerus3 olecranon process
Ulnar nerve block:approx. 1 cm proximal to the ulnar nerve sulcus.
2 13
32
Local anaesthetics:3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Local anaesthetics:3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: 22 or 24 G
Guiding structures and method: The injection is made on the flexor side between the tendons of the radialflexor carpi muscle of the wrist and the long palmar muscle (occasionallymissing). After eliciting paresthesias, withdraw the 25 G needle slightlyand apply 5 ml of the local anaesthetic.
Patient position and method:The arm is stretched out laterally and externally rotated with the handsupinated. Insert the needle approx. 3 – 4 cm proximal to the hand be-tween the tendon of the ulnar flexor carpi muscle and the ulnar artery.After eliciting a light paresthesia, withdraw the needle slightly and inject3 – 5 ml of the local anaesthetic.
Block in the wrist region Median nerve("wrist block")
Block in the wrist region Ulnar nerve("wrist block")
33
2 3 4
5 6 7 8
1
Median nerve block at the wrist
1 pisiform bone2 ulnar n.3 ulnar a.4 flexor carpi ulnaris
tendon5 palmaris longus
tendon6 flexor carpi radialis
tendon7 median n.8 radial a.
Ulnar nerve blockat the wrist
34
Local anaesthetics:10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: 22 or 24 G
Patient position and method:The arm is stretched out laterally with the hand supinated. Subcutaneousinfiltration is performed on the radial side of the wrist 3 – 5 cm proximalto the joint.
Block in the wrist region Radial nerve("wrist block")
35
1 2
Radial nerve block at the wrist:subcutaneous infiltration.
1 superficial branches of the radial n.
2 radial a.
36
1 iliohypogastric n.2 ilioinguinal n.3 genitofemoral n.4 lateral femoral
cutaneous n.5 femoral n.6 obturator n.7 sciatic n.8 pudendal n.
1
XI
XII L1
L1
L2
L2
L3L3
L4L4
L5
L5
Th 12
2
3
4
5
6
67
8
Lumbosacral plexus
37
Lower extremities
Lumbar plexusThe lumbar plexus is formed by the ventral rami of the L1 – L4 spinal nerves. Nerves of the lower extremities relevant for anaesthesia:Femoral nerve with terminal saphenous nerve, lateral femoral cutaneousnerve, obturator nerve.
Anaesthesia techniques:● Psoas compartment block● Femoral block in the inguinal region ("3-in-1 block")● Block of the lateral femoral cutaneous nerve ● Obturator nerve block
2
1
3
4
5
6
7
8
38
Lumbosacral plexus
1 posterior femoral cutaneous n.
2 sciatic n.3 iliohypogastric n.4 ilioinguinal n.5 lateral femoral
cutaneous n.6 genitofemoral n.7 obturator n.8 femoral n.
39
Sacral plexusThe sacral plexus is formed by the ventral rami of the L4 and L5 spinalnerves (lumbosacral trunk) and S1 – S3.Nerves of the lower extremities relevant to anaesthesia:Sciatic n. (common peroneal nerve, tibial nerve), posterior femoral cutaneous nerve
Anaesthesia techniques:● Proximal sciatic nerve block (transgluteal, dorsal, anterior)● Distal sciatic nerve block● Lateral sciatic block (proximal, distal)● Selective blocks (of the peroneal and tibial nerves)● Ankle block
Lower extremities
40
Sensory supply of the lower extremities
1
2
3
4
4
9
5
6
77
3
4
8
9
1012 131011
1 lateral femoral cutaneous n.
2 femoral n.3 peroneal n.4 saphenous n.5 sciatic n.
Areas of sensory distribution:Blue: Femoral nerve and its branches. Yellow: Sciatic n. and its branches. Grey: The lateral femoral cutaneous nerve. Green: Obturator nerve.
6 posterior femoral cutaneous n.
7 obturator n.8 posterior tibial n.9 superficial peroneal n.
10 sural n.
11 deep peroneal n.12 medial plantar n.13 lateral plantar n.
(tibial n.)
41
Sensory supply of the bony structure
3
5
1 tibial nerve: plantar flexion, foot inversion
2 peroneal nerve: dorsiflexion, foot eversion
The correct response forall proximal sciatic nerveblocks should be in thefoot. Either the (mediallysituated) tibial branch(plantar flexion) or the(laterally situated) pero-neal/fibular branch (dor-siflexion) is stimulated.With the Labat andMansour techniques, aresponse in the ischio-crural muscles (flexion ofthe thigh) can also beregarded as a correctmotor response.
Areas of distribution:Blue: Femoral nerve andits branches. Yellow: Sciatic nerve andits branches. Green: Obturator nerve(variable innervation).
1 sciatic n.2 obturator n.3 tibial n.4 femoral n.5 common peroneal n.
Motor response
1
2
1
24
42
Side effects/complications: Spinal anaesthesia, epidural-like block due to spread to theepidural space, hematoma
Local anaesthetics:Initial: 40 – 50 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75%Continuous: 6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h orbolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours)
Patient position and methodPatient in a lateral position with legs flexed, the back kyphotic and theleg to be blocked uppermost.
Guiding structures: L4 vertebral spinous process. A mark is made 3 cm caudal from the L4 vertebral spinous process inthe interspinal line. From this point at a right angle to the interspinal linedraw a line at a right angle to the midline and mark its lateral end after5 cm. Check by palpating the posterior iliac spine, which should be inthe immediate vicinity. After local infiltration, insert a 10 – 12 cm 22 Gneedle in the marked point in a sagittal direction. After bony contact(transverse process of the L5), withdraw the needle a few cm and redi-rect it more cranially. Advance it until stimulation contractions of the qua-driceps muscle appear at 0.3 mA/0.1 ms at a depth of 7 – 11 cm, indi-cating that the tip of the needle is in the immediate vicinity of the femo-ral nerve. Inject a test dose of the local anaesthetic to preclude an intra-spinal needle position.
Comments on the technique:● The most effective method of lumbar plexus blockade ● Injecting at the L3 level does not improve the quality of anaesthesia,
but carries a risk of causing a subcapsular haematoma of the kidney ● Injection into the peritoneal cavity may appear with an injection
depth of > 12 cm ● Complete block of the sacral plexus (sciatic n.) is not possible, even
with higher volumes of local anaesthetic
Psoas compartment block(acc. to Chayen)
Indications:● In combination with proximal sciatic nerve
block, all types of leg surgery (including endoprosthesis)
● Wound treatment in the ventral and lateral thigh regions, skin grafts in the upper thigh
● Physiotherapy● Pain therapy (e. g. postop. after hip
or knee surgery)
Special contraindications:Anticoagulation therapy, same recommendations as for patients with neuroaxial block
43
2 3 4 51
a iliac crestb L4 vertebral spinous
processc sup. post. iliac
spined needle insertion
site: 3 cm caudal and5 cm lateral of theL4 vertebral spinous process
1 lumbar plexus2 psoas major m.3 iliac fascia 4 transverse process
(costal process)5 erector spinae m.
b
a
c
d
Needles:E. g. 22 G, 12 cm needleContinuous: E. g. Plexolong B® 19.5 G, 12 cm (Pajunk co.), UP 18 G/22 G, 11 cm(B. Braun)Continuous: The catheter is advanced 5 cm beyond the tip of the cannula, preferably in acaudal direction
ventral
Body of L5
dorsal
directionof needleinsertion
44
Local anaesthetics:Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%Continuous:6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/ml orbolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needle: E. g. a combination needle Plastic cannula set‚ 18 G, 5 cm (Pajunk co.) or 5.5 cm Contiplex D® (B. Braun)Continuous: The catheter is advanced 5 cm beyond the end of the cannula
Patient position and method:Patient supine with the leg abducted and externally rotated.
Guiding structures: The inguinal fold, femoral artery with vein medial, nerve lateral.The insertion site is 2 cm below the inguinal fold, 1.5 cm lateral of theartery. The stimulation cannula is advanced at a 30° angle in a cranialdirection until occurence of a double-click, indicating passage throughthe fascia lata femoris and the fascia iliaca. A motor stimulus response inthe quadriceps muscle with a "dancing" kneecap at 0.3 mA/0.1 ms indi-cates that the needle tip is in the immediate vicinity of the femoral nerve.
Comments on the technique:Direct stimulus response in the sartorius muscle may mimic a quadricepsresponse but leads to "anaesthesia failure" so make sure that the patelladances! Avoid intraneural needle insertion (nerve stimulation).
Indications:● When used in combination with a
proximal sciatic block, most types of legsurgery
● Wound treatment, skin grafts in the ventral thigh, mobilisation, physiotherapy
● Pain therapy (fractures of the shaft of the femur, postop. after knee joint surgery, e. g. synovectomy, anterior cruciate ligament reconstruction; pain alleviation in fractures of the neck of thefemur)
Special contraindications: None
Relative contraindications: After e. g. fem. popliteal bypass (usefuldevices: Doppler, sono), lymphomas inthe groin
Femoral nerve block in the inguinal region("3-in-1" technique acc. to Winnie, continuous technique acc. to Rosenblatt)
45
1
4
3
2
5
a femoral arteryb needle insertion
site
1 lateral femoral cutaneous n.
2 psoas major m.3 femoral n.4 obturator n.5 femoral a.
Direction of needle: cranially at 30° angle, lateral to and parallel with the femoral artery.
a
a
b
46
Local anaesthetics:10 – 15 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: 20 G, 10 cm short bevel, insulated unipolar needle
The anterior branch (superficial n.) innervates the anterior adductors,the hip joint and, to a varying extent, a section of skin on the inner sur-face of the thigh. The posterior branch (profound n.) innervates the deep adductors and(variably) medial portions of the knee joint.
Patient position and method:Patient supine with the leg abducted.
Guiding structures: Palpate the tendon of the long adductor m. Insert the stimulation needle immediately ventral of the tendon's proximalattachment point. Advance the unipolar needle cranially at an angle ofapprox. 45° to the body's longitudinal axis (toward the sup. ant. iliacspine) and in a slightly dorsal direction. After approx. 4 – 8 cm at 0.3mA/0.1 ms, contractions of the adductors indicate the proximity of theobturator nerve.A catheter technique can be used for continuous block. The catheter isadvanced approx. 3 – 4 cm beyond the tip of the needle in a cranialdirection.
Indications:● TUR of tumors of the ipsilateral
wall of the bladder● Supplementary to incomplete
lumbar plexus (3-in-1) block● Diagnosis and therapy of pain
syndromes in the region of the hip joint
● Adductor spasm
Special contraindications:None
Obturator nerve block
1
473
2
56
47
a femoral arteryb tendon of the
long adductor m.
1 obturator n., anterior(superficial) branch
2 obturator n.,posterior (deep)branch
3 adductor longus m.4 adductor brevis m.5 adductor magnus m.6 gracilis m. 7 needle insertion site
Needle insertion: ventral of the tendon attachment in a cranial-dorsal direction (the obturator nerve is at 4 – 8 cm depth).
ab
48
Local anaesthetics:30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75%
Needle: E. g. 20 G 10 or 15 cm long, insulated unipolar needle with 30° or 15° bevel
Patient position and method: Patient in a lateral position with the side to be blocked uppermost. Thelower leg is stretched, the leg that is to be blocked is flexed in hip andknee-joint.
Guiding structures: Greater trochanter, superior posterior iliac spine.Draw a line between the sup. post. iliac spine and the greater trochanter,from its midpoint a perpendicular line is drawn caudomedially. The nee-dle insertion point is 4 – 5 cm from the first line. A confirming line canbe drawn from the trochanter to the sacral hiatus, the insertion point iswhere the last two lines cross each other. The stimulation needle is advan-ced perpendicularly to the skin. After 5 – 10 cm, contractions of thedorsiflexors of the foot (common peroneal nerve) or of the plantar flexorsof the foot (tibial nerve) at 0.3 mA/0.1 ms indicate the correct positionof the needle in the immediate vicinity of the sciatic nerve.
Comments on the technique:● Occasional vascular puncture (inferior gluteal artery) ● Direct stimulation of the major gluteal muscle must not be mistaken for
the sciatic nerve stimulation response (inject local anaesthetic only at a stimulus response in the lower leg/foot)
● Local LA infiltration recommended
Indications:● All leg surgery when combined with a
lumbar plexus block● Pain therapy (knee joint on the
flexor side, lower leg)● Sympathicolysis
Special contraindications: None
Relative contraindications: Coagulation disorder (Risk of puncturinginferior gluteal artery)
Transgluteal sciatic nerve block(acc. to Labat)
49
1 2
a greater trochanterb superior posterior
iliac spinec site of insertion:
direction of needle perpendicular to the skin, 5 – 10 cm deep
1 piriformis m.2 sciatic n.
a
b c
50
Local anaesthetics:Initial:30 ml lidocaine 1% or mepivacaine 1% or 20 – 30 ml ropivacaine 0.75%Continuous:6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h orbolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needles: 10 cm, 20 G, 30° or 15° bevel unipolar needle Continuous: E. g. 19.5 G, 10 cm bevel, Plexolong set® (Pajunk co.), Contiplex® (B. Braun) The catheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction
Patient position and method: The patient is supine with the leg to be blocked flexed at hip and kneeapprox. 90° and held by an assistant.
Guiding structures: Greater trochanter, ischial tuberosity.Draw a line between the greater trochanter and the ischial tuberosity andmark its midpoint. This point marks the site for needle insertion. The sti-mulation needle is advanced perpendicular to the skin surface in a cra-nial direction. After 5 – 10 cm, contractions of the dorsiflexors of the foot(peroneal n.) or of the plantar flexors (tibial n.) at 0.3 mA/0.1 ms indi-cate the correct position of the needle.
Comments on the technique:Advantage: The patient can remain supine. The technique is easy tolearn. The leg can also be placed in a leg support. A continuous tech-nique can be used.
Indications:● Most types of surgery on the leg when
used in combination with a lumbar plexus block
● Pain therapy● Sympathicolysis
Special contraindications:None
Subgluteal sciatic nerve block(acc. to Raj)
51
1
2
3
a
b
c
a site of insertion:midpoint of line between the greater trochanter and the ischial tuberosity
b greater trochanterc ischial tuberosity
1 sciatic n.2 greater trochanter3 ischial tuberosity
52
Local anaesthetics:Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 20 – 30 ml ropivacaine 0.75%Continuous: 6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx.every 6 hours)
Needles: 20 G, 15 cm, 30° or 15° bevel, insulated unipolar needleContinuous: E. g. 19.5 G, 15 cm, facet tip, Plexolong set® (Pajunk co.) or Contiplex® set(B. Braun) 20 G catheter. The catheter is advanced approx. 4 cm beyond the tip of the cannula
Patient position and method:Patient supine with the leg in a neutral position.
Guiding structures: Superior anterior iliac spine, middle of the symphysis, greater trochanter,the intermuscular space between the sartorius m. and the rectus femoris m.The connecting line between the anterior iliac spine and the middle ofthe symphysis is divided into three equal segments. Draw a line parallelto this line through the middle section of the greater trochanter. Thendraw a perpendicular line from the junction of the medial and middlesegments in a caudal direction. The point where the lines cross eachother marks the needle insertion site. Palpate the intermuscular space be-tween the sartorius m. and the rectus femoris m. in this region. Advancethe needle at a 60° angle approx. 8 – max. 15 cm in a cranial direc-tion. Avoid bone contact. A motor stimulus response in the foot (dorsi- orplantar flexion at 0.3 mA/0.1 ms) indicates that the needle tip is in theimmediate vicinity of the sciatic nerve.
Comments on the technique:The palpation of the space between the sartorius and rectus femorismuscles is very important, because the femoral vessels are displacedmedially and the distance to the injection site is shortened as a result ofthe vertical pressure ("two-finger grasp").
Indications:● Most surgery on the leg when combined
with a lumbar plexus block● Pain therapy (also as a continuous
technique)● Sympathicolysis
Special contraindications:None
Proximal anterior/ventral sciatic nerve block(acc. to Meier)
53
a c
b
a the connecting linebetween the sup. ant. iliac spine and the middle of the symphysis
b greater trochanterc needle insertion
site
1 rectus femoris m.2 sartorius m.3 femoral n.4 femoral a.5 femoral v.6 sciatic n.
Direction of needle insertionNote: "two-finger grasp" into the intermuscu-lar space, sciatic nerve at a depth of 8 – 15 cm.
321 4 5
6
lateral medial
rightthigh
Local anaesthetics:Initial: 30 ml lidocaine 1% or mepivacaine 1% or 20 – 30 ml ropivacaine 0.75%Continuous: 6 ml (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needles: 20 G, 10 cm, 30° or 15° unipolar needleContinuous: E. g. 19.5 G, 10 cm, facetted tip, Plexolong set® (Pajunk co.). The catheteris advanced 4 – 5 cm beyond the needle tip in a cranial direction.
Patient position:Patient supine. The leg lies in neutral position. A small pad or pillow isplaced under the foreleg.
Guiding structures: Greater trochanter, femur shaft.A line is drawn distally from the prominent part of the greater trochanterparallel to the femur. The injection site is approx. 3 cm below this line at5 cm distal to the greater trochanter. The needle enters at the level of thedorsal border of the femur and the needle is directed dorsally (approx.30°) and cranially (approx. 30 – 45°). The sciatic nerve is reached after8 – 10 cm.
Comments on the technique:Muscular contractions in the posterior thigh are frequent. The correctposition of the needle tip in the vicinity of the nerve is confirmed by amotor response in the foot (dorsiflexion or plantar flexion) with a pulseamplitude of 0.3 mA and a pulse width of 0.1 ms. The peroneal nerve isin front of the tibial nerve. Dorsiflexion of the foot is therefore usually theinitial motor response. If no motor response is produced, the needleshould be withdrawn and its direction should be corrected anteriorlywhen it is advanced again.
Indications:● All operations on the leg in combination
with a lumbar plexus block● Pain therapy ● Sympathicolysis
Special contraindications:None
Proximal lateral sciatic nerve block
54
2
1
a
55
a greater trochanterwith a line parallelto the femur
b needle insertion site5 cm distal to thegreater trochanter and 3 cm belowline a (just behindthe femur)
1 greater trochanter2 sciatic n.
Direction of needle:approx. 30°dorsally and cranially
b
Local anaesthetics:Initial:30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine0.75%Continuous: 6 ml/h (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5 mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6hours)
Needles: 22 G, 10 – 12 cm unipolar needleContinuous: E. g. 19.5 G, 10 – 12 cm, catheter 20 G (Plexolong set®, Pajunk co.). Thecatheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction.
Patient position:Patient supine. The leg is supported at the foot so that the thigh sagsfreely.
Guiding structures: Upper border of patella, biceps femoris (long head), vastus lateralis.The needle insertion site is located approx. 12 cm proximal to the upperborder of the patella between the upper border of the biceps femoris andthe lower border of the vastus lateralis. The needle is directed approx.20° – 30° dorsally and approx. 45° cranially. A motor response in thefoot after 6 – 9 cm (peroneal nerve – dorsiflexion, tibial nerve – plantar flexion) at 0.3 mA/0.1 ms indicates that the nerve is immediately nearby.
Comments on the technique:To make it easier to palpate the tendon and belly of the biceps femorismuscle, brief elevation and flexion the patient’s leg is recommended. Anadditional saphenous nerve block is required for complete anaesthesia ofthe lower leg and foot (see page 60). Suitable as a continuous technique(distal sciatic catheter, DSC). The advantage compared to distal (dorsal)sciatic block (see page 58) is that the patient can remain in supine position.
Indications:● Anaesthesia for operation on the foot/ankle● Anaesthesia/pain therapy distal to the knee● Postop. pain therapy (foot/ankle)● Pain therapy/sympathetic block
(achillodynia, diabetic gangrene, circulatoryor wound healing disorders, CRPS)
Special contraindications:None
Distal lateral sciatic nerve block
56
57
1 vastus lateralis m.2 iliotibial tract3 level for anatomical
cross section4 patella5 biceps femoris m.
(long head) with tendon
6 biceps femoris m. (short head)
7 sciatic n. with peroneal division (thinner, lateral) andtibial division (thicker, medial)
a biceps femoris m. (long head)
b tendon of biceps femoris m. (l. h.)
c biceps femoris m. (short head)
d vastus lateralis m.e patella
Direction of needle:20° – 30° dorsally,45° cranially
d
a
e
c b
lateral medial
rightthigh
1
1 3 2 4
5
7
5
26
56
58
Local anaesthetics:Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75%
Patient position and method:Patient in the lateral position with the lower leg semi-flexed in hip andknee. The leg to be blocked is uppermost and stretched, a pillow placedbetween the knees as a comforting support. Alternatively: Patient supinewith the leg to be blocked flexed in the hip and knee (leg support neces-sary).
Guiding structures: Flexion fold ("wrinkle") of the popliteal fossa. Laterally: biceps femorism.; medially: semimembranous m., semitendinous m., popliteal artery.The thumb and the middle finger are placed on the epicondyles and asymmetric triangle is formed cranially with the index finger. This trianglecorresponds closely to the boundaries of the upper popliteal fossa, withits cranial angle approx. 8 – 12 cm proximal to the flexion fold. The in-sertion site is 1 – 2 cm lateral of the tip of the triangle immediatelymedial to the tendon of the biceps femoris muscle. The needleis advanced in a cranial direction at a 30° – 45° angle to the skin andslightly medially. A stimulus-response in the foot can be expected after 4 – 6 cm, (peroneal n.: dorsiflexion; tibial n.: plantar flexion) at 0.3m/0.1 ms and indicates the immediate vicinity of these nerves.
Comments on the technique:The sciatic nerve runs parallel to the popliteal artery. Anatomic arrange-ment in the fossa poplitea, from lateral to medial: biceps femoris muscle,common peroneal nerve, tibial nerve, popliteal artery. In case of a tourni-quet below the knee, it is recommendable to add a saphenous nerveblock (see p. 60). This block is particularly well suited for a continuoustechnique (distal sciatic n. catheter).Note: A large proportion of the sciatic n. consists of sympathetic fibres.Sympathicolysis can be used therapeutically.
Indications:● Anaesthesia for foot/ankle joint surgery● Anaesthesia/analgesia distal of the
knee● Postoperative analgesia (foot/ankle joint)● Analgesia/sympathicolysis (CRPS I or II)
achillodynia, diabetic gangrene, blood circulation disorders or leg ulcer
Special contraindications: None
Distal posterior sciatic nerve block(acc. to Meier)
59
1
3
4
lateral
5
6
72
Continuous: 6 ml/h (5 – 15 ml) ropivacaine 0.2 – 0.375%, max. 37.5mg/h or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx.every 6 hours)
Needles and catheters: Shortbevel, unipolar needle 22 G, 5 – 10 cmContinuous: E. g. 19.5 G, 6 or 10 cm long, 20 G catheter (Plexolong set®, Pajunk co.).The catheter is advanced 4 – 5 cm beyond the tip of the needle
a tendon of the biceps m. of the thigh
b popliteal a.c needle insertion
site approx. 8 – 10 cm proximal to the flexion fold of the popliteal fossa 45°angle cranially, sciatic nerve at a depth of approx. 4 – 6 cm
1 semimembranosus m.
2 semitendinosus m.3 popliteal a.4 biceps femoris m.5 sciatic n.6 tibial n.7 peroneal n.
a
b
c
60
Local anaesthetics:5 – 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: 24 G, 6 cm
Sensory terminal branch of the femoral nerve.
Patient position and method: Patient supine
Guiding structures: Tuberosity of tibia, medial head of the gastrocnemius muscle.The tuberosity of tibia is palpated and subcutaneous infiltration is carriedout with a 6 cm long 24 G needle in the direction of the medial head ofthe gastrocnemius m.
Comments on the technique:Accidental puncture of the saphenous vein (rare) can be excluded byrepeated aspirations.
Indications:● Incomplete lumbar plexus or femoral
nerve block (medial lower leg)● Combination with a distal sciatic block
when tourniquet below the knee is used
Special contraindications: None
Saphenous nerve block
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1
3
2
medial
a tuberosity of tibialb medial head of
gastrocnemius m.c needle insertion
site: subcutaneous injection
direction of insertion toward the medial head of the gastrocnemius m.
1 infrapatellar branchesof the saphenous n.
2 sartorius m.3 saphenous n.
ab
c
62
Local anaesthetics:5 ml lidocaine 1% or mepivacaine 1% or 5 ml ropivacaine 0.75%
Needle: unipolar 22 G, 5 cm
Patient position and methods:Patient supine, palpation of the head of the fibula.The needle insertion point lies 2 cm distal and dorsal. The direction ofthe unipolar needle is perpendicular to the skin, stimulus-response in thefoot (dorsiflexion of the foot) at 1 – 3 cm. Injection of the local anaesthet-ic at 0.3 mA/0.1 ms.
Comments on the technique:Nerve stimulation strongly recommended, as the peroneal nerve is verysensitive.
Indications:● Incomplete anaesthesia following sciatic
block● Diagnostic block● Pain therapy
Special contraindications: None
Common peroneal nerve block
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1 2 3
a head of the fibulab site of insertion
needle perpendicu-lar to the skin
nerve 1 – 3 cm deep
1 biceps femoris m.2 common peroneal n.3 head of fibular bone
lateral
a
b
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The foot is supplied by 5 nerves, 4 of which originate in the sciatic n.(superficial and deep peroneal nerves, tibial and sural nerves). The fifth(saphenous n.) is the terminal branch of the femoral nerve.
Patient position and method: Patient supine
Superficial peroneal nerve:A subcutaneous infiltration is performed between the anterior edge of thetibia and the upper edge of the lateral malleolus with 5 – 10 ml localanaesthetic: (Anaesthesia distribution: Skin on the back of the foot andthe toes, except an area between the greater and second toes.)Sural nerve:The sural n. is blocked by subcutaneous infiltration of 5 ml local anaes-thetic between the Achilles tendon and the lateral malleolus. (Anaesthesiadistribution: Lateral edge of the foot, variable up to the 5th toe.)Saphenous nerve:Subcutaneous infiltration of 5 – 10 ml local anaesthetic from the anterioredge of the tibia to the Achilles tendon, approximately a hand-widthabove the medial malleolus. (Anaesthesia distribution: skin medially fromthe inner ankle variable up to the great toe.)
Comments:If this subcutaneous block is initially performed as a ring-shaped infiltra-tion, subsequent needle-sticks will be pain-free.
Blocks for anaesthesia in the foot (ankle blocks)(acc. to Löfström)
65
1
2 3
Subcutaneous ring infiltration above the ankle to block the – superficial pero-
neal and sural nerves (lateral)
– saphenous n. (medial)
1 sural n.2 superficial peroneal n.3 deep peroneal n.
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Block of the deep peroneal nerve The needle is inserted between the tendon of the long extensor pollicismuscle and the dorsalis pedis artery on the back of the foot. The needleis inserted perpendicularly to the skin and advanced slightly under theartery. Following negative aspiration, injection of 5 ml local anaesthetic. Anaesthesia distribution: Skin of the medial side of the great toe and thelateral side of the 2nd toe.
Local anaesthetics:5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%
Needle: 24 G, 3 – 5 cm
Ankle block Deep peroneal nerve(acc. to Löfström)
67
1
2
3
44
a tendon of the long extensor pollicis muscle
b dorsalis pedis a.
1 superficial peroneal n.2 saphenous n.3 dorsalis pedis a.4 deep peroneal n.
a
b
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The following applies to ankle blocks:
Local anaesthetics:5 – 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per injection
Needles: 22 – 24 G, 4 – 6 cm
Tibial nerve block:The needle insertion point lies directly dorsal to the posterior tibial arteryon the medial side of the joint, or alternatively, directly anterior of theAchilles tendon at the level of the medial malleolus. The needle is insert-ed perpendicular to the skin. 5 – 8 ml local anaesthetic are injectedusing intermittent aspirations.Warning: In case of paresthesias, withdraw the needle to avoid injury tothe nerve. (Anaesthesia distribution: Sole of the foot with the exception ofits extreme lateral and proximal segments.)
Comments (recommendation):Nerve stimulation and a unipolar 5 cm 22 G or 24 G, needle is recom-mended (stimulus-response: Plantar flexion of the toes).
Ankle block Posterior tibial nerve(acc. to Löfström)
Indications:● Incomplete plexus lumbosacral block● Foot surgery● Pain therapie● Diagnostic blocks
Special contraindications:None. In case of neurological deficits,check diagnosis before initiating theblock
69
123
a posterior tibial a. needle insertion dorsal of the artery, direction perpen-dicular to the skin
1 saphenus n.2 posterior tibial a.3 tibial n.
a
Notes – own experience – phone numbers – pain service, etc.
Notes
Notes
Notes – own experience – phone numbers – pain service, etc.
Authors' addresses:
Dr. Gisela Meier, M.D.Head of the Department of Anaesthesia and Pain Therapy Rheumazentrum, Waldburg-Zeil KlinikenHubertusstraße 40D-82487 Oberammergau, Germany
Dr. Johannes Büttner, M.D.Head of the Department of AnaesthesiaBerufsgenossenschaftliche Unfallklinik MurnauProfessor-Küntscher-Straße 8D-82418 Murnau, Germany
The English version was revised by:
Dag Selander, MD, PhD, c/o Selmedic HBBetzensgatan 1S-414 55 Göteborg, Sweden
