Lower extremity nerve blocks: Techniques
- Christina L Jeng, MD
Christina L Jeng, MD
- Assistant Professor of Anesthesiology and Orthopaedics
- Icahn School of Medicine at Mount Sinai
- Meg A Rosenblatt, MD
Meg A Rosenblatt, MD
- Professor of Anesthesiology and Orthopaedics
- Icahn School of Medicine at Mount Sinai
Peripheral nerve blocks of the lower extremity are used for operative anesthesia and/or postoperative analgesia for a variety of lower extremity surgeries.
This topic will discuss the innervation of the lower extremity, techniques and drugs used for lower extremity nerve blocks, and complications specific to these blocks. Where appropriate, the use of perineural catheters for continuous nerve block will be discussed. Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment, and complications common to all nerve blocks are discussed separately. (See "Overview of peripheral nerve blocks".)
INNERVATION: LOWER EXTREMITY
The lumbar plexus is formed by the anterior divisions of the first three lumbar nerves (L1, L2, L3) and part of the fourth lumbar nerve (L4). A branch from the 12th thoracic spinal nerve (T12) often joins the L1 nerve root (figure 1).
The lumbar plexus is located in the posterior third of the psoas muscle, anterior to the lumbar transverse processes. It gives rise to nerves that supply the muscular and cutaneous innervation to the lower extremity, including the iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve (figure 2).
The femoral nerve (L2 to L4) runs through the psoas muscle and emerges at the lower border between the psoas and iliacus muscles, beneath the inguinal ligament lateral to the common femoral artery. The femoral nerve provides motor branches to thigh extensors and sensation to the anterior thigh, femur, knee joint, and medial leg (figure 3 and figure 4). The saphenous nerve is the terminal sensory branch of the femoral nerve.
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- INNERVATION: LOWER EXTREMITY
- LUMBAR PLEXUS (PSOAS COMPARTMENT) BLOCK
- Ultrasound-guided lumbar plexus block
- Nerve stimulator-guided lumbar plexus block
- Perineural catheter lumbar plexus block
- Side effects and complications
- FEMORAL NERVE (3-IN-1) BLOCK
- Ultrasound-guided femoral block
- Nerve stimulator-guided femoral block
- Perineural catheter femoral block
- Side effects and complications
- FASCIA ILIACA (LATERAL FEMORAL CUTANEOUS) BLOCK
- Ultrasound-guided fascial iliaca block
- Landmark-based fascia iliaca block
- Perineural catheter fascia iliaca block
- OBTURATOR NERVE BLOCK
- Ultrasound-guided obturator block
- Nerve stimulator-guided obturator block
- SCIATIC NERVE BLOCK
- Posterior approach
- - Ultrasound-guided sciatic block
- - Nerve stimulator-guided sciatic block
- Anterior approach
- Perineural catheter sciatic block
- POPLITEAL BLOCK
- Ultrasound-guided popliteal block
- Nerve stimulator-guided popliteal block
- Perineural catheter popliteal block
- SAPHENOUS NERVE AND ADDUCTOR CANAL BLOCKS
- Adductor canal block
- - Positioning
- - Ultrasound-guided adductor canal block
- - Perineural catheter adductor canal block
- Saphenous nerve block
- - Side effects and complications
- ANKLE BLOCK
- - Deep peroneal block
- - Superficial peroneal block
- - Tibial block
- - Sural nerve block
- - Saphenous nerve block
- DIGITAL NERVE BLOCK (TOE)
- DRUG CHOICES
- SUMMARY AND RECOMMENDATIONS