Pocket Compendium of Peripheral Nerve Blocks (Regional Anesthesia)

Contents Page Contents 2 3 4 6 7 8

Preface Review of the most important local anaesthetics General technical and safety aspects Systemic effects of local anaesthetic intoxication Postoperative analgesia with Naropin® polybag Care of peripheral nerve catheters for p. o. analgesia

10 12 13

Upper extremities Anatomy of the brachial plexus Sensory supply of the upper extremities Upper extremity motor response to nerve stimulation

14 16 18 20 22

Interscalene plexus block (acc. Meier) Infraclavicular plexus block (acc. Kilka, Geiger, Mehrkens) Infraclavicular plexus block, Raj technique (mod. by Borgeat) Suprascapular nerve block (acc. Meier) Axillary plexus block

24

Blocks in the upper arm region – Multi-stimulation technique (mid-humeral, acc. Dupré) – Radial nerve

26 28 30 32 34 36 40 41 42 44 46 48 50 52 54 56 58 60 62 64 66 68

Blocks in the elbow region – Radial nerve – Musculocutaneous nerve – Median nerve – Ulnar nerve Block in the wrist region ("wrist block") – Median nerve – Ulnar nerve – Radial nerve Lower extremities Anatomy of the lumbosacral plexus Sensory supply of the lower extremities Sensory supply of the bony structure Motor response to stimulus Psoas compartment block (acc. Chayen) Femoral nerve block in the inguinal region (acc. Winnie, Rosenblatt) Obturator nerve block Transgluteal sciatic nerve block (acc. Labat) Subgluteal sciatic nerve block (acc. Raj) Proximal anterior/ventral sciatic nerve block (acc. Meier) Proximal lateral sciatic nerve block Distal lateral sciatic nerve block Distal posterior sciatic nerve block (acc. Meier) Saphenous nerve block Common peroneal nerve block Blocks for anaesthesia in the foot (ankle blocks) – Superficial peroneal nerve – Deep peroneal nerve – Posterior tibial nerve

Preface The development of anaesthesia is currently affected by the growing interest in regional anaesthesia and analgesia. In particular, there is an increasing interest in peripheral nerve blocks, and in many clinics the use of this method is prefered to the central blocks whenever possible, thus becoming increasingly more common. What is the reason of the growing interest and what makes the greater educational and practical efforts involved in the use of regional blocks worthwhile? First of all, it is the implementation of a perioperative anaesthesia and postoperative analgesia concept. A block initiated preoperatively and used intraoperatively continued via a catheter to provide effective postoperative regional analgesia with a low risk of complications. This concept enables early mobilisation and quicker rehabilitation. The effects of regional anaesthesia (mostly in the form of central neuraxial blocks) on various outcome parameters were demonstrated in the CORTRA meta-analysis (Rodgers et al., BMJ 2000; 321:1493) based on the evaluation of 141 clinical studies involving approximately 10,000 patients. Patient groups who underwent surgery under general anaesthesia were compared to those who either received regional anaesthesia or combined general – regional anaesthesia. According to the results, regional anaesthesia reduced postoperative complications and the over-all postoperative mortality rate by 30%. The authors concluded that the most likely reason for the reduction of postoperative complications was the decreased intraoperative stress response due to regional anaesthesia block. Furthermore, we are well aware of the potential risk of severe pain developing into a chronic pain condition, a situation that can and should be avoided. The most reliable way to prevent pain from becoming chronic comprises regional anaesthesia techniques that block the pain stimulus near its origin, both peri- and postoperatively, thereby eliminating acute pain as a special postoperative risk factor. The continuing development of regional anaesthesia and analgesia is important when considering the aspects described above but there are also ethical and economical points of view which call for a wider use of regional anaesthesia. With this compendium of peripheral nerve blocks, we present a brief review of the most commonly used techniques. Thereby we hope to stimulate the interest and understanding among our colleagues for the use of regional anaesthesia techniques.

2

Review of the most important local anaesthetics Action time of regional anaesthetics:

lidocaine 1% lidocaine 1%

Intraoperative and postoperative analgesia

+ ropivacaine 0.75% ropivacaine 0.75%

* ropivacaine 0.2% (– 0.375%)

infusion before * Start onset of post operative pain; otherwise start with an initial bolus.

2

4

6

8

10

12

14

hours

Overview of the most important local anaesthetics for peripheral nerve blocks Substance

Concentration

Dosage*

Time until

Analgesic

Anaesthesia

Anaesthesia

effective

action time

10 – 20 min

8 – 14 h

Analgesia

Analgesia

0.5% – 0.75%

up to 300 mg

(Naropin)

0.2% – 0.375%

up to 28 mg/h

Lidocaine

1% (– 2%) –

up to 600 mg –

10 – 20 min

2–4h

Mepivacaine

1% (– 2%) –

up to 300 mg –

10 – 20 min

3–4h

Anaesthetic potency (ratio to procaine = 1)

Protein binding (%)

Distribution volume (L)

Elimination half-life (h) in plasma

16

94

59

1.9

Lidocaine

4

64

91

1.6

Mepivacaine

4

77.5

84

1.9

Ropivacaine

Ropivacaine

* (manufacturers' recommendations) Special features: Ropivacaine ● Favourable effective dose/toxicity ratio ● Good differential block (analgesia >> motor block) at lower concentrations used for analgesia ● Local anaesthetic with medium action time and low toxicity Lidocaine Mepivacaine ● Effectiveness comparable to lidocaine, but less toxic and slightly longer duration

3

General technical and safety aspects

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 intravascular 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 pressure and the degree of consciousness.

●

Catheter: Daily control of the catheter insertion site, written documentation (see p. 9).

4

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 injection Minimize 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

●

Hematoma Minimize 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 documentation necessary) 5

Systemic effects of local anaesthetic intoxication Symptoms and signs of local anaesthetic intoxication Time

Apnoea Circulatory collapse/Cardiac arrest

CNS symptoms

Coma Seizures

Ventricular fibrillation

Muscular twitching

Ventricular arrhythmia

Confusion

QT-prolongation

Visual disurbances

Hypotension

Verbal/vocalization problems

Bradycardia

Hyperacusis, tinnitus Circumoral tingling,

QRS-widening Temporary hypertension

Lightheadedness

Tachycardia

Cardiovascular symptoms Dose

A relative small dose of local anaesthetic, if accidentally injected intravasculary, may lead directly to seizures with both respiratory and cardiovascular problems, depending on drug and patient conditions. Treatment of local anaesthetic intoxication

Stop LA injection, Give oxygen, Support ventilation, Avoid acidosis

Increasing CNS symptoms: Stop seizures with penthothal, propofol or 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.

6

Postoperative analgesia with Naropin® Polybag

Mobile pump system (CADD-Legacy PCA) for administration of Naropin® Polybag

Pump and Polybag in a carrier bag for mobile patient use

Naropin® 2 mg/ml, 200 ml Polybag analgesically effective concentrations *Real volume of Naropin®

ml

in 200 ml Polybag is 210 ml

additional volume

total mg

total volume ml*

concentrations 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

60

1020

270

3,8

Naropin® 10 mg/ml

7

Care of peripheral nerve catheters for p. o. analgesia in the medical ward

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 corresponding 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

8

Care of peripheral nerve catheters for p. o. analgesia in the medical ward ward Documentation example

9

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 cord e posterior cord f medial cord 1 2 3 4 5 6

7 8 9 10 11 12

medial antebrachial cutaneous n. medial brachial cutaneous n. intercostobrachial n. intercostal n. I intercostal n. II long thoracic n.

suprascapular n. musculocutaneous n. axillary n. radial n. median n. ulnar n.

C4

C4

C5

A

C5 C6 C6 C7

a

B

C8

b 1

d

A

C7

c e

Th 1 f

Th 1

B 9

3

10

11

2

4

5 7

6

8 12

A + B: Sectional plane in the infraclavicular and axillary region. Please note the position of the cords.

10

Upper extremities 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

Sensory supply

Sensory supply of the upper extremities

C3

1

C4 C5

6 medial antebrachial cutaneous n. 7 lateral antebrachial cutaneous n. (musculocutaneous n.) 8 radial n. 9 ulnar n. 10 median n.

1 supraclavicular n. 2 axillary n. (lat. cut. brachial) 3 intercostobrachial n. 4 medial brachial cutaneous n. 5 antebrachial cutaneous dorsal n. (radial n.)

1 C4

2

T2

T2

2

C5

3

4 T1

5 C6 7

T1

6

6

7

C6

C6 8 8 10 9

C7

C7

9 C8

C8 10

12

Upper extremity motor response to nerve stimulation

Motor functions of the peripheral nerves in the upper extremities a b c d

radial n.: stretching elbow and fingers median n.: flexion of the fingers ulnar n.: flexion of the forth and fifth fingers with opposition of the first finger musculocutaneous n.: flexion (and supination) of the forearm

b d a

c

13

Interscalene plexus block (acc. to Meier)

Patient position and method: Patient supine Guiding structures: Lateral border of the sternocleidomastoid m., interscalenus groove The insertion site is at the level of the thyroid notch (approx. 2 cm above the level of the cricoid cartilage) at the posterior edge of the sternocleidomastoid 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 anaesthetic when 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 interscalene block, the direction of the needle is lateral in contrast to Winnies technique (medial, dorsal, caudal). You will come in contact with the plexus at easily a more tangential angle in contrast to the classical approach, where the needle approaches the plexus at a right angle. 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) ● ●

Side effects, complications: Horner s., ipsilateral phrenic block, recurrent block

Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75% Continuous: Ropivacaine 0.2 – 0.375% 6 ml/h (5 – 15 ml), max. 37.5 mg/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 needle Continuous: 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).

14

a sternocleidomastoid m. b interscalene groove c subclavian a. d cricoid cartilage

d

c

a

b 11

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

10

9 8

7

1 2 3 4

5

6

The direction of insertion is caudally and laterally along the interscalene groove, 30° angle to the skin.

15

Infraclavicular plexus block VIB (= vertical infraclavicular block) (acc. to Kilka, Geiger and Mehrkens)

Patient position: Patient supine Jugular notch, ventral acromial process of the scapula. Guiding structures: The distance between the jugular notch and the ventral acromial process is bisected. The insertion site must be directly under the clavicula and take place in a strictly vertical direction. The plexus is reached after approx. 3 cm (max. 5 cm!). Flexion of the fingers at 0.3 mA/0.1 ms form 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 cm When the index finger is placed to have contact with the coracoid process laterally and the clavicle cranially (“Mohrenheim`s fossa”) the medial border of the finger marks the injection point/”finger point”. Always perform this block using a nerve stimulator. A stimulus response only 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 sagittal direction. In comparison with the Raj/Borgeat technique (ref. to this) this technique does not require abduction of the arm. Indications and contraindications: see infraclavicular plexus block, Raj technique (mod. by Borgeat) Side effects, complications: Horner syndrome, pneumothorax, intravascular injection.

Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75% 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 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 5 cm with catheter (Pajunk co.). The catheter is advanced 3 – 4 cm beyond the tip of the cannula.

16

a

a jugular notch b ventral acromial process c 1/2 distance from a – b d “finger point” e coracoid process

1 2 3 4 5 6 7 8

major pectoral m. subclavian a. pectoral n. medial cord posterior cord lateral cord deltoid m. suprascapular n.

d

e

b

c

1 2

7

3

8

4 5 6

Strictly vertical needle insertion (perpendicular to the underlying surface)

17

Infraclavicular plexus block Raj technique (mod. by Borgeat)

Patient position: Patient supine. Guiding structures: Jugular notch, ventral acromial process of the scapula. The needle insertion site is located halfway between the anterior tip of the acromion and the jugular notch approx. 1 cm below the clavicle. For injection, the arm is abducted 90° and elevated 30°. The needle is directed laterally at an angle of approx. 45° – 60° towards the most proximal point at which the axillary artery can still be palpated in the axilla. Comments on the technique: The risk of pneumothorax is low because of the lateral direction of the needle. Intravascular injection (usually venous, cephalic vein) has been observed. Between 3 – 8 cm there should be a motor response in the hand or fingers. Because of the tangential approach to the plexus, a catheter 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 insertion (e.g. pacemaker, port etc.) ● Untreated coagulation disorder

Side effects, complications: intravascular injection, pneumothorax

Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75% 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 6 hours) Needle: Single shot: unipolar 22 G x 6 – 10 cm needle Continuous: E. g. 19.5 G x 10 cm Plexolong with catheter (Pajunk co.). The catheter is advanced 3 – 4 cm beyond the tip of the cannula.

18

a axillary a., anatomical landmark for establishing the needle insertion

3 1 2 3 4 5 6

4

suprascapular n. deltoid m. brachial pl. pectoral n. subclavian a. major pectoral m.

5 6

1

2

Needle insertion site according to VIB anatomical landmarks (p. 16), direction towards the most proximal point of the axillary a., approx. 45° – 60° angle.

19

Suprascapular nerve block (acc. to Meier)

Patient position: The patient is sitting. Guiding structures: Scapular spine, posterior portion of the acromion, medial end of the scapular spine. The midpoint of the line between the lateral posterior portion of the acromion and the medial end of the scapular spine is marked. The insertion site is 2 cm cranial (above) and 2 cm medial of this point. The unipolar needle is advanced 3 – 5 cm laterocaudally and only slightly ventrally at an angle of approx. 30° (in the direction of the head of the humerus) until a correct needle position is indicated by a stimulus response in the infra- or the supraspinous muscles, or until the needle shows 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 (suprascapular artery, extremely rare). The method can also be performed without nerve stimulation (bone contact) and be used with a continuous technique. 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

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/h bolus (alternatively): 10 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours) 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). The catheter is advanced approximately 3 cm beyond the tip of the cannula.

20

a middle point of the scapular spine b needle insertion site: 2 cm medial 2 cm cranial to the middle point

b a

4 1 2 3 4 5

supraspinatus m. infraspinatus m. trapezius m. suprascapular a. transverse scapular ligament 6 suprascapular n. 7 articular branches of the suprascapular n. 8 deltoid m.

5

6

7

3

8 1 2

Direction of needle: Laterocaudal, approx. 30° angle

21

Axillary plexus block

Patient position: Patient supine, arm abducted 90°, externally rotated, elbow flexed approx. 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 and above the artery in a proximal direction at an angle of 30° – 45° to the skin ("click phenomenon" entering neurovascular sheath). Lower the distal end of the needle and advance it further. Check position with a nerve stimulator (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 advancement of the short bevel needle with cannula indicates a correct needle position. Not infrequently, anaesthesia in the radial nerve’s area of distribution is insufficient. 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

Side effects: No special ones

Local anaesthetics: Initial: 30 – 50 ml lidocaine 1% or mepivacaine 1% or 40 ml ropivacaine 0.75% 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 6 hours) 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 inserted through 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.

22

a coracobrachial m. b axillary a.

a

b

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.

8 7

1 2

3

4

5

6

Direction of insertion: medially, above and parallel to the artery, 30° – 45° angle to the skin.

23

Blocks in the upper arm

Multi-stimulation technique (mid-humeral technique acc. Dupré)

Patient position: Patient supine, arm abducted approx. 80°, stretched out, externally rotated. Guiding structures: Junction of the proximal and middle thirds of the upper arm, brachial artery. Find the brachial artery in the medial aspect of the junction of the proximal and middle thirds of the upper arm. Insert the needle between the two palpating fingers just above the brachial artery, and advance it proximally until a response of the median nerve is obtained. Following injection of the local anaesthetic, the needle is withdrawn to a subcutaneous position before the next nerve is located. Then advance it perpendicular 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. is blocked after advancing the needle horizontally under the biceps muscle until adequate stimulation response. It is recommended to raise the belly of the biceps muscle slightly during the block of the musculocutaneous n.. Comments on the technique: Not suited for continuous blocks, time-consuming, generally needs a nerve stimulator. Short onset, but relatively frequent problems with the tourniquet. Well suited for selective supplementary block of individual nerves with an incomplete brachial plexus block. Indications: Anaesthesia of the distal arm, elbow and hand

Special contraindications: None

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

24

a: Needle insertion for median nerve block

1 2 3 4

b: Needle insertion for ulnar nerve block

musculocutaneous n. median n. ulnar n. radial n.

1 2

All individual blocks performed via one single skin puncture.

3

4

c: Needle insertion for radial nerve block

d: Needle insertion for musculocutaneous nerve block

25

Blocks in the upper arm

Radial n.

Patient position: Patient supine. Guiding structures: Middle upper arm. The arm is lying abducted and externally rotated (arm support). Insert the needle in the space between the flexor muscles and the triceps muscles on 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

Local anaesthetics: Initial: 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: Unipolar 22 G x 4 – 6 cm

26

Radial n. block at the middle upper arm: site and direction of needle insertion.

course of the radial n. in the upper arm

27

Blocks in the elbow region

Radial nerve

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 tendon and advance it toward lateral epicondyle until it contacts the bone. Inject the local anaesthetic when a stimulus response of the radial nerve is obtained at 0.3 mA/0.1 ms or infiltrate the local anaesthetic in a fanshaped pattern while slowly withdrawing the needle. Comments on the technique: When supplementing incomplete plexus block, the block must be performed using nerve stimulation. This block is also ideal to combine with a s. c. musculocutaneous block in this same area.

Blocks in the elbow region

Musculocutaneous n. (Sensory supply of the radial side of the lower arm)

Patient position and method: Arm stretched out, externally rotated with the hand supinated. Subcutaneous injection lateral (radial) to the biceps tendon toward the lateral epicondyle of the humerus. Comments on the technique: Combination with a radial block at the level of the elbow is possible (one insertion, one needle). Injections that go too deep are the most frequent cause of failure!

The following applies both for blocks of the radial and the musculocutaneous nerves in the region of the elbow: Indications: ● Incomplete brachial plexus block ● Cimino shunt

Local anaesthetics: 3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per injection Needle: 24 G short bevel, unipolar

28

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.

1 2 3

4 5 6 7

Musculocutaneous block: subcutaneous infiltration lateral (radial) to the biceps tendon.

29

Blocks in the elbow region

Median nerve

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 artery tangential to the nerve using a unipolar 22 G needle of 4 cm length. A stimulus response of the median nerve expected at a depth of 1 – 2 cm. Please note: Mm = Median nerve medial to the artery.

Blocks in the elbow region

Ulnar nerve

Patient position and method: The arm is abducted, with elbow flexed 30°. The site of insertion is approx. 1 cm proximal to the sulcus of the ulnar nerve (between the medial epicondyle of the humerus and the olecranon). The needle is directed tangentially along the ulnar nerve, and 3 – 5 ml local anaesthetic 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 is flexed. Avoid pressure and paresthesias, the nerve is very sensitive! It is recommended to use a unipolar needle (22 G, 5 cm) and nerve stimulation.

The following applies for blocks in the region of the elbow and for both the median and the ulnar nerves: Indications: ● Incomplete plexus block ● Diagnostic block ● Pain therapy

Local anaesthetics: 3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per injection Needle: 22 G 4 – 5 cm

30

Median nerve block: approx. 1 cm medial to the brachial artery.

Ulnar n. 1 ulnar n. 2 medial condyle of the humerus 3 olecranon process

3

2

1

Ulnar nerve block: approx. 1 cm proximal to the ulnar nerve sulcus.

31

Block in the wrist region

Median nerve

("wrist block")

Guiding structures and method: The injection is made on the flexor side between the tendons of the radial flexor carpi muscle of the wrist and the long palmar muscle (occasionally missing). After eliciting paresthesias, withdraw the 25 G needle slightly and apply 5 ml of the local anaesthetic. Local anaesthetics: 3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75%

Block in the wrist region

Ulnar nerve

("wrist block")

Patient position and method: The arm is stretched out laterally and externally rotated with the hand supinated. Insert the needle approx. 3 – 4 cm proximal to the hand between the tendon of the ulnar flexor carpi muscle and the ulnar artery. After eliciting a light paresthesia, withdraw the needle slightly and inject 3 – 5 ml of the local anaesthetic. Local anaesthetics: 3 – 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 22 or 24 G

32

Median nerve block at the wrist

5 1 2 3 4 5 6 7 8

6

7

8

pisiform bone ulnar n. ulnar a. flexor carpi ulnaris tendon palmaris longus tendon flexor carpi radialis tendon median n. radial a.

1

2

3

4

Ulnar nerve block at the wrist

33

Block in the wrist region

Radial nerve

("wrist block")

Patient position and method: The arm is stretched out laterally with the hand supinated. Subcutaneous infiltration is performed on the radial side of the wrist 3 – 5 cm proximal to the joint. Local anaesthetics: 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 22 or 24 G

34

Radial nerve block at the wrist: subcutaneous infiltration.

1 superficial branches of the radial n. 2 radial a.

1

2

35

Lumbosacral plexus 1 2 3 4 5 6 7 8

iliohypogastric n. ilioinguinal n. genitofemoral n. lateral femoral cutaneous n. femoral n. obturator n. sciatic n. pudendal n.

Th 12

L1 XI XII

L1

L2

L2 L3 L3 1 L4

L4

2 L5

L5

3

4 5

6

8

7

36

6

Lower extremities Lumbar plexus The 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 cutaneous nerve, 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

37

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.

3 4

5 6

7 8

1 2

38

Lower extremities Sacral plexus The sacral plexus is formed by the ventral rami of the L4 and L5 spinal nerves (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

39

Sensory supply of the lower extremities 1 lateral femoral cutaneous n. 2 femoral n. 3 peroneal n. 4 saphenous n. 5 sciatic n.

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.)

1 5 6 2 7

7

3

3

4 4 8

4 9 9

11

10 12

13

10

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.

40

Sensory supply of the bony structure 1 2 3 4 5

sciatic n. obturator n. tibial n. femoral n. common peroneal n.

1 2

4

5 Areas of distribution: Blue: Femoral nerve and its branches. Yellow: Sciatic nerve and its branches. Green: Obturator nerve (variable innervation).

3

Motor response 1 tibial nerve: plantar flexion, foot inversion 2 peroneal nerve: dorsiflexion, foot eversion 1 The correct response for all proximal sciatic nerve blocks should be in the foot. Either the (medially situated) tibial branch (plantar flexion) or the (laterally situated) peroneal/fibular branch (dorsiflexion) is stimulated. With the Labat and Mansour techniques, a response in the ischiocrural muscles (flexion of the thigh) can also be regarded as a correct motor response.

2

41

Psoas compartment block (acc. to Chayen)

Patient position and method Patient in a lateral position with legs flexed, the back kyphotic and the leg to be blocked uppermost. Guiding structures: L4 vertebral spinous process. A mark is made 3 cm caudal from the L4 vertebral spinous process in the interspinal line. From this point at a right angle to the interspinal line draw a line at a right angle to the midline and mark its lateral end after 5 cm. Check by palpating the posterior iliac spine, which should be in the immediate vicinity. After local infiltration, insert a 10 – 12 cm 22 G needle in the marked point in a sagittal direction. After bony contact (transverse process of the L5), withdraw the needle a few cm and redirect it more cranially. Advance it until stimulation contractions of the quadriceps muscle appear at 0.3 mA/0.1 ms at a depth of 7 – 11 cm, indicating that the tip of the needle is in the immediate vicinity of the femoral nerve. Inject a test dose of the local anaesthetic to preclude an intraspinal 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 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

Side effects/complications: Spinal anaesthesia, epidural-like block due to spread to the epidural 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 or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours) 42

a d a iliac crest b L4 vertebral spinous process c sup. post. iliac spine d needle insertion site: 3 cm caudal and 5 cm lateral of the L4 vertebral spinous process

c

b 1

2

3

4

5

1 2 3 4

lumbar plexus psoas major m. iliac fascia transverse process (costal process) 5 erector spinae m.

direction of needle insertion Body of L5

ventral

dorsal

Needles: E. g. 22 G, 12 cm needle Continuous: 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 a caudal direction

43

Femoral nerve block in the inguinal region ("3-in-1" technique acc. to Winnie, continuous technique acc. to Rosenblatt)

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 the artery. The stimulation cannula is advanced at a 30° angle in a cranial direction until occurence of a double-click, indicating passage through the fascia lata femoris and the fascia iliaca. A motor stimulus response in the quadriceps muscle with a "dancing" kneecap at 0.3 mA/0.1 ms indicates 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 quadriceps response but leads to "anaesthesia failure" so make sure that the patella dances! Avoid intraneural needle insertion (nerve stimulation). Indications: ● When used in combination with a proximal sciatic block, most types of leg surgery ● 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 the femur)

Special contraindications: None Relative contraindications: After e. g. fem. popliteal bypass (useful devices: Doppler, sono), lymphomas in the groin

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 or bolus (alternatively): 20 ml ropivacaine 0.2 – 0.375% (approx. every 6 hours) 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

44

a femoral artery b needle insertion site

b a a

1 lateral femoral cutaneous n. 2 psoas major m. 3 femoral n. 4 obturator n. 5 femoral a.

1

2 3

5

4

Direction of needle: cranially at 30° angle, lateral to and parallel with the femoral artery.

45

Obturator nerve block

The anterior branch (superficial n.) innervates the anterior adductors, the hip joint and, to a varying extent, a section of skin on the inner surface 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 proximal attachment point. Advance the unipolar needle cranially at an angle of approx. 45° to the body's longitudinal axis (toward the sup. ant. iliac spine) and in a slightly dorsal direction. After approx. 4 – 8 cm at 0.3 mA/0.1 ms, contractions of the adductors indicate the proximity of the obturator nerve. A catheter technique can be used for continuous block. The catheter is advanced approx. 3 – 4 cm beyond the tip of the needle in a cranial direction. 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

Local anaesthetics: 10 – 15 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 20 G, 10 cm short bevel, insulated unipolar needle

46

a femoral artery b tendon of the long adductor m.

a b

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

1 2 3

7

4 5 6

Needle insertion: ventral of the tendon attachment in a cranial-dorsal direction (the obturator nerve is at 4 – 8 cm depth).

47

Transgluteal sciatic nerve block (acc. to Labat)

Patient position and method: Patient in a lateral position with the side to be blocked uppermost. The lower leg is stretched, the leg that is to be blocked is flexed in hip and knee-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 needle insertion point is 4 – 5 cm from the first line. A confirming line can be drawn from the trochanter to the sacral hiatus, the insertion point is where the last two lines cross each other. The stimulation needle is advanced perpendicularly to the skin. After 5 – 10 cm, contractions of the dorsiflexors of the foot (common peroneal nerve) or of the plantar flexors of the foot (tibial nerve) at 0.3 mA/0.1 ms indicate the correct position of 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 puncturing inferior gluteal artery)

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

48

a

a greater trochanter b superior posterior iliac spine c site of insertion: direction of needle perpendicular to the skin, 5 – 10 cm deep

b 1

c 2

1 piriformis m. 2 sciatic n.

49

Subgluteal sciatic nerve block (acc. to Raj)

Patient position and method: The patient is supine with the leg to be blocked flexed at hip and knee approx. 90° and held by an assistant. Guiding structures: Greater trochanter, ischial tuberosity. Draw a line between the greater trochanter and the ischial tuberosity and mark its midpoint. This point marks the site for needle insertion. The stimulation needle is advanced perpendicular to the skin surface in a cranial 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 indicate the correct position of the needle. Comments on the technique: Advantage: The patient can remain supine. The technique is easy to learn. The leg can also be placed in a leg support. A continuous technique 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

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 6 hours) 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

50

a site of insertion: midpoint of line between the greater trochanter and the ischial tuberosity b greater trochanter c ischial tuberosity

c

b a

1 sciatic n. 2 greater trochanter 3 ischial tuberosity

1

2 3

51

Proximal anterior/ventral sciatic nerve block (acc. to Meier)

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 of the symphysis is divided into three equal segments. Draw a line parallel to this line through the middle section of the greater trochanter. Then draw a perpendicular line from the junction of the medial and middle segments in a caudal direction. The point where the lines cross each other marks the needle insertion site. Palpate the intermuscular space between the sartorius m. and the rectus femoris m. in this region. Advance the needle at a 60° angle approx. 8 – max. 15 cm in a cranial direction. Avoid bone contact. A motor stimulus response in the foot (dorsi- or plantar flexion at 0.3 mA/0.1 ms) indicates that the needle tip is in the immediate vicinity of the sciatic nerve. Comments on the technique: The palpation of the space between the sartorius and rectus femoris muscles is very important, because the femoral vessels are displaced medially and the distance to the injection site is shortened as a result of the 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

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. 37.5 mg/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 needle Continuous: 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

52

a

c

a the connecting line between the sup. ant. iliac spine and the middle of the symphysis b greater trochanter c needle insertion site

b 1 1 2 3 4 5 6

2

3

4

5

rectus femoris m. sartorius m. femoral n. femoral a. femoral v. sciatic n.

6 lateral

medial right thigh

Direction of needle insertion Note: "two-finger grasp" into the intermuscular space, sciatic nerve at a depth of 8 – 15 cm.

53

Proximal lateral sciatic nerve block

Patient position: Patient supine. The leg lies in neutral position. A small pad or pillow is placed under the foreleg. Guiding structures: Greater trochanter, femur shaft. A line is drawn distally from the prominent part of the greater trochanter parallel to the femur. The injection site is approx. 3 cm below this line at 5 cm distal to the greater trochanter. The needle enters at the level of the dorsal border of the femur and the needle is directed dorsally (approx. 30°) and cranially (approx. 30 – 45°). The sciatic nerve is reached after 8 – 10 cm. Comments on the technique: Muscular contractions in the posterior thigh are frequent. The correct position of the needle tip in the vicinity of the nerve is confirmed by a motor response in the foot (dorsiflexion or plantar flexion) with a pulse amplitude of 0.3 mA and a pulse width of 0.1 ms. The peroneal nerve is in front of the tibial nerve. Dorsiflexion of the foot is therefore usually the initial motor response. If no motor response is produced, the needle should be withdrawn and its direction should be corrected anteriorly when it is advanced again. Indications: ● All operations on the leg in combination with a lumbar plexus block ● Pain therapy ● Sympathicolysis

Special contraindications: None

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 6 hours) Needles: 20 G, 10 cm, 30° or 15° unipolar needle Continuous: E. g. 19.5 G, 10 cm, facetted tip, Plexolong set® (Pajunk co.). The catheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction.

54

a greater trochanter with a line parallel to the femur b needle insertion site 5 cm distal to the greater trochanter and 3 cm below line a (just behind the femur)

a

b

1 greater trochanter 2 sciatic n.

1

2 Direction of needle: approx. 30° dorsally and cranially

55

Distal lateral sciatic nerve block

Patient position: Patient supine. The leg is supported at the foot so that the thigh sags freely. Guiding structures: Upper border of patella, biceps femoris (long head), vastus lateralis. The needle insertion site is located approx. 12 cm proximal to the upper border of the patella between the upper border of the biceps femoris and the lower border of the vastus lateralis. The needle is directed approx. 20° – 30° dorsally and approx. 45° cranially. A motor response in the foot 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 femoris muscle, brief elevation and flexion the patient’s leg is recommended. An additional saphenous nerve block is required for complete anaesthesia of the 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, circulatory or wound healing disorders, CRPS)

Special contraindications: None

Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75% 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 6 hours) Needles: 22 G, 10 – 12 cm unipolar needle Continuous: E. g. 19.5 G, 10 – 12 cm, catheter 20 G (Plexolong set®, Pajunk co.). The catheter is advanced 4 – 5 cm beyond the needle tip in a cranial direction.

56

1

1 vastus lateralis m. 2 iliotibial tract 3 level for anatomical cross section 4 patella 5 biceps femoris m. (long head) with tendon 6 biceps femoris m. (short head) 7 sciatic n. with peroneal division (thinner, lateral) and tibial division (thicker, medial)

3

2

5

4

6

5

lateral

medial

1 6 2 7 5 right thigh 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

e d

Direction of needle: 20° – 30° dorsally, 45° cranially

c

b

a

57

Distal posterior sciatic nerve block (acc. to Meier)

Patient position and method: Patient in the lateral position with the lower leg semi-flexed in hip and knee. The leg to be blocked is uppermost and stretched, a pillow placed between the knees as a comforting support. Alternatively: Patient supine with the leg to be blocked flexed in the hip and knee (leg support necessary). Guiding structures: Flexion fold ("wrinkle") of the popliteal fossa. Laterally: biceps femoris m.; medially: semimembranous m., semitendinous m., popliteal artery. The thumb and the middle finger are placed on the epicondyles and a symmetric triangle is formed cranially with the index finger. This triangle corresponds closely to the boundaries of the upper popliteal fossa, with its cranial angle approx. 8 – 12 cm proximal to the flexion fold. The insertion site is 1 – 2 cm lateral of the tip of the triangle immediately medial to the tendon of the biceps femoris muscle. The needle is advanced in a cranial direction at a 30° – 45° angle to the skin and slightly medially. A stimulus-response in the foot can be expected after 4 – 6 cm, (peroneal n.: dorsiflexion; tibial n.: plantar flexion) at 0.3 m/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 arrangement in the fossa poplitea, from lateral to medial: biceps femoris muscle, common peroneal nerve, tibial nerve, popliteal artery. In case of a tourniquet below the knee, it is recommendable to add a saphenous nerve block (see p. 60). This block is particularly well suited for a continuous technique (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

Local anaesthetics: Initial: 30 – 40 ml lidocaine 1% or mepivacaine 1% or 30 ml ropivacaine 0.75% 58

a

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

c b

4 1 semimembranosus m. 2 semitendinosus m. 3 popliteal a. 4 biceps femoris m. 5 sciatic n. 6 tibial n. 7 peroneal n.

5 1

6

2

7

3

lateral

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 6 hours) Needles and catheters: Shortbevel, unipolar needle 22 G, 5 – 10 cm Continuous: 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

59

Saphenous nerve block

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 carried out with a 6 cm long 24 G needle in the direction of the medial head of the gastrocnemius m. Comments on the technique: Accidental puncture of the saphenous vein (rare) can be excluded by repeated 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

Local anaesthetics: 5 – 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 24 G, 6 cm

60

a tuberosity of tibial b medial head of gastrocnemius m. c needle insertion site: subcutaneous injection

b

a

direction of insertion toward the medial head of the gastrocnemius m. c 1

2

1 infrapatellar branches of the saphenous n. 2 sartorius m. 3 saphenous n.

medial 3

61

Common peroneal nerve block

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 of the unipolar needle is perpendicular to the skin, stimulus-response in the foot (dorsiflexion of the foot) at 1 – 3 cm. Injection of the local anaesthetic at 0.3 mA/0.1 ms. Comments on the technique: Nerve stimulation strongly recommended, as the peroneal nerve is very sensitive.

Indications: ● Incomplete anaesthesia following sciatic block ● Diagnostic block ● Pain therapy

Special contraindications: None

Local anaesthetics: 5 ml lidocaine 1% or mepivacaine 1% or 5 ml ropivacaine 0.75% Needle: unipolar 22 G, 5 cm

62

a

a head of the fibula b site of insertion needle perpendicular to the skin nerve 1 – 3 cm deep

b

1 biceps femoris m. 2 common peroneal n. 3 head of fibular bone

1

2

3 lateral

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Blocks for anaesthesia in the foot (ankle blocks) (acc. to Löfström)

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 the tibia and the upper edge of the lateral malleolus with 5 – 10 ml local anaesthetic: (Anaesthesia distribution: Skin on the back of the foot and the toes, except an area between the greater and second toes.) Sural nerve: The sural n. is blocked by subcutaneous infiltration of 5 ml local anaesthetic between the Achilles tendon and the lateral malleolus. (Anaesthesia distribution: Lateral edge of the foot, variable up to the 5th toe.) Saphenous nerve: Subcutaneous infiltration of 5 – 10 ml local anaesthetic from the anterior edge of the tibia to the Achilles tendon, approximately a hand-width above the medial malleolus. (Anaesthesia distribution: skin medially from the inner ankle variable up to the great toe.) Comments: If this subcutaneous block is initially performed as a ring-shaped infiltration, subsequent needle-sticks will be pain-free.

64

Subcutaneous ring infiltration above the ankle to block the – superficial peroneal and sural nerves (lateral) – saphenous n. (medial)

3

2 1 sural n. 2 superficial peroneal n. 3 deep peroneal n.

1

65

Ankle block

Deep peroneal nerve (acc. to Löfström)

Block of the deep peroneal nerve The needle is inserted between the tendon of the long extensor pollicis muscle and the dorsalis pedis artery on the back of the foot. The needle is inserted perpendicularly to the skin and advanced slightly under the artery. Following negative aspiration, injection of 5 ml local anaesthetic. Anaesthesia distribution: Skin of the medial side of the great toe and the lateral side of the 2nd toe. Local anaesthetics: 5 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% Needle: 24 G, 3 – 5 cm

66

a a tendon of the long extensor pollicis muscle b dorsalis pedis a.

b

4 4 1 2 3 4

superficial peroneal n. saphenous n. dorsalis pedis a. deep peroneal n.

3

2

1

67

Ankle block

Posterior tibial nerve (acc. to Löfström)

Tibial nerve block: The needle insertion point lies directly dorsal to the posterior tibial artery on the medial side of the joint, or alternatively, directly anterior of the Achilles tendon at the level of the medial malleolus. The needle is inserted perpendicular to the skin. 5 – 8 ml local anaesthetic are injected using intermittent aspirations. Warning: In case of paresthesias, withdraw the needle to avoid injury to the nerve. (Anaesthesia distribution: Sole of the foot with the exception of its extreme lateral and proximal segments.) Comments (recommendation): Nerve stimulation and a unipolar 5 cm 22 G or 24 G, needle is recommended (stimulus-response: Plantar flexion of the toes).

The following applies to ankle blocks: Indications: ● Incomplete plexus lumbosacral block ● Foot surgery ● Pain therapie ● Diagnostic blocks

Special contraindications: None. In case of neurological deficits, check diagnosis before initiating the block

Local anaesthetics: 5 – 10 ml lidocaine 1% or mepivacaine 1% or ropivacaine 0.75% per injection Needles: 22 – 24 G, 4 – 6 cm

68

a

a posterior tibial a. needle insertion dorsal of the artery, direction perpendicular to the skin

1 saphenus n. 2 posterior tibial a. 3 tibial n.

3

2

1

69

Notes

Notes – own experience – phone numbers – pain service, etc.

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 Kliniken Hubertusstraße 40 D-82487 Oberammergau, Germany Dr. Johannes Büttner, M.D. Head of the Department of Anaesthesia Berufsgenossenschaftliche Unfallklinik Murnau Professor-Küntscher-Straße 8 D-82418 Murnau, Germany The English version was revised by: Dag Selander, MD, PhD, c/o Selmedic HB Betzensgatan 1 S-414 55 Göteborg, Sweden