Lower Extremity Blocks


Article Author:
Thomas Rodziewicz
Bo Zhu


Article Editor:
Emily Garmon


Editors In Chief:
Sisira Reddy
Joseph Nahas
Chokkalingam Siva


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/3/2019 9:12:45 PM

Introduction

The lumbosacral plexus (L1 to S4 nerve roots) innervates the lower extremity. Unlike the brachial plexus in the upper extremity, the lumbosacral plexus is not easily blocked with a single-injection technique. Consequently, neuraxial blocks were preferred in the past when lower extremity anesthesia or analgesia was desired. As technological advancements have increased the number of outpatient procedures, neuraxial techniques have become less desirable. [1][2][3][4]Simultaneously, ultrasound-guided techniques have gained widespread use and popularity, which has improved identification of individual nerves and accuracy of lower extremity blocks. Although two or more separate injections are usually required for a complete lower extremity block, this is often the best option available for outpatients.

Anatomy

The lumbosacral plexus divides into four nerves (femoral, lateral femoral cutaneous, obturator, and sciatic), which entirely innervate the lower extremity. The femoral nerve provides sensation and motor function to the anterior thigh. It continues as the saphenous nerve to provide sensation to the medial leg, foot, and great toe. The lateral femoral cutaneous nerve supplies sensation in the lateral thigh. The obturator nerve supplies sensory to the medial thigh and motor to the thigh adductors. Neither the lateral femoral cutaneous nor the obturator nerve have any sensory or motor input to the lower leg. The sciatic nerve runs with the posterior cutaneous nerve of the thigh and provides sensory and motor to the posterior thigh. The sciatic nerve continues posteriorly and divides into the tibial and common peroneal nerves just cephalad to the popliteal fossa, and provides sensory and motor to the anterior, lateral, and posterior lower leg. Five nerves provide sensory and motor to the foot: 

  • Saphenous nerve supplies sensation to the medial foot and great toe
  • Deep peroneal supplies the web space between the great toe and the second toe
  • Superficial peroneal nerve supplies the dorsal foot and toes
  • Sural nerve supplies the lateral foot and fifth toe
  • Posterior tibial nerve supplies the sole and plantar surface of the toes.

Indications

Lower extremity blocks are used for people who are having surgery on the hip, knee, ankle, or foot. In many cases, the patient may not be a candidate for general or neuraxial anesthesia.[5][6]

Contraindications

Lower extremity blocks should not be performed under the following conditions:[7][8]

  • Presence of coagulopathy
  • Low platelet count
  • Patient on oral anticoagulants
  • Skin infection at the site of the block
  • Systemic infection
  • Allergy to local anesthetic

Equipment

Equipment used includes:

  • Povidone iodine solution or chlorhexidine
  • Sterile towels and gauze
  • Sterile gloves (gown is required for catheter placement, but not single shot block)
  • Control syringe to aspirate before injection of local anesthetic (block volume is typically 20 mL to 40 mL) 
  • Needles (18 or 20 gauge needle for drawing up the local anesthetic and a 25 gauge needle for injection)
  • Local anesthetic with epinephrine and/or other additives, such as dexamethasone or dexmedetomidine

Personnel

It is important to understand that a lower extremity block is a minor procedure but has the potential to cause major complications. Thus, the procedure should be performed in a designated area with standard American Society of Anesthesiologists (ASA) monitors, intravenous access, and resuscitation drugs and equipment immediately available, including intralipid.

Technique

Types and Techniques

The femoral nerve can be blocked deep to the fascia iliaca just caudad and medial to the anterior superior iliac spine (fascia iliaca compartment) or at the femoral crease. Anatomic, stimulator, and ultrasound-guided techniques have been described. The fascia iliaca is a continuous band of fascia in this region, so local anesthetic injected under this fascia reliably produces a block of the femoral and lateral femoral cutaneous nerves. The obturator nerve is less reliably blocked the more caudad the block is performed. The saphenous nerve can be blocked at the mid-shaft femur (adductor canal) or with a field block at the tibial plateau. Saphenous nerve blocks have gained recent popularity because the sensation is blocked while sparing motor function for ideal physical therapy and rehabilitation.

The sciatic nerve is blocked in the gluteal region (classical approach) between the greater trochanter and ischial tuberosity, just deep to the gluteus muscles and superficial to the quadratus femoris. The sciatic nerve can also be blocked as it travels through the thigh adductors (anterior sciatic approach). Finally, the sciatic nerve can be blocked approximately 6 cm above the popliteal fossa (popliteal block) before the nerve dividing into the tibial and common peroneal nerves. Anatomic and ultrasound-guided approaches have been described for blockade of the sciatic nerve at these three main locations.

A complete block of the foot can be accomplished at the ankle with five injections. The saphenous nerve is blocked anterior to the medial malleolus. The deep peroneal nerve is blocked at the anterior ankle between the extensor hallucis longus and extensor digitorum longus. The superficial peroneal nerve is blocked anterior to the lateral malleolus. The sural nerve is blocked between the lateral malleolus and the Achilles tendon. The posterior tibial nerve is blocked posterior to the medial malleolus.

Complications

Local Complications from the Injection

  • Hematoma
  • Infection
  • Injury to the nerve
  • Anesthetic blockade of adjacent structures
  • Block failure

Systemic Toxicity

  • Dizziness, lightheadedness
  • Blurred vision
  • Ringing, buzzing in ears
  • Metal taste in mouth
  • Numbness/tingling around mouth, fingers or toes
  • Drowsiness or confusion
  • Seizures and cardiac arrest

Clinical Significance

The femoral nerve block includes both motor and sensory nerves. This block can be used for surgery on the knee or repair of trauma to the medial aspect of the upper and lower extremity. After the procedure, the patient will have marked weakness in the quadriceps and should not be allowed to ambulate until all sensation has returned.

The adductor canal block is similar to the femoral nerve block but only affects the lower extremity and blocks the sensory nerves. It can also be used for surgery on the knee and medial aspect of the lower leg.

The popliteal block at the knee is often used for surgery on the lower extremity.

The fascia iliac compartment block can block the femoral, obturator and lateral femoral cutaneous nerves. It is often used for hip fractures and total hip arthroplasties. The block provides prolonged pain relief in the hip, anterior and medial thigh area.

Most lower extremity blocks last 6 to 24 hours. However, it is important to remember that sometimes these local nerve blocks may not work or the duration may be short. Other options for lower extremity blocks include the use of spinal and epidural anesthesia.

Enhancing Healthcare Team Outcomes

Lower extremity blocks are usually performed by anesthesiologists but it is vital that a nurse is dedicated to the monitoring of the patient. Resuscitative equipment must be in the room where the procedure is being done. Complications, though rare, do have the potential to cause cardiac or respiratory arrest, bleeding and nerve damage.[9] an interprofessional team approach will provide the safest and best results for the patient. [Level V]


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Lower Extremity Blocks - Questions

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In a properly performed femoral nerve block, where should the local anesthetic spread?



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Where should the needle be inserted to perform a sciatic nerve block at the location where the tibial and common peroneal nerves divide?



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A patient with numerous comorbidities is about to undergo knee surgery. The anesthesiologist decides to perform a nerve block at the location shown in the image. What is the key benefit of such a block?

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Lower Extremity Blocks - References

References

Vermeylen K,Desmet M,Leunen I,Soetens F,Neyrinck A,Carens D,Caerts B,Seynaeve P,Hadzic A,Van de Velde M, Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer study. Regional anesthesia and pain medicine. 2019 Feb 22;     [PubMed]
Tran Q,Salinas FV,Benzon HT,Neal JM, Lower extremity regional anesthesia: essentials of our current understanding. Regional anesthesia and pain medicine. 2019 Jan 11;     [PubMed]
Griffioen MA,OʼBrien G, Analgesics Administered for Pain During Hospitalization Following Lower Extremity Fracture: A Review of the Literature. Journal of trauma nursing : the official journal of the Society of Trauma Nurses. 2018 Nov/Dec;     [PubMed]
Zhang X,Sun C,Bai X,Zhang Q, Efficacy and safety of lower extremity nerve blocks for postoperative analgesia at free fibular flap donor sites. Head     [PubMed]
Bugada D,Bellini V,Lorini LF,Mariano ER, Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiology clinics. 2018 Sep;     [PubMed]
Sinha SK,Suter S, New blocks for the same old joints. Current opinion in anaesthesiology. 2018 Oct;     [PubMed]
Borenstein TR,Anand K,Li Q,Charlton TP,Thordarson DB, A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty. Foot     [PubMed]
Fraser TW,Doty JF, Peripheral Nerve Blocks in Foot and Ankle Surgery. The Orthopedic clinics of North America. 2017 Oct;     [PubMed]
Fiedler MA, AANA journal course: update for nurse anesthetists-improving the safety of subarachnoid and epidural blocks--Part A. AANA journal. 1997 Aug;     [PubMed]

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