54 Lower Extremity
Nerve Blocks
Uma Shastri | Kwesi Kwofie | Emine Aysu Salviz | Daquan Xu | Admir Hadzic
INTRODUCTION
Lower extremity blocks (LEBs) are common techniques
for surgical anesthesia and postoperative analgesia. They
are being used more frequently in the setting of outpa-
tient surgery worldwide because of their favorable recov-
ery and side effect profile when compared with general
and neuraxial anesthesia.1-3 LEBs may decrease the inci-
dence of postoperative pain syndromes, including chronic
postamputation phantom limb pain.4,5 In addition to
surgical applications, LEBs have also been reported to
be beneficial in patients with complex regional pain syn-
drome, chronic cancer pain, peripheral vascular diseases
(ischemia, Reynaud’s disease, peripheral embolism),
intractable phantom limb pain, and spasticity.6-9 Con-
tinuous LEBs with perineural catheters can also provide
analgesia for an extended period.6,10 Moreover, neuroly-
sis of lower extremity peripheral nerves can also be per-
formed with techniques analogous to peripheral nerve
blockade.11,12
Ultrasound-guided techniques are becoming more preva-
lent methods of performing LEBs in many centers. Several
reports have suggested that ultrasound guidance results in
more precise needle and catheter placement during LEBs
than do blocks performed with nerve stimulator or landmark
techniques only or with both.13
This chapter provides an overview of the relevant anat-
omy of the lower extremity, technical aspects of perform-
ing LEBs, and common indications for their use in clinical
practice.
ANATOMY
Innervation of the lower extremity is derived from both the
lumbar plexus and the sacral plexus, sometimes referred as
the lumbosacral plexus.
LUMBAR PLEXUS
The lumbar plexus is made up of the L1 through L5 spinal
nerve roots. As the L2, L3, and L4 roots of the lumbar plexus
depart from their spinal nerves and emerge from the inter-
vertebral foramen, they enter the posterior third of the psoas
muscle.14 Once in the muscle, these roots then become orga-
nized into anterior and posterior divisions. The divisions
reunite to form the iliohypogastric, ilioinguinal, genito-
femoral, lateral femoral cutaneous, femoral, and obturator
732
nerves15 (Fig. 54.1). The most significant nerves in the lower
extremity are the femoral, lateral femoral cutaneous, and
obturator nerves.
The femoral nerve is formed by the posterior divisions of
L2-4. The nerve descends from the plexus lateral to the
psoas muscle. The femoral nerve innervates the rectus
femoris, vastus medialis, vastus intermedius, and vastus
lateralis muscles. It also provides cutaneous sensory inner-
vation to much of the anterior and medial aspects of the
thigh, as well as the medial part of the leg distal to the knee
(Fig. 54.2).
The lateral femoral cutaneous nerve is formed from the L2
and L3 nerve roots and, as its name indicates, is a cutaneous,
sensory nerve. It provides sensation to the lateral aspect of
the thigh (see Fig. 54.2).
The obturator nerve (L2-4) provides sensory innervation to
a variable portion of the leg proximal to the knee, as well as
motor innervation to the adductor muscles (see Fig. 54.2).
The iliohypogastric and ilioinguinal nerves are primarily sen-
sory nerves that arise from L1 and supply innervation to the
skin of the suprapubic and inguinal regions.
The genitofemoral nerve arises from the L1 and L2 roots
and supplies motor innervation to the cremasteric muscle
and additional sensory innervation to the inguinal area.
SACRAL PLEXUS
The sacral plexus is formed from the L4-S3 nerve roots
(Fig. 54.3). It is shaped like a triangle pointing toward the
sciatic notch, with its base spanning across the anterior
sacral foramina. The roots of the sacral plexus lie on the
anterior surface of the lateral sacrum and form the sciatic
nerve on the ventral surface of the piriformis muscle.16 The
sacral plexus gives rise to one major nerve and six collateral
nerve branches. The sciatic nerve exits the pelvis through
the greater sciatic notch and then descends between the
greater trochanter of the femur and the ischial tuberosity.
It runs along the posterior part of the thigh to the lower
third of the femur, where it diverges into two divisions: the
tibial and common peroneal. The sciatic nerve provides
motor and sensory innervation to the hamstring muscles
and the entire leg below the knee with the exception of
the cutaneous region medially, which is innervated by the
saphenous nerve (see Fig. 54.2). The posterior cutaneous
nerve of the thigh exits the pelvis with the sciatic nerve but
then diverges posteriorly to become a cutaneous nerve that
is the major sensory nerve from the sacral plexus within
the thigh.17