Chapter
Lower extremity nerve blocks
61 Mônica M. Sá Rêgo and Adam B. Collins
his chapter presents an overview of the anatomy and describes
the most commonly used techniques for performance of lower
extremity nerve blocks.
Lumbar plexus
he lumbar plexus (Fig. 61.1) is formed by the anterior rami
of the irst four lumbar spinal nerves (L1–4) with occasional
contributions from T12 and L5. Lower-extremity nerves orig-
inating from the lumbar plexus include the femoral nerve (L2–
4), obturator nerve (L2–4), and lateral femoral cutaneus nerve
(L2–3).
Femoral nerve block
Anatomy
he femoral nerve originates from L2–4 and is the largest
nerve of the lumbar plexus. It emerges from the psoas muscle,
descending in the groove between the psoas and the iliacus. On
its course to the thigh, it remains deep to the fascia lata and
fascia iliaca, where the femoral vessels lie in a plane between
these two fascial layers. At the level of the inguinal ligament, it
lies anterior to the iliopsoas muscle and lateral to the femoral
artery. At the level of the inguinal crease, the femoral nerve is
wider and more supericial than at the level of the inguinal lig-
ament. Ater passing under the inguinal ligament, the femoral
nerve divides into anterior and posterior branches. he femoral
nerve supplies the sartorius, pectineus, and quadriceps muscles;
the knee joint; the skin of the anterior and medial thigh; and the
medial aspect of the leg (Fig. 61.2). he surface landmarks for a
femoral nerve block are the anterior superior iliac spine, pubic
tubercle, inguinal ligament, inguinal crease, and femoral artery
pulse (Fig. 61.3).
he femoral nerve is closely associated with the femoral
artery and vein but is not located in the same anatomic compart-
ment. hese vessels travel in the femoral sheath, but the femoral
nerve lies over the iliopsoas muscle and is physically separated
from the vessels by the fascia iliaca. his position prevents local
anesthetic spread around the nerve if injected on the side of the
vascular bundle. he mnemonic VAN, which describes the rela-
tionship of the femoral vein, artery, and nerve medially to lat-
erally, should be remembered (Fig. 61.4).
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Technique
he patient should be supine with the leg to be blocked posi-
tioned in slight abduction. Ater sterile skin preparation and
draping, the skin is iniltrated with 1% lidocaine. A 22-gauge
short-bevel insulated stimulating needle is inserted at a 45◦
angle cephalad, 1 cm lateral to the femoral artery pulse just
below the inguinal crease. he peripheral nerve stimulator is set
at 1.5 to 2.0 mA. he needle is advanced slowly until upward
movement of the patella is observed. he current output is
decreased and the needle advanced until the patellar movement
is seen with a stimulation of 0.3 to 0.5 mA. Ater negative aspi-
ration, 20 ml of local anesthetic is injected in small increments.
he femoral nerve also may be blocked as part of the fas-
cia iliaca compartment block. A short-bevel needle is intro-
duced below the junction of the medial and lateral thirds of the
inguinal ligament and slowly advanced until two losses of resis-
tance are felt (fascia lata and fascia iliaca), then 20 to 30 ml of
the local anesthetic is injected.
If using ultrasound technology, a linear high-frequency
transducer (10–15 MHz) is applied in the short axis just inferior
to the inguinal ligament (that extends from the anterior supe-
rior iliac spine to the pubic tubercle; Fig. 61.4). Ater identifying
the femoral vessels, the artery and vein can be distinguished by
compression with the transducer. he femoral vein is collapsible
under the pressure, whereas the femoral artery has pulsations.
At this level, the femoral nerve has a lattened triangular shape,
is usually hyperechoic, and may show small fascicles (Fig. 61.5).
It lies at an angle at the junction between the hyperechoic sub-
cutaneous tissue and hypoechoic iliopsoas muscle.
Using the out-of plane (OOP) approach, a 22-gauge short-
bevel 2–3 inch needle is inserted caudal to the transducer at
a 45◦ cephalad inclination, aiming for the lateral edge of the
femoral nerve (Fig. 61.4). Two fascial pops can be appreciated
by palpation and sonogram. he irst is the needle traversing the
fascia lata and the second, the fascia iliaca.
For the IP approach, a longer, 22-gauge 3.5–4 inch needle
is advanced laterally to medially under real-time visualization
(Fig. 61.5). Eforts should be made to image the tip of the needle,
not only the shat, to avoid vascular puncture that may result
from advancing the needle too far. Short-bevel needles tend to
deform fascia and then produce signiicant recoil as they pierce

fascial planes, requiring some redirection to achieve optimal
needle position.
Ater negative aspiration, 20 to 30 ml of local anesthetic
solution is injected incrementally with real-time monitoring of
the distribution of the solution (Fig. 61.6). Needle position may
have to be adjusted to produce circumferential spread.
Lateral femoral cutaneous nerve block
Lateral femoral cutaneous nerve block is used for the diagnosis
and treatment of meralgia paresthetica, and is combined with
femoral and/or sciatic nerve blocks to allow the use of a thigh
tourniquet. It also may be done to provide anesthesia on the
lateral aspect of the thigh for skin procedures.
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Chapter 61 – Lower Extremity Nerve Blocks
Figure 61.1. The lumbar plexus.
Anatomy
he lateral femoral cutaneous (L2–3) nerve emerges along the
lateral border of the psoas muscle caudad to the ilioinguinal
nerve. It courses deep to the iliac fascia to emerge from the fascia
immediately inferior and medial to the anterior superior iliac
spine. It divides into anterior and posterior branches below the
inguinal ligament.
Technique
A short-bevel 22-gauge needle is inserted 2 cm medial and
2 cm caudal to the anterior superior iliac spine. he needle is
advanced until a pop and loss of resistance are felt as the needle
passes the fascia lata. About 10 ml of local anesthetic solution is
injected in a fanlike fashion above and below the fascia lata.
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 Part 10 – Regional Anesthesia
Figure 61.2. Cutaneous distribution of the femoral nerve.
Obturator nerve block
he obturator nerve block is more oten combined with the
femoral, sciatic, and lateral femoral cutaneous blocks for surg-
eries on the lower extremities. It can be used as a single nerve
block in urologic surgery to suppress the obturator relex dur-
ing transurethral resection of lateral bladder wall, or to relieve
adductor muscle spasm.
Anatomy
he obturator nerve (L2–4) emerges medially to the psoas mus-
cle at the pelvic brim. It runs caudad in the retroperitoneum to
the obturator canal, where it divides into anterior and poste-
rior branches. hese provide sensory innervation of the medial
thigh and hip joint and motor supply to the thigh adductors.
he landmarks for this block are the anterior and superior iliac
spines, pubic tubercle, inguinal ligament, femoral artery, and
tendon of the long abductor muscle.
Technique
he block is performed at the inguinal level to facilitate its
performance and make it less uncomfortable for patients. he
inguinal fold is identiied, and a line is drawn from the femoral
artery pulse to the tendon of the long adductor muscle (iden-
tiied during leg abduction). A 22-gauge needle connected to
a nerve stimulator is inserted at the midpoint of the line at a
30◦ angle and directed anteriorly/posteriorly and cephalad. he
needle is advanced slowly and slightly laterally until a response
at 0.3 to 0.5 mA from the major adductor muscle is obtained.
About 10 to 15 ml of local anesthetic solution is then injected
ater negative aspiration.
372
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Sciatic nerve block
Anatomy
he sciatic nerve, the largest nerve in the body, originates from
L4–S3 in the pelvis on the anterior surface of the piriformis
muscle (Fig. 61.7). It exits the pelvis through the greater sci-
atic foramen, then descends between the greater trochanter of
the femur and the ischial tuberosity. It runs along the poste-
rior thigh to the lower part of the femur, where it splits into the
tibial and common peroneal nerves (usually 5–12 cm proximal
to the popliteal fossa crease). In the popliteal fossa, the sciatic
nerve runs slightly lateral to the midpoint between the biceps
femoris (lateral) and the semitendinosus tendons (medial),
where it lies lateral and supericial in relation to the popliteal
vessels.
he common peroneal nerve descends along the head and
neck of the ibula. Its terminal branches are the supericial and
deep peroneal nerves. he tibial nerve is larger and descends
vertically through the popliteal fossa. Its terminal branches
are the medial and lateral plantar nerves. Because the tibial
nerve has a more deined sheath, an injection of a large vol-
ume of local anesthetic in its sheath may have a higher success
rate compared with injection in the common peroneal sheath.
he cutaneous distribution of the sciatic nerve is shown in
Fig. 61.8.
Several approaches to block the sciatic nerve have been
described since Victor Pauchet irst presented the sciatic nerve
block in 1920. he sciatic nerve block can be performed
via the classic approach (Labat), the subgluteal approach (di
Benedetto), the Franco approach, or the popliteal fossa distal
approach. he sciatic nerve block is indicated for major pro-
cedures below the knee, and it is usually combined with the
femoral nerve block.
Technique
Classical approach
he landmarks used for the classical approach are the greater
trochanter and the posterior superior iliac spine (Fig. 61.9a).
he patient should be in the lateral position, slightly rotated for-
ward, with the dependent leg extended and the leg to be blocked
lexed. he landmarks are marked and a line is drawn between
them. A perpendicular line is then drawn distal to the mid-
point of the above line. he needle insertion site is 4 cm dis-
tal to the midpoint (Fig. 61.9b). Ater sterile skin preparation
and draping, the skin is iniltrated with 1% lidocaine. A 4–6
inch needle is inserted perpendicular to all planes. he nerve
stimulator is set at 1.5 to 2.0 mA, and the needle is advanced
slowly and the current gradually reduced until twitches of the
foot are seen at 0.3 to 0.5 mA (Fig. 61.10). he sciatic nerve is
usually located at a depth of 5 to 8 cm with this approach. Ater
negative aspiration, 20 to 25 ml of local anesthetic solution is
injected slowly. If the aforementioned approach fails to elicit
twitches, the needle is redirected in a slightly caudal or cephalad
direction.
 Chapter 61 – Lower Extremity Nerve Blocks

B
Figure 61.3. Surface landmarks and technique for blockade of the femoral nerve. (A) Anatomic position of the femoral nerve. (B) Landmarks and needle
insertion point for femoral nerve block.

373
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 Figure 61.4. Femoral block OOP approach. VAN, femoral
vein, artery, and nerve; X, needle insertion site.

A B
Figure 61.5. Femoral block IP approach. FA, femoral artery; FV, femoral vein; FN, femoral nerve; IPM, iliopsoas muscle.

Figure 61.6. Femoral nerve post injection. FA, femoral artery; FV, femoral vein; FN, femoral nerve; LA, local anesthetic.

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 Chapter 61 – Lower Extremity Nerve Blocks

Subgluteal approach
he subgluteal approach has the potential to decrease the dis-
comfort usually seen with the classical posterior approach.
he patient is placed at the same position as for the classical
approach. he landmarks are the greater trochanter of the femur
and the ischial tuberosity. A line is drawn between the two,
with the midpoint marked. he needle insertion point will be
4 cm caudad to the midpoint marked. he needle should be
inserted perpendicular to all planes and foot twitches noticed,
as described earlier (Fig. 61.11).

Franco approach
he Franco approach is based on the concept that the relation
of the sciatic nerve to the pelvis is similar in all adults and that
the posterior projection of the ischial tuberosity is located at
approximately the same distance from the midline. he land-
mark for this approach is the intergluteal sulcus (midline). A
point 10 cm lateral to the midline is marked, and the needle is
inserted at this point. his approach can be performed with the
patient in the lateral or prone position. he rest of the technique
is similar to the classical approach.

Popliteal fossa approach (posterior and lateral)

he popliteal fossa block is used primarily for foot and ankle
surgery and postoperative pain control. he analgesia provided
by popliteal fossa blocks lasts longer than that of ankle blocks.
he popliteal fossa block can be performed through a poste-
rior or lateral approach, and it can be done as a single injec-
tion or continuous technique. Both approaches are discussed
below.

Posterior approach
he patient should be in the prone position, and the foot to be
blocked should be either protruding from the end of the bed
Figure 61.7. The sciatic nerve.

Figure 61.8. Cutaneous distribution of the branches of the

sciatic nerve.

375
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 Part 10 – Regional Anesthesia

Figure 61.9. Posterior (classical Labat) approach

to sciatic nerve block. (A) Landmarks. (B) Point of
needle insertion.

Figure 61.10. Movements observed when stimulating branches of the sciatic nerve.

376
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or slightly elevated, to allow for observation of foot movement.
he landmarks are the popliteal fossa crease, the tendon of the
biceps femoris laterally, and the tendons of the semitendinosus
and semimembranosus medially. he patient is asked to lex the
knee to facilitate visualization of the tendons. he point of nee-
dle insertion is marked at 7 to 9 cm above the popliteal fossa
crease, at the midpoint between the tendons (Fig. 61.12).
Under sterile technique and skin iniltration with 1% lido-
caine, a 22-gauge stimulating needle is inserted and directed
proximally at a 45◦ angle. his should not result in local
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Chapter 61 – Lower Extremity Nerve Blocks
Figure 61.11. Subgluteal approach to sciatic
nerve block. (A) Landmarks. (B) Point of needle
insertion.
muscular twitches. he stimulating current is decreased from
1.5 to 2.0 mA until foot twitches are observed at 0.3 to 0.5 mA,
usually at 3 to 5 cm from the skin (Fig 61.10b). Ater nega-
tive aspiration, 30 ml of local anesthetic is injected. Injection of
local anesthetic ater stimulation of the tibial nerve is preferred,
because it may result in a higher success rate.
he continuous popliteal block technique is similar to the
aforementioned technique, but a 17-gauge Touhy type needle
is used to allow insertion of a catheter. he catheter should
be inserted 5 to 10 cm beyond the skin. Popliteal catheters
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 Part 10 – Regional Anesthesia

Figure 61.12. Popliteal block OOP approach. X, needle insertion site.

A B
Figure 61.13. Popliteal block IP approach. PA, popliteal artery; TN, tibial nerve; CPN, common peroneal nerve; BFM, biceps femoris muscle.

378
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Figure 61.14. Popliteal block post injection. TN, tibial nerve; CPN, common peroneal nerve; LA, local anesthetic.
have been used successfully to manage postoperative pain ater
lower-extremity orthopedic procedures.
When this block is performed with the use of ultrasound
imaging, the patient is positioned prone, as described above,
for the OOP approach. Ater patient preparation, a linear
high-frequency transducer (10–15 MHz) is applied in short
axis slightly above the popliteal crease (Fig. 61.13). Once the
popliteal artery is identiied, the tibial nerve usually lies just
supericial and can be traced retrograde until it joins with the
common peroneal nerve, at the point of the bifurcation of the
sciatic nerve (Fig. 61.13). Sliding and tilting the transducer tend
to make the bifurcation more evident, as the operator can see
one structure becoming two. his is usually the best location
to perform a successful conduction block, because the proxi-
mal sciatic nerve is usually deeper and more encased in muscle,
making it harder to image well. A 22-gauge short-bevel 2–3 inch
needle is inserted with a 45◦ cephalad angulation and slowly
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Chapter 61 – Lower Extremity Nerve Blocks
advanced as the transducer is manipulated to seek the needle
tip position.
Lateral approach
he lateral approach usually is used when the patient cannot be
placed in the prone position. he patient should be in the supine
position with the foot to be blocked elevated to allow visualiza-
tion of foot movement. he landmarks for this approach are the
popliteal fossa crease, the vastus lateralis muscle, and the biceps
femoris muscle. Under sterile technique, the needle is inserted
in the groove between the vastus lateralis and biceps femoris
muscle, about 10 cm above the popliteal crease. he needle is
advanced perpendicular to skin until it contacts the femur, then
it is withdrawn and redirected at a 30◦ angle posteriorly until
foot twitches (depth of 5–7 cm) are observed, as with the pos-
terior approach. he IP approach with the use of ultrasound
imaging has the advantage of allowing the patient to remain
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 Part 10 – Regional Anesthesia
supine. he ipsilateral leg is elevated on a lit or suspended by
a sling to allow enough space beneath the thigh for the ultra-
sound probe. A 20- or 22-gauge 3–4 inch needle is introduced
using landmarks as described above (Fig. 61.13). he needle is
advanced under real-time visualization, adjusting the angle and
position of the transducer to image the needle shat and tip.
Either the entire sciatic nerve or the tibial and common per-
oneal components should show local anesthetic spreading cir-
cumferentially, with approximately 30 ml of solution (Fig. 61.13
and Fig. 61.14).
he popliteal nerve block, in combination with a saphenous
nerve block, provides anesthesia and postoperative analgesia for
foot and ankle procedures. he saphenous nerve can be blocked
380
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Figure 61.15. Innervation of the foot. (A)
Anatomy of the five nerves innervating the foot. (B)
Cutaneous distribution of the nerves of the foot.
just above or below the anterior and medial aspect of the knee
or by performing a femoral nerve block.
Ankle block
he ankle block is indicated for distal foot surgery, the most
common being surgery for the diabetic foot and for bunion
surgery. It is commonly done with landmarks alone, but
ultrasound can help identify many of the nerves and improve
success rates.
Anatomy
here are ive peripheral nerves that innervate the foot (Fig.
61.15). he saphenous nerve is a branch of the femoral nerve

Figure 61.16. Injection sites for ankle block.
and supplies the medial aspect of the foot and ankle. he other
four nerves are branches of the sciatic nerve. he sural nerve
originates from the tibial nerve and the communicating super-
icial peroneal branches, and innervates the lateral aspect of
the foot. he deep peroneal and supericial peroneal nerves are
branches of the common peroneal nerve and innervate the area
between the irst and second toes and the dorsal aspect of the
foot, respectively. he posterior tibial nerve supplies the lower
and posterior surface of the heel and the plantar aspect of the
foot.
Technique
he block is most easily performed with the patient supine, with
the foot to be blocked elevated on a support (Fig. 61.16). he
landmarks are the medial and lateral malleoli, the Achilles ten-
don, the extensor hallucis longus tendon, and the tibial and dor-
salis pedis pulses.
he tibial nerve is blocked posterior to the medial
malleolus. A 22-gauge needle is inserted posterior to the
posterior tibial artery pulse, and 5 ml of local anesthetic solution
is injected. he deep peroneal nerve is blocked with an injec-
tion of 5 ml of local anesthetic solution immediately lateral to
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Chapter 61 – Lower Extremity Nerve Blocks
the extensor hallucis longus tendon (have the patient extend
the great toe) deep to the retinaculum. he saphenous, sural,
and supericial peroneal nerves are blocked at the level of the
malleoli with a subcutaneous injection of 10 to 15 ml of local
anesthetic solution in a circumferential line between the two
malleoli.
It is advisable to block all ive nerves, as there are varia-
tions in the dermatomal nerve supply. Epinephrine should not
be used with the local anesthetic for ankle blocks because of the
risk of causing ischemia in the foot.
Suggested readings
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91:8–15.
Chelly JE, Greger J, Casati A. Continuous lateral sciatic blocks for
acute postoperative pain management ater major ankle and foot
surgery. Foot Ankle Int 2002; 23:749–752.
Choquet O, Nazarian S, Manelli H. Bloc obturateur au pli inguinal:
Etude anatomique. Ann Fr Anesth Reanim 2001; 20:131s.
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 Part 10 – Regional Anesthesia
Di Benedetto P, Bertini L, Casati A, et al. A new posterior approach
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