Introduction to Lower

Extremity Regional Anesthesia

Anesthesia Toolbox Project

Brian F. S. Allen, MD
Department of Anesthesiology
Vanderbilt University
 Faculty Disclosure
None
 Learning Objectives
Upon completion of this activity, participants will be
able to
 Describe the anatomy of the nerves to the lower extremity
 Identify the sensory and motor distribution of the nerves to
the lower extremity
 Describe the common regional blocks of the lower extremity
 Case Scenario

A 72 yo male with CAD, DM, HTN and PVD presents for a left
BKA. He had a history of post operative cognitive dysfunction
following his last surgery under GA. You desire to place a
surgical block for this case. What block would be appropriate?
 Regional Anesthesia?
Surgical Procedure
 Location
 Requirement for postop pain control
 Etc….

PNS Anatomy
 dermatomes, osteotomes, motor innervation

Indications
 Analgesic vs. anesthetic blocks
 Postop pain?

Contraindications
 Anatomy
Lumbar Plexus Lumbosacral Plexus
L1 to L4 L4 to S3

Iliohypogastric N. Cephalad to:

Lumbar
Ilioinguinal N.
Plexus

Lateral Femoral
Cutaneous N.

Femoral N.
Obturator N. Caudad to:
Lumbosacral
Plexus
 Lower Extremity Dermatomes

L1 S3

L1 L2
L3
L2 L5

L3
L4
L3

L4
S2
S1
S2 L5
L5

S1
L4
S1
L5 L5
L5
 Nerves vs Roots

L1 S3
Lumbar Plexus:
L2-4
L1 L2
Includes Femoral,
L2 L5
Obturator, Lateral
femoral cutaneous L3

L4
S2

Lumbosacral S1
S2 L5
Plexus:
L4-S2
Includes Sciatic,
L4
Posterior femoral S1
cutaneous,
L5
and L5
hamstring muscular
branches
Lower Extremity Osteotomes

Obturator N

Femoral N

Tibial N

Common
Peroneal N
 Lower Extremity Osteotomes

Obturator N

Lumbar Plexus
Femoral N

Lumbosacral Tibial N

Plexus
Common
Peroneal N
 Lower Extremity Blocks
Lumbar Plexus Parasacral

Lateral Femoral Obturator

Cutaneous

Femoral High Sciatic

(Anterior, Transgluteal, Infragluteal)

Saphenous Popliteal Sciatic

Tibial Peroneal

Ankle
 Lower Extremity Blocks
Hip, Lumbar Plexus Parasacral
Thigh,
Knee
LFC Obturator

Thigh, High Sciatic

Knee, Femoral (Anterior, Transgluteal, Infragluteal)
Calf

Knee,
Saphenous Popliteal Sciatic
Calf,
Foot Tibial Peroneal

Foot
Ankle
 Lumbar Plexus Parasacral

Lateral Femoral Obturator

Cutaneous

Femoral High Sciatic

(Anterior, Transgluteal, Infragluteal)

Saphenous Popliteal Sciatic

Tibial Peroneal

Ankle
 Femoral Nerve
Block LFCN
 Femur LFCN

Fem
 Anterior thigh
 Knee Ob PFCN

 Medial leg

Saph
(Fem)

Sural

Superficial
Peroneal
Deep Posterior
Peroneal Tibial
 Inguinal Ligament
Femoral
Anatomy
Iliopsoas

Pectineus

Sartorius

Quadriceps:
Vastus Lateralis,
Vastus Medialis
Vastus Intermedius
Rectus Femoris
 Needle Insertion
Femoral for nerve stim:
1 cm lateral to pulse
Anatomy

Femoral N.
Femoral A.
Femoral V.

Saphenous N.

Acronym:
NAVel to the Navel
Lateral Medial

Femoral Anatomy
Lateral Medial

Femoral Anatomy
Fascia Lata
Fascia Iliaca
F em
oral
Ner
ve
FA

Iliopsoas
Lateral Medial

In Plane Femoral Anatomy

Needle Out of Plane
Approach Needle Approach

FA
 Saphenous
Block LFCN
 Knee LFCN
Fem
 Medial lower leg
 Medial ankle Ob PFCN

 Great toe

Saph
(Fem)

Sural

Superficial
Peroneal
Deep Posterior
Peroneal Tibial
 Saphenous
Surface Anatomy

A block anywhere along

Adductor Canal can be called:
Subsartorial, Periarterial, or
Adductor Canal Saphenous
Block

Ultrasound
Probe
 Saphenous
Surface Anatomy

Adductor Canal Contents:

Femoral Nerve, Artery, Vein
sandwiched between
Sartorius and Adductors

Adductor Canal
Lateral Medial
Lateral Medial

Sartorius
Saph
N?

Vastus FA Saph
N?

Medialis
FV

Adductor
Longus
Lateral Medial

Ne
Ap edle
pr o Ideal
ach
Periarterial
Spread

FA
 Lateral Femoral
Cutaneous Nerve
Block LFCN
LFCN
Fem
 Lateral thigh
Ob PFCN

Saph
(Fem)

Sural

Superficial
Peroneal
Deep Posterior
Peroneal Tibial
 LFCN Anterior Superior Iliac Spine
Inguinal Ligament

Lateral Femoral
Cutaneous Anatomy

Needle Insertion:
2 cm medial to ASIS
2 cm caudal to ASIS
(Anterior Superior Iliac Spine)

Superficial to Sartorius Muscle

 Popliteal Sciatic
LFCN

• All of the lower leg Fem

LFCN

except the saphenous

Ob PFCN

Saph
(Fem)

Sural

Superficial
Peroneal
Deep Posterior
Peroneal Tibial
 Ischial
Tuberosity

Popliteal Sciatic
Anatomy
Semitendinosus

Semimembranosus

Biceps Femoris, Long

Head Popliteal
Crease
Biceps Femoris, Short
Head

Gastrocnemius
Popliteal Sciatic
Anatomy

Probe location

Sciatic N.

Common Peroneal N. Popliteal A.

Tibial N. Popliteal V.
 Superficial, Dorsal

Lateral Medial

Deep, Ventral
 Superficial, Dorsal

Lateral Biceps Semimembranosus Medial

Common
Femoris Peroneal

Tibial
Needle
Approach
Sciatic Nerve

Deep, Ventral
 Medial Ankle
Saphenous N. Ankle Block
Medial
Maleolus
Anatomy

Sural N.
Superficial
Peroneal N.
Lateral Maleolus

Superficial
Nerves
Images: Phulvar Lateral Ankle
 Medial Ankle
Ankle Block
Sub-Q
Anatomy
Injection
Needle
Insertion

Sub-Q
Injec
tion

Superficial
Nerves
Images: Phulvar Lateral Ankle
 Medial Ankle
Flexor Digitorum Ankle Block
Longus Tendon
Anatomy
Tibialis Posterior
Tendon

Injection
Site

Deep
Nerves
Images: Phulvar Lateral Ankle
 Dorsum
of the Foot
Ankle Block
Anatomy

Deep
Nerves
Deep
Peroneal
Nerve
Dorsalis
Injection Site Pedis A.
• Posterior
Tibial
• Plantar Foot
• Saphenous
• Medial Calf

• Deep
Peroneal
• Web space
between 1st
& 2nd toe • Sural
• Lateral Calf

• Superficial
Peroneal
• Dorsal Foot
 Lumbar Plexus Parasacral
Hip,
Thigh,
Knee Lateral Femoral Obturator
Cutaneous
Thigh, Femoral High Sciatic
Knee, (Anterior, Transgluteal, Infragluteal)

Calf

Knee,
Saphenous Popliteal Sciatic
Calf,
Foot Tibial Peroneal

Foot
Ankle
 Quiz Questions
1. All of the following nerves 2. Which nerve, blocked during
innervate part of the hip or knee an ankle block, is a terminal
joint EXCEPT: branch of the femoral nerve?

A. Lateral Femoral Cutaneous A. Sural

B. Obturator B. Deep Peroneal
C. Sciatic C. Saphenous
D. Saphenous D. Posterior Tibial
 Quiz Questions
3. Which of the following is a useful
landmark for performance of
Lateral Femoral Cutaneous Nerve
Block:
4. The adductor canal is
surrounded by all of the following
muscles EXCEPT:

A. Pubic Tubercle A. Vastus medialis

B. Greater Trochanter B. Rectus femoris
C. Ischial Tuberosity C. Adductor longus
D. Anterior Superior Iliac D. Sartorius
Spine
 Suggested Reading
 Enneking F, Chan V, Greger J, Hadzic A, Lang S, Horlocker T. Lower-
extremity peripheral nerve blockade: Essentials of our current
understanding. Reg Anesth Pain Med. 2005;30(1):4-35.
 Brown, D.L. (2010). 4th Ed. Atlas of Regional Anesthesia. Philadelphia.
Elsevier.
 DVCIPM (MARAA) Book Project:
 http://www.dvcipm.org/clinical-resources/dvcipm-maraa-book-project