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Lower-Extremity Peripheral Nerve Blockade: Essentials of Our Current Understanding

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Lower-Extremity Peripheral Nerve Blockade: Essentials of Our Current Understanding Original Articles Lower-Extremity Peripheral Nerve Blockade: Essentials of Our Current Understanding F. Kayser Enneking, M.D., Vincent Chan, M.D., Jenny Greger, M.D., Admir Hadz˘ic´, M.D., Ph.D., Scott A. Lang, B.Sc., M.D., F.R.C.P.C., and Terese T. Horlocker, M.D. he American Society of Regional Anesthesia a discussion of techniques and applications. In ad- Tand Pain Medicine introduced an intensive dition, we will review neural localization tech- workshop focused on lower-extremity peripheral niques and potential complications. nerve blockade in 2002. This review is the compi- lation of that work. Details concerning the tech- Lower-Extremity Peripheral Nerve niques described in this text are available at the web Anatomy site ASRA.com, including video demonstrations of Lower-extremity PNB requires a thorough un- the blocks. Lower-extremity peripheral nerve derstanding of the neuroanatomy of the lumbosa- blocks (PNBs) have never been as widely taught or cral plexus. Anatomically, the lumbosacral plexus used as other forms of regional anesthesia. Unlike consists of 2 distinct entities: the lumbar plexus and the upper extremity, the entire lower extremity the sacral plexus. There is some communication cannot be anesthetized with a single injection, and between these plexi via the lumbosacral trunk, but injections are generally deeper than those required for functional purposes these are distinct entities.1 for upper extremity block. In addition, neuraxial Details of the motor and sensory branches of the techniques are widely taught and use alternative lumbosacral plexus are summarized in Tables 1 and methods for providing reliable lower-extremity an- 2 and Figures 1 and 2. The lumbosacral plexus esthesia. Over the past decade, several develop- arises from at least 8 spinal nerve roots, each of ments have led to an increased interest in lower which contains anterior and posterior divisions that extremity PNBs, including transient neurologic innervate the embryologic ventral or dorsal por- symptoms associated with spinal anesthesia, in- tions of the limb. With the exception of a small creased risk of epidural hematoma with the intro- cutaneous portion of the buttock (which is supplied duction of antithromboembolic prophylaxis regi- by upper lumbar and sacral segmental nerves), the mens, and evidence of improved rehabilitation innervation of the lower extremity is entirely outcome with continuous lower-extremity PNBs. through branches of the lumbosacral plexus. The This review will focus on the anatomy of the lum- nerves to the muscles of the anterior and medial bosacral plexus and its terminal nerves, followed by thigh are from the lumbar plexus. The muscles of the buttocks, the posterior muscles in the thigh, and all the muscles below the knee are supplied by the From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL (F.K.E.); Regional Anesthe- sacral plexus. There are a multitude of approaches sia and Acute Pain Service, University Health Network, Univer- to each peripheral nerve block described for the sity of Toronto, Ontario, Canada (V.C.); Greater Houston Anes- lower extremity. Thus, a detailed review of the thesia, Houston, TX (A.H.); Department of Anesthesiology, St Luke’s/Roosevelt Hospital Center, New York, NY (J.G.); Depart- course of each of the relevant terminal peripheral ment of Anesthesia, University of Calgary, Calgary, Alberta, nerves of the lower extremity is warranted in this Canada (S.A.L.); and Department of Anesthesia, Mayo Clinic, review. Rochester, MN. Accepted for publication October 13, 2004. Reprint requests to F. Kayser Enneking, M.D., Department of Lumbar Plexus Anatomy Anesthesiology, PO Box 100254, Gainesville, FL 32610-0254. E-mail: [email protected]fl.edu The lumbar plexus is formed within the psoas © 2005 by the American Society of Regional Anesthesia and muscle from the anterior rami of T12-L4.1-4 The Pain Medicine. 1098-7339/05/3001-0002$30.00/0 branches of this plexus, the iliohypogastric, ilioin- doi:10.1016/j.rapm.2004.10.002 guinal, genitofemoral, lateral femoral cutaneous, 4 Regional Anesthesia and Pain Medicine, Vol 30, No 1 (January–February), 2005: p 4–35 Lower-Extremity Peripheral Nerve Blocks • Enneking et al. 5 Table 1. Lumbar Plexus Anatomy Spinal Articular Nerve Segment Motor Innervation Motion Observed* Sensory Innervation Branches Iliohypogastric T12-L1 Int/ext oblique Ant abdominal wall Inferior abd wall None Transverse abdominis Upper lat quadrant of buttock Ilioinguinal L1 Int oblique Ant abdominal wall Inferior to medial aspect of None inguinal ligament Portion of genitalia Genitofemoral L1-L2 Cremaster Testicular Inferior to mid portion of None inguinal ligament Spermatic cord Lateral Femoral L2-L3 None Anterior lateral and posterior Cutaneous aspects of thigh terminating in prepatellar plexus Femoral L2-L4 Anterior division Sartorious Medial aspect of the lower Anterior medial skin of the None thigh thigh Pectineus Adductor of thigh None Posterior division Quadriceps Knee extension, patellar Ant thigh Hip and knee ascension Saphenous Medial leg from the tibia to the medial aspect of the foot Obturator L2-L4 Anterior division Gracilus, adductor brevis & Thigh adduction Variable, posterior medial Hip longus pectineus thigh, medial knee Posterior division Obturator externus, Thigh adduction with Knee adductor magnus lateral hip rotation Abbreviations: Int, internal; Ext, external; Ant, anterior; Abd, abdominal; Lat, lateral. *Motion observed refers to the observed motor response with electrical stimulation of that nerve. and femoral and obturator nerves emerge from the Femoral Nerve. The femoral nerve is formed psoas laterally, medially, and anteriorly (Figs 2 and by the dorsal divisions of the anterior rami of the 3). Of these, the femoral, lateral femoral cutaneous, second, third, and fourth lumbar nerves. The fem- and obturator nerves are most important for lower- oral nerve emerges from the psoas muscle in a extremity surgery. fascial compartment between the psoas and iliacus Table 2. Sacral Plexus Anatomy Spinal Nerve Segment Motor Innervation Motion Observed* Sensory Innervation Articular Branches Gluteal nerves L4-S2 Piriformis, sup/inf gemellus Buttocks with lat hip Upper medial aspect of Hip obturator internus, rotation buttock quadratus femoris Sciatic, tibial L4-S3 Biceps femoris, Hamstrings with knee Medial and lat heel Hip knee, and ankle semitendinosus, extension Sole of foot adductor magnus Popliteus Knee flexion Plantar flexion Gastrocnemius, soleus, Toe flexion flexors of foot Sciatic, peroneal L4-S3 Short head of biceps Knee flexion Distal anterior leg, Knee and ankle Superficial femoris peroneus Foot inversion dorsum of foot longus, brevis Deep Extensors of foot, toes Dorsiflexion of foot, Web space of 1st toe Ankle ankle Sural None None None None Components from Post calf, lat border None peroneal & tibial of foot and 5th toe Post cut nerve of S1-S3 None None Distal medial quadrant None thigh of buttock perineum, post thigh including popliteal fossa Abbreviations: Sup, superior; Inf, inferior; Lat, lateral; Post, posterior; Cut, cutaneous. *Motion observed refers to the observed motor response with electrical stimulation of that nerve. 6 Regional Anesthesia and Pain Medicine Vol. 30 No. 1 January–February 2005 Fig 3. A contrast radiograph after lumbar plexus block injection. The radiograph shows a typical oblique descent of the lumbar plexus branches into the pelvis contained within the iliopsoas muscle: 1, spinous processes outlin- ing midline; 2, dispersion of radiopaque dye; 3, pelvis. Fig 1. Dermatomes and osteotomes of the lumbosacral plexus are illustrated. (Courtesy of Mayo Foundation.) division and quickly arborizes (Fig 4). At the level of the inguinal ligament, there are dense fascial planes, the fascia lata, and fascia iliaca. The femoral muscles, in which it gives off articular branches to nerve is situated deep to these fascial planes. The the hip. It enters the thigh posterior to the inguinal femoral artery, vein, and lymphatics reside in a ligament. There it lies lateral and posterior to the separate fascial compartment medial to the nerve. femoral artery. This relationship to the femoral ar- The anterior division of the femoral nerve gives tery exists near the inguinal ligament, but not after off the medial and intermediate cutaneous nerves the nerve enters the thigh. As the nerve passes into that supply the skin of the medial and anterior the thigh, it divides into an anterior and a posterior surfaces of the thigh. The muscular branches of the anterior division of the femoral nerve supply the sartorius muscle and the pectineus muscle and ar- ticular branches to the hip. The posterior division of the femoral nerve gives off the saphenous nerve, which is the largest cutaneous branch of the femo- ral nerve, and the muscular branches to the quad- riceps muscle and articular branches to the knee. The terminal nerves of the posterior division of the femoral nerve, the saphenous and the vastus medialis nerves, continue distally through the ad- ductor canal. After leaving the adductor canal, the saphenous nerve emerges from behind the sartorius muscle, in which it gives off an infrapatellar branch and then continues distally to supply the cutaneous innervation of the anteromedial lower leg down to the medial aspect of the foot. Obturator Nerve. The obturator nerve is a branch of the lumbar plexus formed within the substance of the psoas muscle from the anterior division of the second, third, and fourth lumbar nerves. It is the nerve of the adductor compartment of the thigh, which it reaches by piercing the medial Fig 2. Lumbosacral plexus. Anatomic depiction of the border of the psoas and passing straight along the lumbosacral plexus with the major peripheral nerves of sidewall of the pelvis to the obturator foramen. the lower extremity. (Courtesy of Mayo Foundation.) After entering the thigh through the obturator Lower-Extremity Peripheral Nerve Blocks • Enneking et al. 7 monstrable. In 23% of patients, a zone of hypoes- thesia was present on the superior medial aspect of the popliteal fossae. Only 20% of the patients showed a sensory deficit on the inferior aspect of the medial thigh.
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