Nerve Blocks of the Lumbar Plexus

Transcription

1 27th ESRA Regional Anaesthesia Cadaver Workshop Innsbruck, Austria, February 23 24, 2018 Nerve Blocks of the Lumbar Plexus Paul Kessler Department of Anaesthesiology and Intensive Care Medicine Orthopaedic University of Frankfurt

2 Faculty Disclosure X No, nothing to disclose Yes, please specify: Company Name Honoraria/ Expenses Consulting/ Advisory Board Funded Research Royalties/ Patent Example: company XYZ x x x Stock Options Ownership/ Equity Position Employee Other (please specify)

3 Nerve Blocks of the Lumbar Plexus Lumbar plexus block (LPB) Femoral nerve block (FNB) Adductor canal block (ACB) Lateral femoral cutaneous nerve block (LFCNB) Fascia iliaca block (FIB) Obturator nerve block (ONB)

4 Lumbar Plexus Hebl JR et al, Atlas of RA and US-guided Nerve Blockade

5 Lumbar Plexus Block Landmarks for Nerve Stimulation Technique 2 1/3 2/ Capdevila X et al., Anesth Analg Chayen D et al., Anesthesiology Winnie AP et al., Anesthesiol Rev Capdevila X et al., Anesth Analg Dekrey et al., Anesth Analg Pandin et al., Anesth Analg 2002

6 Lumbar Plexus Block Stimulation Response: Quadricep contractions Puncture depth: 6 10 cm If contact with transverse process L5 Push forward 2 cm Contraction of the adductors too medial Contraction of the plexus sacralis too medial and caudal

7 Local anesthetic Lumbar Plexus Block Single Shot/intermittent bolus e.g.: ml prilocaine/mepivacaine 1%, ropivacaine % Continuous e.g.: 5 15 ml/h ropivacaine % PCRA Ropivacaine 0,2%, basal 5 8 ml/h, Bolus 10 ml/h, lockout 60 min

8 Total spinal anesthesia Gentili et al., Ann Fr Anesth Reanim 1998; Pousman RM et al., Anesthesiol 2003 Cardiac arrest after PCB Huet O et al., Anesthesiology 2003, Auroy Y et al., Anesthesiology 2002 Hematoma (retroperitoneal, Psoas) Weller et al., Anesthesiol 2003, Klein SM et al., Anesthesiol 1997 Accidental kidney hematoma Aida et al., Anesthesiol 1996, Köster O et al., Röntgen Bl 1983 Catheter malposition abdominally or retroperitonelly Capdevila X et al., AA 2002 Side Effects and Complications of Lumbar Plexus Block Epidural and intrathecal malposition of the catheter De Biasi et al., RAPM 2003; Litz RJ et al., RAPM 2004

9 Lumbar Plexus Block Psoas compartment block Posterior lumbar plexus block Psoas QL Erector spinae Karmakar M,, Textbook of RA, Hadzic, 2017

10 Gogarten W et al. Eur J Anaesthesiol 2010;27: Horlocker TT et al, Reg Anesth Pain Med 2010;35: Because of the morbidity associated with retroperitoneal haematoma, lumbar plexus merit the same recommendations that apply to neuraxial blockade (Class IIa, level C).

11 Subcostal Approach Shamrock Paramedian Transverse Paramedian sagittal Trident Visible Human Project

12 BMI: 55,4

13 Iliac Crest PSIS Spine Sacrum Longitudinal Parasagittal Scan

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15 Trident Sign

16 Longitudinal Parasagittal Scan of L3 L4 Skin Erector spinae M PM PM PM PM TP TP TP Lumbar Plexus ventral

17 Paramedian Transverse Approach Visible Human Project

18 Iliac Crest PSIS Spine Paramedian Transverse Scan

19 Skin Transverse Paravertebral Scan between 2 adjacent transverse processes QLM ESM Spinous process LP PM Vertebral body Articular Process ventral

20 Skin Longitudinal Parasagittal Psoas Block Needle advancement ESM PM Spinous process Articular Process Vertebral body ventral

21 Subcostal Approach Shamrock Visible Human Project

22 The "Shamrock Method" a new and promising technique for ultrasound guided lumbar plexus blocks Sauter AR et al, Br J Anaesth, e letter, 2013

23 Transvers process QL ventral Psoas Erector spinae Vertebral body

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25 lateral anterior posterior QL Psoas Erector spinae IVC Vertebral body Transvers process

26 Injection anterior posterior medial

27 US guided Lumbar Plexus Block 2018 Advanced deep block US guided LPB safer, offers advantages over the landmark techniques Combination with nerve stimulation mandatory for correct needle tip position Optimal US guided technique: depends on personel skills, but Shamrock technique seems favourable Challenging in overweight patients

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29 Femoral Nerve Block Indications Anterior thigh, femur, and knee surgery In combination with proximal sciatic nerve block, operative procedures on the whole leg Preoparative pain relief for femoral neck fractures Post op pain therapy after hip + knee surgery Mobilisation/Physiotherapy after hip + knee surgery Contraindications Local infections, patient refusal Manifested coagulation disorder Relative Fem. pop. Bypass (only NS)

30 Femoral Nerve Block 3 in 1 Block Stimulation response: Quadriceps contractions, dancing Patella Puncture depth: 2 4 cm If contractions of M.sartorius lateralize

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32 US-guided Femoral nerve Block Needling out of plane (OOP) in plane (IP)

33 US-guided Femoral Nerve Block: in-plane Hebl JR et al, Atlas of RA and US-guided Nerve Blockade

34 Femoral Nerve Block: in-plane medial lateral lateral medial

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36 More selective Blocks for major knee surgery? Adductor canal block

37 Femoral triangle Adductor canal sensory Saphenus n. Medial femoral cutaneous n. Medial retinacular n. Articular branches of obturator n. motor 1 nerve for vastus medialis m.

38 Differential Indications: Femoral Nerve Blocks Femoral nerve block Thigh + knee surgery, tourniquet Femoral triangle block Thigh + knee surgery, tourniquet Adductor canal block Knee surgery Saphenus nerve block Foot surgery Saphenus nerve block Foot surgery

39 Adductor Canal Block - IP

40 Adductor Canal Blockade OOP-Injektion posterior Sartorius M Saphenous Nerve Vastus medialis M anterior Adductor longus M

41 Adductor Canal Blockade OOP-Injection posterior anterior

42 Lateral Femoral Cutaneous Nerve Block (LFCN)

43 LFCN Block Indications Anesthesia of the lateral thigh (e.g., donor area for a skin graft) Provides anesthesia along with femoral, obturator and sciatic blocks to the thigh for surgical procedures above the knee and for thigh tourniquet Meralgia paresthetica

44 US guided LFCN Block Sartorius M Tensor fasciae latae M Rectus M

45 Lateral Femoral Cutaneus Nerve below the ASIS

46 Lateral Femoral Cutaneous Nerve Block 1. Sartorius M 2. Tensor fasciae lata M 3. LFCN 4. Fascia lata Meier, Büttner, Atlas der peripheren Regionalanästhesie

47 Lateral Femoral Cutaneus Nerve in plane approach

48 Fascia lata LFCN Sono-Anatomy Tensor fascia Lata M Sartorius M lateral LFCN medial

49 medial LFCN Sono-Anatomie lateral

50 LFCN In-plane + Injection LFCN Fascia lata Sartorius M lateral Tensor fascia Lata M medial

51 medial LFCN In-plane + Injection lateral

52 Fascia Iliaca Block Poor man s femoral nerve block

53 Fascia Iliaca Block Essentials Blockade of femoral nerve + LFCN Indications: anterior thigh and knee surgery, analgesia following hip and knee procedures, hip fracture Local anesthetic: ml of dilute local anesthetic (e.g., 0.2% ropivacaine)

54 Fascia Iliaca Block Infra inguinal Supra inguinal

55 Infra-inguinal Fascia Iliaca Block medial to lateral lateral medial

56 Fascia lata Infra-inguinal Fascia Iliaca Block Needle advancement Sart. M lateral medial Fascia iliaca Iliacus muscle

57 Infra-inguinal Fascia Iliaca Block Dissection and spread of LA lateral medial

58 Supra-inguinal FIB

59 US-guided supra-inguinal fascia iliaca block Iliacus muscle (IM), fascia iliaca (FI), psoas muscle (PM), sartorius muscle (S), tensor fascia lata muscle (TFL), ilium (I), deep circumflex iliac artery (DCIA), subcutaneous tissue (SCT). Hebbard P et al, Anaesthesia, 2011, 66, pages

60 US-guided supra-inguinal fascia iliaca block Subcutaneous fat Fascia iliaca cranial Iliacus M caudal

61 US-guided supra-inguinal fascia iliaca block kranial kaudal

62 Obturator Nerve Block

63 PROMETHEUS Atlas der Anatomie, Thieme Verlag 2011 Obturator Nerve

64 Skin innervation by obturator nerve according to different authors Tsui BCH, Atlas of US- and NS-guided RA

65 Obturator Nerve Block Indications Suppression of the adductor reflex for transurethral lateral bladder wall resection Treatment of adductor spasm Adjunct to femoral nerve blocks for postoperative medial knee joint pain analgesia Additional analgesia after major knee surgery Technique Nerve Stimulation US guided Local Anaesthetic ml ropivacaine 0.2%, prilocaine 1%

66 Hebl JR et al, Atlas of RA and US-guided Nerve Blockade

67 Obturator Nerve Block medial P.Bigeleisen, US-Guided RA +PM

68 Obturator Nerve Obturator Nerve 4 1. Adductor longus 2. Adductor brevis 3. Adductor magnus 4. Anterior branch 5. Posterior branch Meier & Büttner: Atlas der peripheren Regionalanästhesie,

69 Obturator Nerve IP

70 Obturator Nerve OOP

71 Obturator Nerve AL Anterior Branch lateral Pectineus M AB medial Posterior Branch AM

72 Anterior Branch AL Pectineus M Posterior Branch AB AM

73 Right Obturator Nerve: lateral to medial lateral medil

74 Obturator Nerve Block Injection of the Anterior Branch medial AL LA lateral AB Anterior Branch

75 Obturator Nerve Block Injection of the Anterior Branch medial lateral