Landmarks for Peripheral Nerve Blocks: Upper and Lower Extremities

124 Pages·2007·1.76 MB·English

by  Didier A. Sciard

Landmarks for
Peripheral Nerve
Blocks
Upper and Lower
Extremities
SECOND EDITION
Didier A. Sciard, M.D.
Maria E. Matuszczak, M.D.
Associate Professors
Department of Anesthesiology
The University of Texas–Houston Medical School
Houston, Texas
A U T H O R
C O N S I D E R AT I O N S
This pocket book is not designed to
replace a regular atlas or textbook of
regional anesthesia but may be carried
by any anesthesiologist who wants to
refresh his or her knowledge quickly.
The focus is on landmarks, some
anatomic considerations, and tips.
Regional anesthesia can be used as the
sole anesthetic technique or can be
combined with general anesthesia for
postoperative pain management.
In any case this technique must be per-
formed for the patient’s benefit so as to
achieve the best and safest surgical con-
ditions.
Anew scientific truth does not triumph because
it convinces its opponents, making them see the
light, but rather because its opponents eventually
die and a new generation grows up that is
familiar with it.
Max Planck (1858–1947)
Contributing author: Nicholas Lam, M.D.
Assistant Professor
Department of Anesthesiology
The University of Texas–Houston Medical School
Houston, Texas
Illustrator: Alexandre Matuszczak
Acquisitions Editor: Brian Bown
Managing Editor: Nicole T. Denoski
Project Manager: Fran Gunning
Manufacturing Manager: Ben Rivera
Marketing Manager: Angela Panetta
Design Coordinator: Stephen Druding
Production Services: Intenational Typesetting and Composition
© 2008 by Lippincott Williams & Wilkins, a Wolters Kluwer business
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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form
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Printed in China
Library of Congress Cataloging-in-Publication Data
Sciard, Didier A.
Landmarks for peripheral nerve blocks : upper and lower extremities/
Didier A. Sciard, Maria E. Matuszczak ; contrbuting author, Nicholas Lam ;
illustraor, Alexandre Matuszczak.—2nd ed.
p. ; cm.
ISBN-13: 978-0-7817-8752-9
ISBN-10: 0-7817-8752-1
1.Nerve block—Handbooks, manuals, etc. I.Matuszczak, Maria E. II.Lam,
Nicholas. III.Title.
[DNLM: 1.Nerve Block—methods—Handbooks. 2.Lower
Extremity—Handbooks. 3.Peripheral Nerves—anatomy & histology—Handbooks.
4.Upper Extremity—Handbooks.WO231S416L2008]
RD84.S462008
617.4’8—dc22
2007029223
Care has been taken o confirm the accuracy of the information presented and o describe generallyaccepted
practices. However, the authors, editors, and publisher are not responsible for erors or omissions or for any con-
sequences from application of the information in this book and make no warranty, expressed or implied, wth
respect o the currency, completeness, or accuracy of the contents of the publication. Application of this infoma-
tion in a particular situation remains the professional responsbility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in govenment regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any
change in indications and dosage and for added wanings and precautions. This is particularly important when
the recommended agent is a new or infrequently employed drug.
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10 9 8 7 6 5 4 3 2 1
C O N T E N T S
Author Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii
Principles of Neurostimulation . . . . . . . . . . . . . . . . . . . . .vii
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Upper Extremity Landmarks . . . . . . . . . . 1
Brachial Plexus Block . . . . . . . . . . . . . . . . . . . . . 5
Interscalene Approach . . . . . . . . . . . . . . . . . . . . . . . .16
Supraclavicular Approach . . . . . . . . . . . . . . . . . . . . .19
Infraclavicular Approach . . . . . . . . . . . . . . . . . . . . .21
Axillary Approach . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Humeral Canal Approach . . . . . . . . . . . . . . . . . . . . .28
Blocks at the Elbow . . . . . . . . . . . . . . . . . . . . . . 33
Ulnar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Musculocutaneous . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Blocks at the Wrist . . . . . . . . . . . . . . . . . . . . . . 39
Median . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Ulnar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Radial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Complementary Block . . . . . . . . . . . . . . . . . . . . 43
Flexor Digitorum Sheath Block . . . . . . . . . . . . . . . .43
v
Lower Extremity Landmarks . . . . . . . . . 45
Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Sciatic Nerve Blocks . . . . . . . . . . . . . . . . . . . . . 55
Proximal Posterior Approach . . . . . . . . . . . . . . . . . .56
Parasacral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Classic Posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Lithotomy (Raj’Approach) . . . . . . . . . . . . . . . . . . . . . . . .61
Subgluteal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Proximal Lateral Approach . . . . . . . . . . . . . . . . . . . .65
Proximal Anterior Approach . . . . . . . . . . . . . . . . . .66
Distal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Lateral Popliteal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
High Popliteal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Classic Posterior Popliteal . . . . . . . . . . . . . . . . . . . . . . . . .71
Lumbar Nerves . . . . . . . . . . . . . . . . . . . . . . . . . 73
Lumbar Nerve Blocks . . . . . . . . . . . . . . . . . . . . 77
Posterior Approach (Lumbar Plexus Block) . . . . . .77
Anterior Approach (Femoral Block) . . . . . . . . . . . .80
Anterior Approach (Fascia Iliaca Approach) . . . . .83
Complementary Blocks . . . . . . . . . . . . . . . . . . . 85
Obturator Nerve Block (Classic Approach) . . . . . .85
Obturator Nerve Block (Distal Approach) . . . . . . .86
Lateral Femoral Cutaneous Nerve Block . . . . . . . .88
Saphenous Nerve Block . . . . . . . . . . . . . . . . . . . . . . .90
Ankle Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
vi
P R I N C I P L E S O F
N E U R O S T I M U L AT I O N
Appropriate Location and Equipment
• Room equipped with standard ASAmonitors
• Immediate access to resuscitative drugs and
equipment
• Equipment checked
• Neurostimulators able to deliver a current of
up to 5-mAintensity, frequency of 1 or 2 Hz (1
or 2 impulses per second), impulse duration of
0.1 to 1 msec (0.1 to 0.3 msec for a motor nerve
stimulation and 1 msec for a sensory nerve
stimulation)
• Insulated needles of 1, 2, 4, and 6 inches (2.5, 5,
10, and 15 cm)
• Catheter sets with 2-, 4-, and 6-inch (5-, 10-, and
15-cm) introducer needles
vii
Technique
• Check nerve stimulator and connecting cables
for their proper function.
• Skin prep and local infiltrate for needle inser-
tion.
• Minimal distance between skin electrode and
needle.
• After skin puncture, gradually increase the
intensity up to 1.5 mAat 0.3 msec.
• Search in 3 axes (see picture on page x).
• As soon as the first twitch is obtained, impulse
duration (msec) should be decreased to 0.1
msec. Then intensity (mA) is slowly decreased
while approaching the nerve to a minimal sti-
mulation intensity of 0.5 to 0.3 mA.
• Aspirate for blood.
• Loss of motor response after injection of 1 mL
of local anesthetic and return of the motor
response when intensity is increased.
• No resistance or pain during injection.
• Slow and fragmented injection.
viii