Peripheral Regional Anesthesia Tutorial

Preface
After so many of our colleagues have ex-

pressed the wish for a pocket edition of
our Peripheral Regional Anesthesia Tutorial
published by the Ulm Rehabilitation Hospi-
tal (RKU), we have now complied by offer-
ing this compact version. The fundamentals
contained in this condensed guide still grow
from the now almost 20 years of clinical and
practical experience gained in our hospital. Prof. H.-H. Mehrkens, M.D.
Director, Dept. of Anesthesiology/
This book differs from the previous, more Intensive Care Medicine
comprehensive Tutorial Script in that it in-
cludes many new developments and supplemental information. These
shall be incorporated into the next edition of the tutorial script and its
coming Internet version.
It is here that I would like to extend my very special thanks to the man-
aging Senior Physician of our Department, Dr. Peter Geiger. Without
his tireless assistance, the production of the compact version of this
pocket tutorial would not have been possible. Additional thanks go to
B. Braun Melsungen, whose continuing technical and financial support
have been invaluable for the completion of this work.
We would appreciate your suggestions and criticisms and look forward

to your many visits at our Internet Forum www.nerveblocks.net.
Ulm, June 2004 Prof. H.-H. Mehrkens, M.D.
RKU-Kompendium_engl-4.indd 1 22.04.2005 07:35:16

Contents
General
Equipment ........................................................................... 4
Anatomy: Diagram of the brachial plexus ............................ 8
Anatomy: Diagram of the lumbosacral plexus ..................... 9
Local anesthetic-induced systemic intoxication ................. 11
Continuing education materials......................................... 72
Upper extremity
Anterior interscalene nerve block ...................................... 12

Posterior interscalene nerve block ..................................... 16
Vertical infraclavicular block .............................................. 20
Axillary nerve block ........................................................... 24
Suprascapular nerve block ................................................. 28

Lower extremity
Psoas compartment block.................................................. 32

Femoral nerve block .......................................................... 36
Saphenous nerve block ...................................................... 40
Obturator nerve block........................................................ 44
Parasacral sciatic nerve block ............................................ 48
Transgluteal sciatic nerve block ......................................... 52
Anterior sciatic nerve block ............................................... 56
Subtrochanteric sciatic nerve block ................................... 60
Lateral distal sciatic nerve block ........................................ 64
Popliteal sciatic nerve block............................................... 68

Equipment
Equipment
Nerve stimulator
• Current range from 1.0 – 0.1 mA
• Pulse duration 0.1 ms (mixed nerve)
1.0 ms (sensory nerve)
• Constant square wave pulse over a wide impedance range
e.g. Stimuplex® HNS 12 (B. Braun Melsungen AG)
Single shot technique

• Unipolar needles of varying lengths
e.g.: Stimuplex® D (B. Braun Melsungen AG)
Catheter technique
• Unipolar needles in a plastic introducer of varying lengths
e.g.: Contiplex® D Sets with a flexible and non-wired catheter
(B. Braun Melsungen AG)

Equipment
Stimuplex® HNS 12 (B. Braun Melsungen AG)
Stimuplex® D (B. Braun Melsungen AG)
Contiplex® D, Contiplex® Tuohy (B. Braun Melsungen AG)

Equipment
Drugs
Conventional, medium-acting local anesthetics (LA) like

• prilocaine
• mepivacaine
and long-acting ones like

• ropivacaine
• bupivacaine.
For anesthesia, we prefer a combination of

• prilocaine 1 % (20 – 40 ml) and ropivacaine 0.5 – 0.75 %
(10 – 20 ml) or bupivacaine 0.5 % (10 – 20 ml).
This combination has the advantage that a LA with comparably

low toxicity is given primarily and inadvertent intravascular in-
jections mostly occur during the prodromal stage. Subsequently,
a long-acting LA is administered to achieve a blockade of suf-
ficient duration.
For analgesia, 0.2% ropivacaine is generally administered. The

preferred mode of delivery is through a PCA pump equipped
with basal rate and bolus settings or by continuous infusion
through the nerve catheter. Intermittant bolus injections are
rarely used.

Equipment
Stimulation and injection technique

1. Initial current 1.0 mA
2. Pulse duration 0.1 ms (mixed nerve)
3. Threshold current 0.3 – 0.2 mA
4. Aspiration test 5 – 10 ml LA injected slowly
5. Increase to 1.0 mA initial current No stimulatory response
Recurring stimulatory
response:
may indicate (partial) intra-
vascular needle position.
Attempt careful aspiration,
perform reinjection slowly
with constant verbal moni-
toring.
6. Administration of remaining LA 1.0 mA
7. Catheter placement after primary LA administration
Upper extremity: Approx. 3 cm beyond the end
of the introducer sheath
Lower extremity: Approx. 5 cm beyond the end
of the introducer sheath
8. Catheter aspiration test

Anatomy
Diagram of the brachial plexus
1
2
4 3
5
A
6
B
C
D
E
F
12
13
7 14
8 10 11 15
9
A Upper trunk 5 Musculocutaneus nerve

B Middle trunk 6 Axillary nerve
C Lower trunk 7 Radial nerve
D Lateral cord 8 Median nerve
E Posterior cord 9 Ulnar nerve
F Medial cord 10 Medial brachial cutaneous nerve
11 Medial antebrachial cutaneous nerve
1 Dorsal scapular nerve. 12 Long thoracic nerve
2 Suprascapular nerve 13 Subscapular nerve
3 Subclavian nerve 14 Axillary artery
4 Pectoral nerves 15 Thoracodorsal nerve

Anatomy
Diagram of the lumbosacral plexus
2
3
4 5 6
1 Lateral femoral cutaneous nerve
2 Femoral nerve
3 Genitofemoral nerve
4 Sciatic nerve
5 Obturator nerve
6 Pudendal nerve

10

Intoxication
Local anesthetic-induced systemic intoxication
CARDIO- CEREBRAL
CIRUCLATORY
Degree of
intoxication
Asystole Seizure
Confusion
Bradycardia
Dizziness
Extrasystoles
Tinnitus
Hypotension
Metallic taste
Hypertension Mentally
Tachycardia “abnormal”
11

Overview
Anterior interscalene nerve block

(Anterior approach according to Meier)
Indications
• Operative procedures on the shoulder, proximal upper arm and
lateral clavicle
• Analgesia
Contraindications
• Contralateral phrenic and recurrent paresis
Side effects / complications

• Horner´s syndrome
• Phrenic paresis
• Recurrent paresis
• Vessel puncture (external jugular vein)
Anatomical landmarks
• Sternocleidomastoid muscle
• Superior thyroid notch
• Scalenus gap
• VIB (vertical infraclavicular blockade) point
1 Sternocleidomastoid muscle,
2 Thyroid notch, 3 Puncture site
12

Upper extremity
3 2
13

Method
Anterior interscalene nerve block
Blockade technique
The patient lies supine, head turned slightly to contralateral side,
shoulder and arm positioned comfortably.
Puncture site:
Posterior edge of the sternocleidomastoid muscle at the level of the
thyroid notch (1.5 – 2 cm above the cricoid). Insertion direction tan-
gential to the course of the plexus in the direction of the VIB point or
anterior axillary line.
Puncture depth: 2 – 4 cm.
Positive stimulatory response from the upper trunk (lateral cord):

biceps and/or brachial muscle.
Dosage
30 – 50 ml LA

e.g. Stimuplex® D, 50 mm
Catheter technique
e.g. Contiplex® D-Set, 55 mm
Advance the soft plastic catheter max. 3 cm beyond the end of
the introducer sheath.
14

Upper extremity
? What to do when ...?

Stimulation of the axillary nerve (deltoid mus-
cle) or radial nerve (triceps muscle) occurs:
Leave the needle in place Administer LA.
Stimulation of the suprascapular nerve (leva-

tor scapulae muscle) occurs: The insertion direc-
tion is too lateral and dorsal Retract the needle,
advance it markedly more to the ventral and some-
what more medial.
Stimulation of the phrenic nerve (unilateral

singultus) occurs: The insertion direction is too
ventral and medial Retract the needle, advance it
slightly more to the lateral and dorsal.
Blood is aspirated: Retract the needle, check

direction of puncture Re-advance needle.
! Potential errors and hazards

Always avoid a medial direction of puncture:
• Risk of puncturing large vessels (carotid and verte-
bral arteries, internal jugular vein).
• Risk of intrathecal injection = high spinal!
(Most suitable and reliable stimulatory response:
biceps and/or brachial muscle = most lateral part of
plexus [C5])
15

Overview
Posterior interscalene nerve block

(Posterior approach according to Pippa)
Indications
• Operative procedures on the shoulder, proximal upper arm and
lateral clavicle
• Analgesia
Contraindications
• Contralateral phrenic and recurrent paresis

• Phrenic paresis
• Recurrent paresis
• Vessel puncture
• Spinous process C7 (vertebra prominens)
• Spinous process C6
• Cricoid
• Sternocleidomastoid muscle
1 C6, 2 C7, 3 Puncture site
16

Upper extremity
17

Method
Posterior interscalene nerve block
Blockade technique
Patient is in axially aligned recumbent position (or seated); the cervi-
cal spine is flexed backwards; shoulder and arm are relaxed.
Puncture site:
3 cm midline between the two spinous processes C6 and C7,
Insertion direction 5 – 10° to the lateral, aimed at the height of the
cricoid.
Puncture depth: 6 – 8 cm, depending on the distance between punc-
ture site and posterior edge of the sternocleidomastoid muscle.
Positive stimulatory response from the upper trunk (lateral cord):
biceps and/or brachial muscles.
Dosage
30 – 50 ml LA

e.g. Stimuplex® D, 80 – 100 mm
Catheter technique
e.g. Contiplex® D-Set, 80 – 110 mm
18

Upper extremity

Stimulation of the axillary nerve (deltoid mus-
cle) or radial nerve (triceps muscle) occurs:
Leave the needle in place Administer LA.
Stimulation of the suprascapular nerve (leva-

tor scapulae muscle) occurs: Insertion direction
too lateral Retract the needle, advance it slightly to
the medial and slightly deeper.
Stimulation of the phrenic nerve (unilateral

singultus) occurs: Insertion direction too deep and
too medial Retract the needle, advance it more to
the lateral and less deep.
Blood is aspirated: retract the needle, check

puncture direction Re-advance the needle.

Always avoid a medial insertion direction:
• Risk of puncturing the vertebral artery.
• Risk of intrathecal injection = high spinal!
(Most suitable and reliable stimulatory response:
biceps and/or brachial muscle = most lateral part of
plexus [C5])
19

Overview
Vertical infraclavicular block (VIB)

(Approach according to Kilka, Geiger, Mehrkens)
Indications
• Operative procedures on the distal upper arm, forearm and hand
• Analgesia
Contraindications
• Chest deformities
• Healed, but dislocated (shortened) fracture of the clavicle

• Phrenic paresis
• Vessel puncture (cephalic vein, subclavian artery and vein)
• Pneumothorax
• Suprasternal notch
• Lateral edge of the acromion
• Infraclavicular fossa
1 Lateral edge of acromion, 2 Suprasternal notch,

3 Infraclavicular fossa, 4 Puncture site
20

Upper extremity
3
1
4
2
21

Method
Vertical infraclavicular block
Blockade technique
The patient is supine, with his hand relaxed on abdomen.
Puncture site:
Midway between ventral apophysis of the acromion and the supra-
sternal notch, directly below the clavicle (medial edge of the infracla-
vicular fossa). Insertion direction must be absolutely perpendicular to
the supporting surface (operating table).
Positive stimulatory response from the posterior cord:

Extensor or flexor muscle D 1 – 3 (= radial or median nerve).
Dosage
30 – 50 ml LA

Catheter technique
22

Upper extremity

Lateral landmarks (ventral apophysis of acro-
mion) cannot be found: Palpation of the clavicle
from medial to lateral leads to the acromioclavicular
joint The lateral edge of the acromion is located
ventral and lateral. Palpation of the crest of the scap-
ula from dorsal to lateroventral leads to the acromion
and stops at the correct site.
Stimulation of the musculocutaneous nerve
(biceps muscle = lateral cord) occurs: Puncture is
too medial and superficial Retract the needle, shift
it subcutaneously to the lateral (0.3 – 0.5 cm) and
then advance it perpendicularly (!) approx. 0.5 – 1 cm
deeper than before.
Blood is aspirated: Puncture site is too medial or
too far away from the lower clavicular edge Retract
the needle, check lateral landmarks (ventral apophysis
of the acromion) and re-advance the needle.

• Puncture too medial (establish a lateral landmark as
described above).
• Puncture is not performed in a perpendicular direction.
• Puncture depth orientation: estimated distance be-
tween surface and palpable lower clavicular margin
+ 1 cm (Beware > 4 cm in persons with asthenic
physiques).
23

Overview
Axillary blockade
(Approach according to de Jong)
Indications
• Operative procedures on the elbow, forearm and hand
• Analgesia
Contraindications
• No particular

• Haematoma if the radial artery is injured
• Axillary artery
• Coracobrachialis muscle
• Medial bicipital groove
• Pectoralis major and minor muscles
= Puncture site
24

Upper extremity
25

Method
Axillary blockade
Blockade technique
With the patient supine, the shoulder joint is abducted 90°, elbow
joint extended 90°.
Puncture site:
Slightly above the axillary artery in the gap between artery and
coracobrachialis muscle, at the highest point in the axilla and slightly
beneath the pectoralis major muscle.
Insert the needle approx. 30° parallel to the axillary artery, taking a
very superficial course.
Positive stimulatory response from median nerve: flexor digitorum
muscles.
Dosage
30 – 50 ml LA

Catheter technique
Advance the soft plastic catheter 5 cm beyond the end of the
introducer sheath.
26

Upper extremity

There is no stimulatory response:
The puncture has probably gone too deep Retract
the needle and advance at a flatter (more tangential)
angle, watching out for any “fascial click“.
Stimulation of the musculocutaneous nerve:

The needle is not positioned within the neurovascular
sheath Retract the needle, advance it less deep and
more tangential to the artery.

• Puncture too deep.
• Difficulties identifying the axillary artery.
27

Overview
Suprascapular nerve block

(Approach according to Meier)
Indications
• Frozen shoulder (for pain management and mobilization therapy)
• Analgesia
Contraindications
• No particular

• No particular
• Spine of scapula
1 Lateral end of the spine of scapula,

2 Medial end of the spine of scapula, 3 Puncture site
28

Upper extremity
3
1
29

Method
Suprascapular nerve block
Blockade technique
The patient is seated, hand on their contralateral shoulder.
Puncture site:
1 – 2 cm cranial and medial to the mid-spine. Insertion direction
approx. 45° caudad and lateral towards the humerus head.
Positive stimulatory response: supraspinatus or infraspinatus muscles.
Dosage
20 – 30 ml LA

Catheter technique
Advance the soft plastic catheter < 3 cm beyond the end of the
introducer sheath.
30

Upper extremity

There is no stimulation response:
Try to find the floor of the supraspinous fossa or
retract the needle and advance it at a flatter angle
towards the humerus head.
Note two important aspects:

1. A muscular stimulatory response is not imperative
to achieve blockade.
2. The suprascapular nerve is not involved in the
(sensory) skin supply of the shoulder!

• Puncture is made too deep and steep.
31

Overview
Psoas compartment block

(Approach according to Chayen)
Indications
• Operative procedures in the lumbar plexus supply area
• In combination with proximal sciatic nerve block for compli-
cated operations on the whole leg distal to the hip (total knee
arthroplasty, cruciate ligament replacement ...)
• Analgesia
Contraindications
• Extreme hyperlordosis (relative)
• Coagulation disorders

• Vessel puncture (paravertebral veins)
• Dissemination similar to epidural anesthesia (contralateral)
• High (total) spinal anesthesia
• Posterior superior iliac spine
• Iliac crest
• Spinous process L4
• Costal process L5
1 Iliac crest, 2 Posterior superior iliac spine,

3 Spinous process L 4, 4 Puncture site
32

Lower extremity
1
2
4
33

Method
Psoas compartment block
Blockade technique
The patient is in the lateral recumbent position (or seated), the
cervical spine is flexed backwards.
Puncture site:
3 cm caudad and 4 cm midline to the spinous process L4. Sagittal in-
sertion direction; upon contact with transverse process L5 retract and
lower the needle, and advance it over the transverse process (2 cm).
Positive stimulatory response from the femoral nerve: quadriceps
muscle (usually the vastus lateralis muscle). Puncture is also possible
at the level of the transverse process L4; now advance the caudad
aligned needle under the transverse process.
Dosage
30 – 50 ml LA, test dose 5 ml

Catheter technique
Advance the soft plastic catheter < 5 cm beyond the end of the
introducer sheath.
34

Lower extremity

Stimulation of the obturator nerve (contrac-
tion of the adductor group) occurs: Puncture
direction is too medial Retract the needle, then
lateralize it somewhat.
Stimulation of the fourth lumbar nerve

(= lumbosacral trunk, contractions in the
peroneal group) occurs:
Puncture direction is much too medial Retract the
needle; advance it markedly in the lateral direction.
No transverse process contact and no

stimulatory response is achieved:
Puncture site and/or direction may be too lateral
Check the distance between puncture site and
midline (max. 4 cm), and, if needed, adjust the punc-
ture direction to the patient‘s position. Adequate
stimulatory response may also be possible without
prior transverse process contact!

Always avoid a medial puncture direction
(towards the spinal column)!
• Risk of epidural or even intrathecal dissemination
of the LA. Perform a test dose.
35

Overview
Femoral nerve block
Indications
• Operative procedures in areas supplying the femoral and
lateral femoral cutaneous nerves
• In combination with proximal sciatic nerve block, operative
procedures on the whole leg (from distal thigh to foot)
• Analgesia
Contraindications
• No particular

• Vessel puncture (of the femoral vein or artery)
• Groin
• Femoral artery
• Anterior superior iliac spine
• Pubic tubercle
• Inguinal ligament
1 Anterior superior iliac spine,

2 Pubic tubercle, 3 Puncture site
36

Lower extremity
37

Method
Femoral nerve block
Blockade technique
The patient lies on his back, his leg loosely abducted and turned to
the outside.
Puncture site:
2 cm caudad to the groin, 1 – 2 cm lateral to the femoral artery.
Puncture direction: 30 – 45° cranial parallel to the artery.
Positive stimulatory response from the femoral nerve: Rectus muscle

of the thigh (“dancing patella“).
Dosage
30 – 50 ml LA

Catheter technique
38

Lower extremity

Stimulation of the sartorius muscle
(medial contraction) occurs:
Puncture direction usually too medial
Retract the needle, and shift it slightly to
the lateral.
Direct stimulation of the sartorius

muscle (rare):
Puncture direction is usually too lateral
Shift the needle slightly to the medial.
Femoral artery puncture:

Retract the needle Shift puncture direction
to the lateral.

• LA injection in the case of sartorius muscle stimulation.
39

Overview
Saphenous nerve block
Indications
• Operative procedures in the area supplying the saphenous nerve
• In combination with distal sciatic nerve block for operations on
the whole lower leg and foot
• Analgesia
Contraindications
• No particular

• No particular
• Patellar crest
• Sartorius muscle
• Vastus medialis muscle
= Puncture site
40

Lower extremity
41

Method
Saphenous nerve block
Blockade technique
The patient is supine on his back, with the extended leg in a neutral
position, rotated slightly outwardly.
Puncture site:
Approx. 2 – 4 cm cranial and medial of the upper patellar crest over
the sartorius muscle. Puncture direction perpendicular through the
muscle up to the subsartorial fatty tissue.
Positive responses include paresthesias on the medial lower leg at a

pulse duration of 1.0 ms.
Dosage
10 – 15 ml LA

Catheter technique
introducer sheath.
42

Lower extremity

Motor stimulatory response comes from
the vastus medialis muscle:
Can be considered “positive“ Inject LA.
Patient is uncooperative:
Femoral nerve block (as described above) with
reduced LA volume (20 ml).
Alternative technique: Subcutaneous infiltra-
tion below the medial knee joint from the medial
head of the gastrocnemius muscle to the tibial
tuberosity (10 – 15 ml LA).

• No particular.
43

Overview
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
Contraindications
• No particular

• Vessel puncture (obturator artery or vein)
• Origin of the adductor longus muscle
• Pubic tubercle
• Femoral artery
1 Adductor longus muscle, 2 Puncture site
44

Lower extremity
45

Method
Obturator nerve block
Blockade technique
The patient is supine on his back, his leg is rotated outwardly and
abducted.
Puncture site:
5 – 10 cm beneath the pubic tubercle directly lateral to the tendon
origin of the adductor longus muscle. Puncture direction approx. 45°
craniolateral pointing towards the anterior superior iliac spine.
Positive stimulatory response from adductor group.
Dosage
10 – 15 ml LA

Catheter technique
introducer sheath.
46

Lower extremity

Persistent adductor spasm despite (proper)
obturator nerve block occurs:
Perform an additional femoral nerve block, which will
block any accessory obturator nerve that runs together
with femoral nerve.
Note:
The adductor reflex for transurethral lateral bladder
wall can only be reliably suppressed by a separate ob-
turator nerve block (not by a femoral nerve block nor
spinal anesthesia!).

• No particular.
47

Overview
Parasacral sciatic nerve block

(Approach according to Mansour)
Indications
• Operative procedures in areas supplying the sciatic nerve
• In combination with psoas compartment block/femoral nerve
block for operations on the whole leg
• Analgesia
Contraindications
• No particular

• Vessel puncture (inferior gluteal artery)
• Ischial tuberosity
1 Greater trochanter, 2 Posterior superior iliac spine,

3 Ischial tuberosity, 4 Puncture site
48

Lower extremity
4
3
49

Method
Parasacral sciatic nerve block
Blockade technique
The patient is placed in the lateral recumbent position, hip flexed
45°, knee flexed 70°, or both knees against the abdomen (favorable
when combined with a psoas compartment block).
Puncture site:
Approx. 5 – 6 cm caudad to the posterior superior iliac spine along
the connecting line to the ischial tuberosity. Insertion direction
20 – 30° caudad to midline between ischial tuberosity and greater
trochanter.
Positive stimulatory response from the peroneal and tibial nerves:
extensors or flexors of the foot/toes.
Dosage
20 – 40 ml LA

Catheter technique
introducer sheath.
50

Lower extremity

Bone contact occurs:
Shift puncture site further caudad or puncture direction
more caudad.
No stimulatory response is elicited:

Shift puncture direction more caudad and lateral.

• LA injection upon stimulatory response from the
gluteal muscles.
51

Overview
Transgluteal sciatic nerve block

(Approach according to Labat)
Indications
• Operative procedures in areas supplying the sciatic nerve
• Analgesia
Contraindications
• No particular

• Vessel puncture (inferior gluteal artery)
• Greater trochanter
• Sacral hiatus
1 Greater trochanter, 2 Posterior superior iliac spine,

3 Ischial tuberosity, 4 Sacral hiatus, 5 Puncture site
52

Lower extremity
5
3
53

Method
Transgluteal sciatic nerve block

Blockade technique
The patient is placed in the lateral recumbent position; hip flexed 45°,
knee flexed 70° (“stable recumbent position“).
Puncture site:
4 – 5 cm mediocaudal on the mid-perpendicular lines between great-
er trochanter and posterior superior iliac spine; connecting line be-
tween the greater trochanter and sacral hiatus intersects the insertion
point at the mid-perpendicular line. Insertion direction perpendicular
to the surface.
Positive stimulatory response from the peroneal or tibial nerves:

Dosage
20 – 40 ml LA

Catheter technique
introducer sheath.
54

Lower extremity

Contraction of gluteus maximus muscle
(= direct muscle stimulation) occurs: Continue
to advance the needle until the typical response is
elicited.
Stimulatory response from the ischiocrural

muscles group: LA injection possible Delayed
onset of action.
Bone contact, no stimulatory response:

Correct insertion direction to midline between greater
trochanter and ischial tuberosity.

• LA injection upon stimulatory response from the
gluteal muscles.
55

Overview
Anterior sciatic nerve block

(Approach according to Meier)
Indications
• Operative procedures in the area supplying of the sciatic nerve
• Analgesia
Contraindications
• No particular

• Vessel puncture (femoral artery and vein, inferior gluteal artery
and vein)
• Neural injury (femoral nerve)
• Pubic symphysis
• Compartment between sartorius and rectus femoris muscles.
1 Anterior superior iliac spine, 2 Pubic symphysis,

3 Greater trochanter, 4 Puncture site
56

Lower extremity
57

Method
Anterior sciatic nerve block

Blockade technique
The patient is supine on his back, with the leg in a neutral position.
Puncture site:
Divide into thirds the line connecting the anterior superior iliac spine
and the middle of the pubic symphysis. A perpendicular line at the
transition from the medial to the middle third intersects a parallel line
to the inguinal ligament through the greater trochanter at the inser-
tion point. Palpate the muscle compartment and press against the
femur with two fingers. This forces the vessels to the medial. Insertion
direction is sagittal and 70 – 80° cranial without any femur contact.
Dosage
20 – 40 ml LA

Catheter technique
introducer sheath.
58

Lower extremity

Primary femur contact occurs: Insertion point
too far to the lateral Retract the needle and
shift insertion to the medial.
Primary vessel puncture (femoral vein or

artery): Insertion too far medial Retract the
needle and shift the insertion to the lateral.
Deep vessel puncture (gluteal artery and

vein): Correct insertion direction slightly to the
lateral.
Stimulation of femoral nerve branches:

Retract the needle and “bypass“ stimulation area.

• A neutral leg position is imperative.
59

Overview
Subtrochanteric sciatic nerve block

(Approach according to Guardini)
Indications
• Operative procedures in the area supplying of the sciatic nerve
• Analgesia
Contraindications
• Status secondary to total ipsilateral hip replacement (relative)

• No particular
• Ischial tuberosity
1 Greater trochanter,
2 Ischial tuberosity, 3 Puncture site
60

Lower extremity
3
2
61

Method
Subtrochanteric sciatic nerve block
Blockade technique
The patient is supine, with the leg in a neutral position or rotated
slightly inwards. Padding under the lower leg and pelvic helps with
orientation.
Puncture site:
Approx. 2 cm dorsal and 3 – 4 cm distal to the greater trochanter. In-
sertion direction horizontal and somewhat cranial towards the ischial
tuberosity without femur contact.

Dosage
20 – 40 ml LA

Catheter technique
62

Lower extremity

Femur contact occurs: Insertion too far ventral
Move insertion more to the dorsal.
No stimulatory response is elicited: Direct

insertion a little to the ventral and emphasize inward
rotation in the hip joint.
Alternative technique:
Leg is rotated slightly inward with flexed knee joint
“upright“ on the table.
Puncture site: 2 – 3 cm caudad from the mid-point
of the line connecting greater trochanter and ischial
tuberosity. Insertion direction is cranial and slightly
medial.

• Make sure that the leg is in a neutral position
(with a slight inward rotation).
63

Overview
Lateral distal sciatic nerve block
Indications
• Operative procedures in the areas supplying the sciatic nerve
on the whole lower leg and foot
• In combination with saphenous nerve block for operations of
the whole lower leg
• Analgesia
Contraindications
• Stent (relative)

• Vessel puncture (popliteal artery/vein)
• Patellar crest
• Vastus lateralis muscle
• Long head of the biceps femoris muscle
1 Patellar crest, 2 Puncture site
64

Lower extremity
65

Method
Lateral distal sciatic nerve block
Blockade technique
The patient is supine on his back, with the leg in a neutral position
(rotated slightly inwards), padding under the lower leg.
Puncture site:
Approx. 3 – 8 cm above the patella in the lateral muscle compart-
ment between lower edge of the vastus lateralis muscle and biceps
femoris muscle. Insertion direction slightly dorsocranial.

Dosage
30 – 40 ml LA

Catheter technique
66

Lower extremity

No stimulatory response is elicited:
Insertion direction is usually too far ventral
Correct to the dorsal.
Femur contact occurs:

Puncture site and/or insertion direction too far to
the ventral Check puncture site, correct to dor-
sal if needed; shift insertion direction more to the
dorsal.
Vessel puncture popliteal artery/vein:

Puncture too deep and too ventral Retract the
needle, correct insertion direction to the dorsal,
reduce insertion depth.

• Make sure that the leg is in a neutral position
(with a slight inward rotation).
67

Overview
Popliteal sciatic nerve block
Indications
• Operative procedures in the area supplying the sciatic nerve of
the lower leg and foot
• In combination with saphenous nerve block, operations on the
whole lower extremity
• Analgesia
Contraindications
• Stent (relative)

• Vessel puncture (popliteal artery/vein)
• Popliteal fossa
• Popliteal fold
• Long head of the biceps femoris muscle
• Medial and lateral epicondyle of the femur
1 Lateral epicondyle of the femur,

2 Medial epicondyle of the femur, 3 Puncture site
68

Lower extremity
1 2
69

Method
Popliteal sciatic nerve block
Blockade technique
The patient is either in the prone position or lying on his side, leg
extended.
Puncture site:
Approx. 8 – 12 cm above the fold of the popliteal fossa at the medial
edge of the biceps femoris muscle, laterally marking the popliteal
fossa. Insertion direction approx. 30° cranial and slightly lateral.
Positive stimulatory response from the peroneal and tibial nerves:

Dosage
30 – 40 ml LA

Catheter technique
70

Lower extremity

Femur contact occurs:
Insertion too deep and too medial Retract the needle
Correct puncture direction or insertion site to the
lateral, reduce insertion depth.
Vessel puncture popliteal artery/vein:

Puncture too deep and too medial Retract the needle
Correct insertion direction to the lateral, reduce inser-
tion depth.

• Puncture site is too far caudad (popliteal fold):
It may be that the tibial nerve (med.) and peroneal
nerve (lat.) are separated so far apart that complete
blockade cannot be achieved with a single LA injec-
tion at the two sciatic branches.
71

Other publications appearing in this series
• Brochure
Peripheral Regional Anesthesia
at the Ulm Rehabilitation Hospital
• 3-part Video Tutorial (VHS)

• Interactive CD-ROM Tutorial

These materials can be B. Braun Melsungen AG

requested at the following Mediaservice
address: Tel. (0 56 61) 71 - 16 38
Fax (0 56 61) 71 - 16 32
Carl-Braun-Straße 1
D-34212 Melsungen
Online Tutorial
www.nerveblocks.net
The state of medical knowledge is subject to constant change due to new research and clinical evi-
dence. The authors of this book have been very careful to comply with the current state of the art.
Nevertheless, users of this information carry their own responsibility and liability when establishing
the diagnosis and implementing therapy.
The Tutorial was made possible by the kind support of B. Braun Melsungen AG.
Nr. 6064605

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Preface

After so many of our colleagues have ex-

We would appreciate your suggestions and criticisms and look forward

Ulm, June 2004 Prof. H.-H. Mehrkens, M.D.

RKU-Kompendium_engl-4.indd 1 22.04.2005 07:35:16

Anterior interscalene nerve block ...................................... 12

RKU-Kompendium_engl-4.indd 2 22.04.2005 07:35:42

Psoas compartment block.................................................. 32

RKU-Kompendium_engl-4.indd 3 22.04.2005 07:35:42

Single shot technique

RKU-Kompendium_engl-4.indd 4 22.04.2005 07:35:42

Stimuplex® HNS 12 (B. Braun Melsungen AG)

Stimuplex® D (B. Braun Melsungen AG)

Contiplex® D, Contiplex® Tuohy (B. Braun Melsungen AG)

RKU-Kompendium_engl-4.indd 5 22.04.2005 07:35:42

Conventional, medium-acting local anesthetics (LA) like

and long-acting ones like

For anesthesia, we prefer a combination of

This combination has the advantage that a LA with comparably

For analgesia, 0.2% ropivacaine is generally administered. The

RKU-Kompendium_engl-4.indd 6 22.04.2005 07:35:45

Stimulation and injection technique

RKU-Kompendium_engl-4.indd 7 22.04.2005 07:35:45

Diagram of the brachial plexus

A Upper trunk 5 Musculocutaneus nerve

RKU-Kompendium_engl-4.indd 8 22.04.2005 07:35:45

Diagram of the lumbosacral plexus

RKU-Kompendium_engl-4.indd 9 22.04.2005 07:35:46

RKU-Kompendium_engl-4.indd 10 22.04.2005 07:35:47

Local anesthetic-induced systemic intoxication

RKU-Kompendium_engl-4.indd 11 22.04.2005 07:35:47

Anterior interscalene nerve block

Side effects / complications

RKU-Kompendium_engl-4.indd 12 22.04.2005 07:35:47

RKU-Kompendium_engl-4.indd 13 22.04.2005 07:35:47

Anterior interscalene nerve block

Puncture depth: 2 – 4 cm.

Positive stimulatory response from the upper trunk (lateral cord):

Single shot technique

RKU-Kompendium_engl-4.indd 14 22.04.2005 07:35:50

? What to do when ...?

Stimulation of the suprascapular nerve (leva-

Stimulation of the phrenic nerve (unilateral

Blood is aspirated: Retract the needle, check

! Potential errors and hazards

RKU-Kompendium_engl-4.indd 15 22.04.2005 07:35:50

Posterior interscalene nerve block

Side effects / complications

1 C6, 2 C7, 3 Puncture site

RKU-Kompendium_engl-4.indd 16 22.04.2005 07:35:50

RKU-Kompendium_engl-4.indd 17 22.04.2005 07:35:50

Posterior interscalene nerve block

Single shot technique

RKU-Kompendium_engl-4.indd 18 22.04.2005 07:35:52

? What to do when ...?

Stimulation of the suprascapular nerve (leva-

Stimulation of the phrenic nerve (unilateral

Blood is aspirated: retract the needle, check

! Potential errors and hazards

RKU-Kompendium_engl-4.indd 19 22.04.2005 07:35:52