Kaan Yücel M.D., Ph.D.

1. NERVE BLOCKS • Kaan Yücel M.D., Ph.D. 21.March.2012 Thursday

2. NERVE BLOCKS UPPER EXTREMITY

3. BrachialPlexusBlock • Injectionof an anestheticsolutionintoorimmediatelysurroundingtheaxillarysheathinterruptsconduction of impulses of peripheralnerves. • Thedistalpart of thesheath is closedwithfingerpressure, and a syringeneedle is insertedintotheproximalpart of thesheath. • Sensationblocked in alldeepstructures of theupperlimbandthe skin distaltothemiddle of thearm.

4. Brachialplexus can be anesthetizedusing a number of approaches: Interscaleneblock Supraclavicularblock Infraclavicularblock Axillaryblock

5. Interscalene Block PROCEDURE • Intervalbetweenthescalenemuscles • Rootsof theupperpart of thebrachialplexus can be blocked.

6. SupraclavicularBlock PROCEDURE Between scalenusanterior& scalenusmedius directedcaudallybehindsubclavianarterytoward uppersurface of 1st rib brachialplexuscompact uppermiddlelowertrunks

7. InfraclavicularBlock PROCEDURE • Identifythemiddleof theclavicle • Inserttheneedle 1 in. (2.5 cm) inferiortoit • Anatomy of complications • Vesselpuncture • Hematomaformation

8. AxillaryBlock PROCEDURE • Palpateaxillaryarterywithintheaxillarysheathhighup in theaxilla • Abductthearmtoan anglegreaterthan90° • Compressthearterythere • Inserttheneedprox. tothepoint of compression • Disadvantage: Leaking of anestheticintomusculocutanouesnerve • Anatomyof complications • Vesselpuncture • Hematomaformation

9. MusculocutaneousNerveBlock PROCEDURES Indications Repair of lacerations on thelateralborder of theforearm Brachialplexusapproach Musculocutaneous + Rest of thebrachialplexus Sufficientlyhigh in theaxillarysheath Lateralcutaneousnerve of theforearmapproach Betweenbiceps & brachialisjustabovelateralepicondyle Lateraltobicepstendon on a linebetween twoepicondyles of thehumerus

10. MedianNerveBlock • Area of anesthesia • Lateralhalf of thepalm • Palmaraspect of lateral 3 ½ fingers • including nail beds on thedorsum

11. MedianNerveBlock PROCEDURES Block @ elbow • Elbowjointextended, palpate • brachialartery@cubitalfossa on medialside of bicepsbrachiitendon • -Insertneedle on medialside of brachialartery • -Here mediannervelies on medialside of tendonsof flexorcarpiradialis& tothelateralside of theflexordigitorumsuperficialis Block @ wrist

12. UlnarNerveBlock PROCEDURES Indications Repairof lacerations of thehand& fingers Where it enterstheforearm betweenolecranonprocess& medialepicondyle Justlateraltoflexorcarpiulnaristendon @ levelof distaltransversecrease of thewrist Ulnararterylateralside of theulnarnerve Block @ elbow Block @ wrist

13. RadialNerveBlock PROCEDURES Indications Repair of lacerations of thehand Block @ elbow Halfwaybetweenbicepsbrachiitendon &tip of lateralepicondyle Block @ wrist At thelevel of theproximaltransverseflexorcrease on thelateralside of theradialartery

14. DigitalNerveBlocks • Area of anesthesia • Skin of thefingers • Eachfinger • suppliedbyfourdigitalnerves at • 2 o’clock, 5 o’clock, 7 o’clock, and 10 o’clockpositions. • Indications • Repairof lacerationsinvolvingindividualfingers; removal of nails

15. DigitalNerveBlocks Palmardigitalnerves (ulnar&mediannerves) Palmarsurface:Medial 1 ½ fingers includingtheir nail beds Palmarsurface: Lateral3 ½ fingers Dorsaldigitalnerves (ulnar&radialnerves) Dorsalsurface of theproximalparts of medial 1 ½ fingers Dorsalsurface of theproximalparts of lateral 3 ½ fingers

16. DigitalNerveBlocks PROCEDURES Web spacemethod At the web space, digitalnervesareabouttoenterthefingers. A block on bothsides of thefingers Dorsalmetacarpalmethod Betweenthemetacarpalbones, stoppingjustshort of thepalmar skin Theanestheticsolutionwillblockthecommonpalmaranddorsaldigitalnerves

17. NERVE BLOCKS LOWER EXTREMITY Distal nerve blocks of the lower limb

18. FemoralNerveBlock • Area of anesthesia • Front & medialside of thethigh, extendingdownthemedialside of theknee & leg • Medialborder of thefoot as far as ballof thebigtoe • Belowthemidpoint of theinguinalligamentandlateraltothefemoralartery PROCEDURE

19. Lateral Cutaneous Nerve of the Thigh Block • Area of anesthesia • Anterolateralsurface of thigh • downtothelateralside of theknee PROCEDURE Justinferiortotheinguinalligamentabout 0.5 in. (1.3 cm) medialto ASIAS

20. SciaticNerveBlock Anteriorapproach An advancedblocktechnique For surgery on the leg below the knee, particularly on the ankle and foot Completeanesthesia of the leg below the knee with the exception of the medial strip of skin, innervated by the saphenous nerve Landmarks Femoral crease Femoral artery pulse Needle insertion point marked 4-5 cm distally on the line passing through the pulse of the femoral artery and perpendicular to the femoral crease.

21. SciaticNerveBlock Posteriorapproach Wideclinicalapplicabilityforsurgeryandpainmanagement of thelowerextremity Oneof themostcommonlyusedtechniques in aneshetsiapractice Anesthesiaof the skin of the posterior aspect of the thigh, hamstrings and biceps muscles, part of hip and knee joint, and entire leg below the knee, with the exception of the skin of the medial aspect of the lower leg Indications: Surgery on the knee, tibia, ankle, and foot Landmarks: Greater trochanter, superior posterior iliac spine, midline between the two

22. PoplitealNerveBlock • Blockof thesciaticnerve in thepopliteal fossa withthepatient in theproneposition. • Idealforsurgeriesofthelowerleg, particularlythefootandankle. Popliteal fossa crease Tendon of bicepsfemoris (laterally) Tendons of semitendinosusandsemimembranosusmuscles (medially) Theneedleinsertionpoint is marked at 7 cm. abovethepopliteal fossa crease at themidpointbetweenthetendons.

23. CommonPeronealNerveBlock • Area of anesthesia • Anterior & lateralsides of theleg • Dorsumof thefoot& toes • includingthemedialside of thebigtoe PROCEDURE Belowthehead of thefibula

24. SuperficialPeronealNerveBlock • Area of anesthesia • Loweranterior & lateralsides of leg • Dorsumof foot & toes • except • Cleftbetween1st & 2nd toes • deepperonealnerve • Lateralside of littletoe • suralnerve PROCEDURE Lowerpart of thelegbyalong a transverselineconnectingmedial & lateralmalleoli

25. DeepPeronealNerveBlock • Area of anesthesia • Cleftbetweenbig & secondtoes PROCEDURE • Palpatethedorsalispedisarterymidwaybetweenmedial & lateralmalleoli • Footdorsiflexed, observeextensordigitorumlongus& extensorhallucislongus • Thenerveon thelateralside of thearterybetweenthesetendons • - Inserttheneedleoverthenerve

26. TibialNerveBlock • Area of anesthesia • Sole of thefoot PROCEDURE Behindmedialmalleolus Pulsations of posteriortibialarterymidwaybetweenmedialmalleolus & theheel Thenerveliesimmediatelyposteriortotheartery, andtheanestheticneedle can be inserted at thislocation.

27. SuralNerveBlock Areaof anesthesia Lateralborder of foot& lateralside of littletoe Midwaybetween lateralmalleolus &Achillestendon PROCEDURE

28. SaphenousNerveBlock • Area of anesthesia • Medialside of theleg • Medialborder of thefootdown • as far as theball of bigtoe PROCEDURE Medialside of kneeeither overmedialfemoralcondyle or lowerdownovercondyleof thetibia Avoidgreatsaphenousvein Alternative@ anklewhere it passesanteriortomedialmalleolus

29. ToeNerveBlocks Areaof anesthesia Skin of thetoes Eachtoe is suppliedbyfourdigitalnerves@ 2 o’clock, 5 o’clock, 7 o’clock, & 10 o’clockpositions. Aroundthebase of eachtoe PROCEDURE PlantardigitalnervesMedial & lateralplantarnerves DorsaldigitalnervesSuperficialperonealnerve Except : Cleftbetweenbigtoe&secondtoeDeepperonealnerve Lateralsideof littletoeSuralnerve