Lower limb plexus and nerves anatomy

anatomy US
It's guidance
hot
is essentiel will help you

Philippe B. Macaire MD!

Consultant in Anesthesiology and Pain!
Anaesthesia dpt and Pain Interventional Clinic!
Rashid Hospital - Trauma Centre!
Dubai Health Authority - UAE
Lower limb innervation
innervation of lower limb
innervation of lower limb
 Anatomical variations

60 % 40 %

Cutaneous innervation extremely variable +++

!
Jochum D. Techniques. Membre inférieur. Anatomie. http://www.alrf.asso.fr/
!
Bouaziz H et al. An Evaluation of the Cutaneous Distribution After Obturator
Nerve Block. Anesth Analg. ! 2002 Feb;94(2):445-449.
innervation of lower limb : Errors

Only 40%
Lumbar plexus

Neuro-stimulation motor
responses:

•  Femoral nerve:
•  Contraction of the
quadriceps with ascent of the
patela; ideal response.
•  Vastus medialis.
•  Vastus lateralis

•  Obturator nerve:
•  Anterior branch ;
contraction of the adductor
longus and gracilis muscles.
•  Posterior branch:
contraction of the adductor
magnus.
Lumbal plexus block or psoas cpt block

How to
perform
correctly?
Lumbal plexus block or psoas cpt block

Muscle psoas
Muscle carré des
lombes
Muscles sacro
lombaires

Compartiment psoas
Lumbal plexus block or psoas cpt block
 Lumbal plexus block or psoas cpt block

• Deep block:
– 60 to 100mm L4
! …oins de
Enfin !!!
douleurs.
• Processus
costiforme
– Farny et Al 1994

L5
Lumbal plexus block or psoas cpt block

…oins de
Enfin !!!
douleurs.

Dissection par Bertrand Fabre Paris

Lumbal plexus block or psoas cpt block

…oins de
douleurs.

1/3

2/3 40 mm

Capdevila
Winnie APet1975
al Anesth Analg. 2002,
Lumbal plexus block or psoas cpt block
Brit J Anaesth 2008!
Brit J Anaesth 2008!
Lumbal plexus block or psoas cpt block
The main approaches...
The main approaches...
The new approach... “Shamrock”

Puncture:
• In plane.
The new approach... “Shamrock”

Puncture:
• In plane.
The new approach... with a process

Step 1

Puncture:
• In plane.
 The new approach... “Shamrock”

Step 2 Identify inferior pole of kidney

Puncture:
• In plane.
 The new approach... “Shamrock”

Step 3

Puncture:
• In plane.
The new approach... “Shamrock”

Puncture:
• In plane.
The new approach... “Shamrock”

Puncture:
• In plane.
Lumbal plexus block or psoas cpt block
Traps...

Photo : PJ Zetlaoui
 Femoral nerve

How to
perform
correctly?
Femoral nerve anatomy
 Femoral nerve > Saphenous nerve
!
• Derived from the posterior division of the
femoral!
nerve!
!
• Follows the posterior surface of the
sartorius muscle!
to its attachment on the tibia!
!
• Then divides into infrapatelar and distal
cutaneous!
branches!
!
• Supply the medial aspect of the leg from
the knee to!
the medial malleolus
Femoral nerve > Saphenous nerve
Femoral nerve > Saphenous nerve
Femoral nerve > Saphenous nerve
Saphenous nerve at the ankle
Saphenous nerve at the ankle
 Obturator nerve
By injecting 20 ml + under
the fascia iliaca lateral to
femoral artery will provide a
block of femoral, Obturator
and lateral femoral
cutaneous nerves!
Alon P Winnie

3 in 1 block does not exist !!

Olivier Choquet
Obturator nerve
Obturator nerve
 Obturator nerve

Femoral

Obturator

Before block After “3 in 1” block After Obturator block

Obturator nerve
Obturator nerve
Obturator nerve anatomy
lateral femoral cutaneous nerve
lateral femoral cutaneous nerve
 Sacral plexus
Neuro-stimulation motor
responses: !
!
Tibial nerve: !
Contraction of the posterior
muscles of the leg.!
Plantar flexion of the foot and
the toes.!
Inversion of the foot.!
!
Common peroneal nerve:!
Contraction of the anterior and
lateral muscles of the leg.!
Dorsi flexion of the foot and the
toes.!
Eversion of the foot.!
!
Inferior gluteal nerve:!
Contraction of the gluteal
muscles..!
Sciatic nerve blocks : The recent evolution
Anatomy
Scan process to identify the anatomy
PSIS

PSIS
Scan process to identify the anatomy

PSIS
Scan process to identify the anatomy

Piriformis muscle
Sciatique Pudendal nerve
Scan process to identify the Sciatic nerve
Scan process to identify the Sciatic nerve

Sciatic n. Gluteal Art.

Scan process to identify the Sciatic nerve
Anatomy
Anatomy
Sciatic anterior approach
< Lat Medial >

<A

LT
M

<N
Sciatic anterior approach
< Lat Medial >

<A

LT
M

<N
Sciatic popliteal approach
Sciatic branches at the ankle

Tibial nerve
 Sciatic branches at the ankle

Tibial nerve TA >

TA = Tibial Artery
TN = Tibial nerve

< TN
Sciatic branches at the ankle

Sural nerve
 Sciatic branches at the ankle

Sural nerve
 Sciatic branches at the ankle

Peroneal nerve :!
• deep!
• superficial
Sciatic branches at the ankle

SP N.
PL

FIBULA

SP N. = Superf Peroneal nerve

PL = Peroneal longus muscle
PB = Perneal brevis muscle
EDL = Extensor digitorum longus muscle
CF = Crural Fascia
Sciatic branches at the ankle

Deep Peroneal nerve :!

 :-)
Philippe B. Macaire MD!
Consultant in Anesthesiology and Pain!
Anaesthesia dpt and Pain Interventional Clinic!
Rashid Hospital - Trauma Centre!
Dubai Health Authority - UAE Slides on demand to !
!
ph.macaire@gmail.com
Registration for 2015/16!
will start by June 15th!
!
Information:!
!
kate@medinfusion.org
 Diploma in !
Regional Anesthesia !
& Analgesia!
Dubai - UAE!
6th Batch 2015/1
 Organisation of the post graduate!
diploma in Regional Anesthesia and Analgesia!
delivered by the French University of
Montpellier in Dubai

Xavier Capdevila MD PhD Mansour Youssef Nadhari MD Philippe B Macaire MD

! ! !
Professor of Anesthesiology and Critical Care Medicine Consultant & Head of Department Senior Consultant
Head of Department Co-Director of the diploma regional anesthesia & Co-Director of the diploma regional anesthesia &
Director of the diploma regional anesthesia & analgesia analgesia analgesia
Department of Anesthesiology and Critical Care Medicine Department of Anesthesiology and Interventional Pain Department of Anesthesiology and Interventional
Lapeyronie University Hospital and Montpellier School of Medicine Pain Medicine
Medicine Rashid Hospital - Trauma Centre Rashid Hospital - Trauma Centre
Montpellier, France Dubai Health Authority - UAE Dubai Health Authority - UAE
Courses and Workshops:

• 3 days in

• January

• feb

• March

• April

• May

Clinical attendance

• 5 days in accredited enters

• One in India in discussion for 15/16

Written exam in June

Certificates delivered by french ministry in December
Faculty 6TH INTERNATIONAL SYMPOSIUM ON
Program
REGIONAL ANALGESIA, MUSCULOSKELETAL
AND INTERVENTIONAL PAIN MEDICINE
Venue
NOVEMBER 6TH & 7TH IN DUBAI - UAE
Registration

Archives

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Welcome to the 6th International Symposium on Musculoskeletal,
Interventional Pain and advanced Regional Analgesia.
Anna Zickerman et Philippe Macaire welcome you to this 6th
Symposium with 12 international speakers.
We have worked diligently to offer you this outstanding “a la carte” Dubai - November 6th 7th 2015
program with these renowned speakers. They will provide you with the
latest developments and “state-of-the-art” knowledge in the world of
the pain where new procedures and techniques are pointing.

Physicians, Sport Medicine Doctors, Anesthesiologists, Surgeons

and Physiatrists are welcome.

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