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Flashcards in UNIT 8 Regional Deck (113):
1

What are the 5 divisions of the spinal column, and how many vertebrae are present in each?

cervical: 7
thoracic: 12
lumbar: 5
sacral: 5 fused
coccygeal: 4 fused

2

know the anatomy of the vertebrae

spinous process connected via lamina to transverse processes
pedicles connect to the vertebral body

all surround the vertebral foramen

3

what are the anatomical borders of the facet joint?

formed by the superior articular process of one vertebrae and the inferior articular process of the one directly above it.

injury to the facet can compress the spinal nerve that exits the respective intervertebral foramina, causing pain & muscle spasm along the associated dermatome

4

order the 5 ligaments of the spinal column from posterior to anterior

supraspinous ligament
interspinous ligament
ligamentum flavum
posterior longitudinal ligament
anterior longitudinal ligamnet

5

what ligaments are penetrated during midline approach to the epidural space? How about the paramedian approach?

midline:
- supraspinous
- interspinous
- ligamentum flavum

paramedian
- ligamentum flavum

6

list all of the structures & spaces b/n the skin and the SC as they would be encountered during a subarachnoid block

skin
subcutaneous tissue
muscle
supraspinous ligament
interspinous ligament
ligamentum flavum
dura mater
arachnoid mater
pia mater

7

what are the boundaries of the epidural space?

cranial border = foramen magnum
caudal border = sacrococcygeal ligament
anterior border = posterior longitudinal ligament
lateral border = vertebral pedicles
posterior border = ligamentum flavum, vertebral lamina

8

What happens when you accidentally inject LA into the subdural space during a SAB? How about during an epidural?

subdural space is a potential space b/n the dura and arachnoid mater

epidural dose injected into the subdural space --> high spinal w/ delayed onset (15-20mins)
spinal dose injected into the subdural space --> failed block

9

What is Batson's plexus, and what is it's significance?

the epidural veins
they drain venous blood from the SC. valveless. pass through the anterior and lateral regions of the epidural space.

obesity & pregnancy increase intraabdominal pressure = plexus engorgement. This is associated w/ an increased risk of needle injury or cannulation

10

What is the plica mediana dorsalis, and what is its significance?

while its existence remains controversial, many speculate that a band of connective tissue courses b/n the ligamentum flavum & dura mater

if it does exist, it could create a barrier that would impact the spread of medications w/in the epidural space.

it has long been considered the culprit for difficult epidrual catheter insertion as well as unilateral epidural blocks

11

what ligament covers the sacral hiatus? What is the significance of this?

sacrococcygeal ligament

this ligament is punctured during the caudal approach to the epidural space.

12

What is a dermatome, and which ones are important to know as you assess a neuraxial anesthetic?

dermatome = area of skin that is innervated by a spinal nerve

C6 = thumb
C7 = 2nd & 3rd digits
C8 = 4th & 5th digits
T4 = nipple
T6 = xiphoid
T10 = umbilicus
T12 = pubic symphysis
L4 = anterior knee

13

compare and contrast the site of action for spinal vs. epidural anesthesia.

spinal
- primary LA action is on the myelinated preganglionic fibers of the spinal nerve roots
- LA also inhibit neuronal transmission in the superficial layers of the SC

epidural
- LA must diffuse through the dural cuff before than can block the nerve roots
- LA also leaks through the intervertebral foramen to enter the paraverterbral area, where they cause multiple paravertebral blocks

14

what factors do and do not contribute to the spread of LA in the subarachnoid space?

DO
- baricity
- patient position
- dose
- site of injection
- volume & density of CSF

DONT
- barbotage
- increased intraabdominal pressure
- speed of injectin
- bevel orientation
- vasoconstrictor addition
- weight
- gender

15

what is the primary determinant of spread for epidural anesthesia?

volume

16

discuss the differential blockade of spinal anesthesia

different types of nerves have different sensitivites to LA blockade
- autonomic first
- sensory second
- motor last

why is this important? autonomic blockade is 2-6 dermatomes higher than sensory block & sensory blockade is 2 dermatomes higher than motor block

17

How is differential blockade different w/ epidural anesthesia?

there is no autonomic differential blockade w/ epidural anesthesia

sensory blockade is 2-4 dermatomes higher than motor

18

compare and contrast nerve fibers in terms of subtype, myelination, function, size, conduction velocity, and block onset.

Aalpha
- heavy myelination
- skeletal m motor + proprioception
- largest
- fastest
- last for block onset

Abeta
- heavy myelination
- touch, pressure
- second largest
- second fastest
- last for block onset

Agamma
- medium myelination
- skeletal m tone
- medium size
- medium velocity
- second to last for block onset

Adelta
- medium myelination
- fast pain, temp, touch
- medium size
- medium velocity
- second to last for block onset

B
- light myelination
- preganglionic ANS
- medium size
- medium velocity
- first for block onset

C
- no myelination
- postganglionic ANS, slow pain, temp, touch
- small size
- slowest velocity
- second for block onset

19

discuss the CV effects of neuraxial anesthesia

sympathectomy --> vasodilation in arterial & venous circulations, although predominantly affects venous capacitance vessels
--> decreased preload, CO, and BP
- volume loading w/ approx 15mL/kg and vasopressors will minimize hypotension

bradycardia is caused by
- T1-T4 preganglionic cardiac accelerator fiber blockade
- bezold-jarisch reflex
- unloading of stretch receptors in the SA node

20

discuss the respiratory effects of neuraxial anesthesia

in healthy patients, there is negligible effects on MV, Tv, rr, dead space, and ABG

accessory muscle function is reduced + abdominal muscles (cough function impairment)
- particularly important w/ COPD

21

how does neuraxial anesthesia affect the neuroendocrine response to stress?

by inhibiting afferent traffic originating from the surgical site, it diminishes the surgical stress response.

this reduces circulating levels of catechols, RAAS, glucose, TSH, and GH

22

how does neuraxial affect GI function?

the gut receives PSNS innervation from CN V and SNS innervation from the sympathetic chain b/n T5-L2

- inhibition of the sympathetic chain allows PSNS function unopposed
--> sphincter relaxation & increased peristalsis

23

how does neuraxial anesthesia affect renal & hepatic blood flow?

as long as systemic BP is maintained, HBF & RBF are unchanged

24

what is the risk of neuraxial anesthesia in the patient w/ coagulopathy? What lab values are considered contraindications to a neuraxial technique?

risk of spinal or epidural hematoma

platelet <100K
PT, aPTT, and/or bleeding time twice the normal value

25

What cardiac pathologies present a risk of hemodynamic collapse w/ neuraxial anesthesia?

valve lesions w/ fixed SV:
- severe AS
- severe MS
- hypertrophic cardiomyopathy

26

what is the risk of a neuraxial technique in the patient w/ intracranial hypertension?

there is an increased chance of brain herniation w/ sudden changes in CSF pressure

27

what is the relationship b/n neuraxial anesthesia & MS?

classic teaching suggests that epidural is ok, but intrathecal may exacerbate symptoms - no good supporting data however.

28

what is the specific gravity of CSF? What factors increase and decrease the spec gravity of CSF?

1.002-1.009

increase:
- hyperglycemia
- uremia
- high protein content
- advanced age
- colder temperature

decrease:
- liver disease
- jaundice
- warmer temperature

29

what is baricity, and how does it influence your selection of LA?

baricity describes the density of a LA solution relative to the CSF.
- isobaric: LA similar to CSF
- hyperbaric: LA higher density
- hypobaric: LA lower density

hyperbaric will sink, hypobaric will rise, isobaric will remain in place.

as a general rule, solutions in dextrose are hyperbaric, saline are isobaric, water are hypobaric.

30

how does a hyperbaric solution distribute in the sitting patient? How about the supine patient?

sitting = sacral nerve roots (i.e. saddle block)

supine = sacrum & thoracic -T4 (since these are the areas of kyphosis

31

How does an hypobaric solution distribute in the sitting patient? How about the supine patient?

sitting = will rise toward the brain (i.e. avoid this)

supine = lower lumbar region (area of lordosis).
- it will not float toward the cervical region bc this would first require it to sink into the thoracic kyphosis

32

what are the 2 classifications of spinal needles?

cutting tip & non cutting tip (pencil point & rounded bevel)

cutting point = Quincke
pencil point = Whitacre, Sprotte
rounded bevel = Greene

33

List 6 examples of spinal needles, and list the pros and cons of each.

cutting tip (Quincke, Pitkin)
- pros = requires less force
- cons = higher risk of PDPH, less tactile feel, needle more easily deflected, more likely to injure cauda equina

pencil point (Sprotte, Whitacre, Pencan)
AND
rounded bevel tip (Greene)
- pros = lower risk of PDPH, more tactile feel, needle less likely to deflect, less likely to injure the cauda equina
- cons = requires more force

34

what are the 3 different types of epidural needles & how are they different from each other

differ in the angle of the needle tip (notice that the needle angle increases in alphabetical order):
crawford = 0 degrees
hustead = 15 degrees
tuohy = 30 degrees
- this curvature + it's blunt tip helps prevent dural puncture

35

How do you dose a caudal anesthetic in a child? an adult?

peds
- sacral block: 0.5mL/kg
- T10: 1mL/kg
- mid-thoracic: 1.25mL/kg

adult
- sacral: 12-15mL
- T10: 20-30mL
avoid midthoracic

36

what are the absolute and relative contraindications to caudal anesthesia?

absolute:
- spina bifida
- meningomyelocele of the sacrum
- meningitis

relative
- pilonidal cyst
- abnormal superficial landmarks
- hydrocephalus
- intracranial tumor
- progressive degenerative neuropathy

37

discuss the mechanism of action of neuraxial opioids.

inhibit afferent pain transmission in the substantia gelatinosa (lamina II) of the dorsal horn

neurotransmission is reduced by:
- decreased cAMP
- decreased Ca++ conductance (pre-synaptic neuron)
- increased K+ conductance (post-synaptic neuron)

epidural opioids diffuse systemically as well

38

do neuraxial opioids cause sympathectomy, skeletal m weakness, and/or changes in proprioception?

NO

39

discuss the commonly used intrathecal and epidural opioids

sufentanil
- intrathecal 5-10mcg
- epidural 25-50mcg
- epidural gtt 10-20mcg/hr

fentanyl
- intrathecal 10-20mcg
- epidural 50-100mcg
- epidural gtt 25-100mcg/hr

dilaudid
- epidural 0.5-1mg
- epidural gtt 0.1-0.2mg/hr

meperidine
- intrathecal 10mg
- epidural 25-50mg
- epidural gtt 10-60mg/hr

morphine
- intrathecal 0.25-0.3mg
- epidural 2-5mg
- epidural gtt 0.1-1mg/hr

40

rank the opioids from most lipophilic to most hydrophilic. How does lipophilicity affect rostral spread in the subarachnoid space?

most lipophilic:
- sufentanil
- fentanyl
- meperidine
- dilaudid
- morphine
most hydrophilic

more hydrophilic drug = less diffusion into systemic circulation, more rostral spread
more lipophilic drug = more diffusion into systemic circulation

41

compare and contrast PK/PD profiles of hydrophilic and lipophilic opioids used for spinal anesthesia.

hydrophilic
- stays in CSF longer
- extensive CSF spread w/ wide band of analgesia + more rostral spread
- acts only in substantia gelatinosa
- delayed onset 30-60min
- DOA longer 6-24hrs
- less systemic absorption
- early & late resp depression
- higher incidence of N/V, pruritis

lipophilic
- stays in CSF shorter
- minimal CSF spread w/ narrow band of analgesia + less rostral spread
- acts in substantia gelatinosa and systemically
- fast onset 5-10mins
- shorter DOA 2-4hrs
- more systemic absorption
- only risk of early resp depression
- lower incidence of N/V, prutritis

42

What are the 4 most important side effects of neuraxial opioids? Which is the most common?

- pruritis (most common)
- respiratory depression
- urinary retention
- N/V

43

Which LA can reduce the efficacy of epidural opioids?

chloroprocaine

44

Which neuraxial opioid can reactivate herpes simplex labialis?

epidural morphine
- best explained by cephalad spread of morphine to the trigeminal nucleus
- usually presents 2-5 days after epidural morphine administration

45

describe the patho & presentation of PDPH

puncturing the dura causes CSF to leak from the subarachnoid space. As CSF pressure is lost, the cerebral vessels dilate + the brainstem sags into the foramen magnum, stretching the meninges & pulling on the tentorium
--> PDPH

classic presentation: fronto-occipital HA +/- N/V, photophobia, diplopia, tinnitus. Supine brings relief.

46

Discuss the risk factors for PDPH

younger age
pregnancy
female
cutting point needle
larger diameter needle
multiple dural punctures
using air for LOR w/ epidural
needle perpendicular to long axis of meninges

47

how do you treat PDPH?

bed rest
hydration
NSAIDs
caffeine (cerebral vasoconstriction)
epidural blood patchy

not opioids

48

how do you perform an epidural blood patch? What is the success rate?

90% success rate/patch
- if HA doesn't resolve after 2 blood patches, other etiologies should be sought

technique:
sterile withdrawal of 10-20mL of autologous venous blood is injected into the epidural space (stop injecting when pressure is felt in legs, buttocks, or back)

49

what are the most common side effects of an epidural blood patch?

backache
radicular pain

50

what is the primary risk of neuraxial anesthesia in the anticoagulated patient? How does this complication present?

risk of epidural hematoma is similar during block placement and catheter removal.

epidural hematoma can cause paralysis. presenting symptoms = LE weakness, numbness, low back pain, bowel/bladder dysfunction.
- surgical decompression w/in 8hrs = best chance of recovery

51

know how long to hold off neuraxial anesthesia after various drugs:
- NSAIDs
- aspirin
- abciximab
- clopidogrel
- ticlopridine
- heparin
- enoxaparin
- warfarin
- tPA, other thrombolytics
- herbal therapies

NSAIDs & aspirin, herbals (garlic, ginkgo, ginseng)
- ok to proceed if pt has normal clotting mechanism & is not on any other blood thinners

abciximab: 1-2 days
clopidogrel: 7 days
ticlopidine: 14 days

SQ heparin: ok to proceed if all else WNL
IV heparin:
- hold 2-4hrs pre-blcok
- hold 1hr post-block
- hold 2-4hrs after removal

enoxaparin: 12-24hrs depending on dosing

warfarin: 5 days (ok to remove cath if INR<1.5)

thrombolytics: absolute contraindication

52

compare and contrast the level of the conus medullaris and dural sac in the adult vs. the infant

SC ends in a taper at the conus medullaris
- adult L1-L2
- infant L3

subarachnoid space terminates at the dural sac
- adult S2
- infant S3

53

what is the cause of cauda equina syndrome? What factors increase the risk?

cause = neurotoxicity is the result of exposure to high concentrations of LA

factors that increase risk:
- 5% lido
- spinal microcatheters (since they focus LA on a small area of the cord)

54

how does cauda equina syndrome present? What is the treatment?

s/s: bladder & bowel dysfunction, sensory deficits, weakness, and/or paralysis

tx: supportive

55

what is the cause of transient neurologic symptoms? What factors increase the risk?

cause: patient positioning, stretching of the sciatic nerve, myofascial strain, muscle spasm
- highly unlikely that neurotoxicity causes TNS

factors that increase risk:
- lidocaine
- lithotomy position
- ambulatory surgery
- knee arthroscopy

56

How do transient neurologic symptoms present? What is the treatment?

s/s:
- severe back & buttock pain that radiates to both legs
- generally develops w/in 6-36hrs & persists for 1-7 days

tx: NSAIDs, opioids, trigger point injections

57

what is the most common organism responsible for post-spinal bacterial meningitis?

ways organism can infect the CSF:
1. failure of aseptic technique
2. bacteremia at time of SAB

streptococcus viridans is one of the most common culprits. it is commonly found in the mouth, and this is why it's critical to wear a mask when performing neuraxial

58

What is the best way to prepare the skin prior to neuraxial anesthesia?

chlorhexidine, isopropyl alcohol, or iodine solutions
- chlorhex is neurotoxic, so let it dry completely

59

what are the 5 main components of the brachial plexus?

roots (5)
trunks (3)
divisions (6)
cords (3)
branches (5)

60

how many trunks are in the brachial plexus? Which nerve roots give rise to each trunk?

3: superior, middle, inferior

C5-6: superior
C7: middle
C8-T1: inferior

61

How many divisions are in the brachial plexus? Which nerve roots give rise to each division?

6 divisions - 3 posterior, 3 anterior

C5-C7: anterior divisions of superior and middle trunks
C8-T1: anterior division of inferior trunk
C5-T1: all 3 posterior divisions

62

How many cords are in the brachial plexus? Which nerve roots give rise to each cord?

3 cords: posterior, lateral, medial

C5-C7: lateral cord
C8-T1: medial cord
C5-T1: posterior cord

63

how many terminal branches are in the brachial plexus? Which roots give rise to each branch?

MSCN C5-7
axillary C5-6
median C5-T1
radial C5-T1
ulnar C8-T1

64

where do the roots turn into trunks?

just beyond the lateral border of the scalene muscles

65

where do the trunks turn into divisions?

underneath the clavicle and over the first rib

66

where do divisions turn into cords?

where the brachial plexus goes under the pectoralis minor muscle

67

where do the cords turn into terminal branches?

in the axilla

68

describe the sensory innervation of the upper extremity

review picture

69

how do you assess each branch of the brachial plexus (sensory & motor)?

axillary
- pinch lateral aspect of shoulder
- arm abduction

musculocutaneous
- pinch lateral aspect of forearm
- elbow flextion

median
- pinch index finger
- thumb opposition

radial
- pinch web space b/n thumb & index finger
- elbow extension, wrist & finger extension

ulnar
- pinch pinky finger
- pinky finger abduction

70

in addition to a brachial plexus block, which nerve must also be anesthetized to foster the tolerance of an upper extremity tourniquet?

intercostobrachial block
- it arises from T2
- field block is required to block this nerve
- w/ arm abducted & externally rotated, begin at deltoid prominence and move inferiorly (5mL)

71

what types of surgical procedures are well suited for an interscalene block? Which are not?

shoulder & proximal upper extremity procedures

not best for those below the level of the elbow since it often spares C8-T1 (which innervates portions of the forearm and hand)

72

be able to identify brachial plexus anatomy on ultrasound for an interscalene block.

(scalene muscles, "stop sign")

73

which approach to the brachial plexus is most likely to cause phrenic nerve paralysis? What are the clinical implications of this?

nearly always blocked when performing an interscalene block, resulting in ipsilateral hemiparesis of the diaphragm
- in healthy pts, this rarely results in respiratory compromise
- in those w/ respiratory disease (COPD), this may result in severe dypsnea, hypercapnia, and hypoxemia.

74

which approach to the brachial plexus is most likely to cause Horner's syndrome? What are the clinical implications of this?

stellate ganglion (cervicothoracic ganglion) is located at C7
- this structure is often blocked during the interscalene approach --> Horner's syndrome (ptosis, miosis, anhidrosis)
- Horner's syndrome indicates a successful block

75

discuss the relationship b/n shoulder arthroscopy, interscalene blocks, and hypotensive bradycardic episodes.

Bezold-Jarisch reflex is the proposed mechanism for hypotensive, bradycardic episodes during shoulder arthroscopy w/ interscalene blocks

s/s = bradycardia, hypotension, syncope

theory: venous pooling in LE reduces venous return
combination of unloaded ventricle, SNS stimulation, an epi uptake from the block results in a profoundly underfilled ventricle that slows it's rate to increase diastolic filling time

76

which types of surgical procedures are well suited for a supraclavicular block? Which are not?

provides a dense block for surgeries at or below the level of the elbow

not ideal for shoulder procedures since it doesn't reliably anesthetize the suprascapular nerve (arising from the proximal upper trunk)

77

be able to identify brachial plexus anatomy on ultrasound for a supraclavicular block

(pleura, first rib, subclavian artery, nerves)

78

what is the greatest risk of a supraclavicular block? Why?

pneumothorax
- cupola of the lung is just medial to the first rib, it is higher on the R side
- tall thin pts have a higher risk
- consider PTX if pt coughs or complains of CP during needle insertion or manipulation

79

what types of surgical procedures are well suited for an infraclavicular block? Which are not?

upper extremity below the elbow

shoulder & upper arm aren't anesthetized

80

be able to identify brachial plexus anatomy on ultrasound for an infraclavicular block

(pectoralis major & minor, subclavian artery w/ cords surrounding it, & subclavian vein)

81

describe the relationship of the terminal branches relative to the axillary artery.

musculocutaneous is anterior & lateral
median is anterior & medial
radial is posterior & lateral
ulnar is posterior & medial

82

be able to identify brachial plexus anatomy on ultrasound for an axillary block

(axillary artery w/ terminal branches surrounding, coracobrachialis muscle, humerus)

83

which nerve is most likely to be missed during an axillary block? Which terminal branch is not included in an axillary block?

musculocutaneous resides in the coracobrachialis muscle; it's not part of the neurovascular sheath that surrounds the axillary artery
- it must be blocked separately

axillary nerve is not included in the axillary block

84

what types of surgical procedures are well suited for an axillary block? Which are not?

upper extremity distal to the elbow

not recommended for procedures below the elbow

85

how do you block the radial nerve in the forearm?

3-5mL LA injected b/n teh biceps tendon and the brachioradialis

86

how do you block the ulnar nerve at the elbow?

elbow is flexed and 3-5mL LA is injected b/n the olecranon & medial epicondyle of the humerus
- using too high a volume can compress the ulnar nerve, resulting in ischemic injury

87

how do you block the median nerve at the forearm?

in the antecubital fossa, 3-5mL LA is injected medial to the brachial artery
- avoid this block in those w/ carpal tunnel syndrome

88

how do you block the radial nerve at the wrist?

subQ injection (field block) of 10mL proximal to the radial styloid
- a field block is used because there are several branches of the radial nerve at this point in the wrist

89

how do you block the ulnar nerve at the wrist?

inject 3-5mL medial to and below the flexor carpi ulnaris tendon
- confirm negative aspiration d/t proximity to the ulnar artery

90

how do you block the median nerve at the wrist?

inject 5mL between the flexor carpi radialis tendon & the flexor palmaris longus tendon

91

How do you perform a Bier block?

- place a double cuff tourniquet on the pt; do not inflate it
- place 22g PIV distally
- elevate extremity x1-2mins for passive exsanguination
- wrap Esmarch bandage to further exsanguinate the extremity
- inflate the distal cuff
- inflate the proximal cuff
- deflate the distal cuff
- remove escmarch bandage
- inject LA (large volume of dilute; ex 50mL of 0.5% lido)

tourniquet pressure should be approx 250 (or 100 greater than SBP)
- can inflate the distal cuff & deflate the proximal cuff if pt is experiencing tourniquet pain

92

A patient complains of tourniquet pain when using a double cuff tourniquet under Bier block. List the sequences of deflating one of the cuffs and inflating the other cuff.

tourniquet pain typically begins at 45-60mins after inflation, and this is the most common reason why a patient would be unable to tolerate a procedure lasting >1hr

1. inflate distal cuff
2. deflate proximal cuff

93

For the patient who received a Bier block, when can you deflate the tourniquet?

toxicity is the most significant risk of IVRA; tourniquet must be inflated for a minimum of 20mins post LA injection.

<20 mins = don't deflate
20-40mins = deflate, immediately reinflate, then deflate again at 1min
>40mins = ok to deflate

94

Name the 6 terminal branches of the lumbar plexus.

lumbar plexus arises from the anterior rami of L1-L4, w/ an occasional contribution from T12. It gives rise to 6 nerves

"I Invariably Get Lazy On Fridays"
Iliohypogastric
Ilioinguinal
Genitofemoral
Lateral femoral cutaneous
Obdurator
Femoral

95

What nerve roots give rise to each nerve of the lumbar plexus?

iliohypogastric L1
ilioinguinal L1
genitofemoral L1-L2
lateral femoral cutaneous L2-L3
obdurator L2-L4
femoral L2-L4

96

know the LE innervation

see picture

97

describe the anatomy of the psoas compartment.

The lumbar plexus is contained within a sheath inside the psoas compartment

at this point, the plexus is:
- lateral to the vertebral column
- anterior to the quadratus lumborum muscle
- posterior to the psoas muscle

98

What nerves are anesthetized by the psoas compartment block? What is another name for this block?

The psoas compartment block (lumbar plexus block) targets three major nerves of the lumbar plexus:
- lateral femoral cutaneous nerve
- femoral nerve
- obdurator nerve

this block is useful when neuraxial anesthesia is contraindicated and/or anesthesia to one LE is preferred

99

Discuss the anatomy of the femoral triangle

the femoral nerve arises from L2-L4, it remains in the groove b/n the psoas major and iliac muscles before entering the femoral triangle

inside the femoral triangle, the femoral nerve runs:
- deep to the inguinal ligament
- anterior to the iliopsoas muscle
- inferior to the fascia lata and fascia iliaca

The triangle is shaped like the "SAIL" of a ship:
- S = sartorius m
- A = adductor longus m
- IL = inguinal ligament

use "VAN" for the structures inside the triangle, medial to lateral
- V = vein
- A = artery
- N = nerve

100

Discuss the anatomy & innervation of the anterior and posterior branches of the femoral nerve.

the division occurs either just before or just after the nerve passes under the inguinal ligamnet

anterior branch innervates the ventral surface of the thigh & the sartorius muscle

posterior branch innervates the quadriceps m, knee joint, and its medial ligament before giving rise to the saphenous nerve.

101

be able to identify the key anatomy for a femoral nerve block on ultrasound

(femoral vein, femoral artery, femoral nerve, IPSM)

102

describe the innervation of the saphenous nerve. What are the implications of this in the context of surgery on the lower extremity?

saphenous nerve is the terminal branch of the posterior division of the femoral nerve
- it provides sensory innervation from the medial aspect of the knee to the medial malleolus
- there is no motor component

this block is useful when combined w/ a popliteal or ankle block

103

Describe the anatomy of the sciatic nerve

arises from L4-5 & S1-3

- it is actually two nerves (tibial & peroneal) contained w/in a sheath
- it exits the pelvis inferior to the piriformis m via the great sacrosciatic foramen
- it continues caudally, passing b/n the major trochanter & the tuberosity of the ischium into the lower 1/3 of the thigh. This is where it divides into tibial and common peroneal nerves.

104

Describe the relevant anatomy for a popliteal block

targets the sciatic nerve in the proximal popliteal fossa.

at this location, the sciatic n is posterior & lateral to the popliteal artery & vein, and is bordered medially by the semitendinosus & semimembranosus muscles, and laterally by the biceps fermoris muscle.

A "triangle" is formed in the posterior knee w/ the base being by the popliteal crease at the knee & the apex formed by the muscles converging.

105

be able to identify the key anatomy for a popliteal nerve block on ultrasound

(popliteal artery & vein, common peroneal & tibial)

106

name the 5 terminal nerves at the level of the ankle. What is the origin for each nerve?

each one is a branch of either the femoral or sciatic nerves.
- the 3 sensory nerves begin w/ an "S"
- the 2 mixed sensory and motor nerves don't begin w/ an "S"

femoral: saphenous
sciatic: deep peroneal, superfiicial peroneal, sural, posterior tibial

107

describe the sensory innervation of the foot and ankle

see picture

108

where is the posterior tibial nerve blocked?

posterior to the medial malleolus

109

where is the sural nerve blocked?

posterior to the lateral malleolus

110

where is the deep peroneal nerve blocked?

between the tendons of teh anterior tibial and extensor digitorum longus muscles

111

where is the superifical peroneal nerve blocked?

anterior to the lateral malleolus

112

where is the saphenous nerve blocked?

anterior to the medial malleolus

113

at the level of the ankle, which nerve is not immediately adjacent to a vascular structure?

superficial peroneal nerve

all of the others are very close to an artery and/or vein, therefore blockade of the superficial peroneal is the least likely to result in an intravascular injection