lower extremity blocks

Question 1

how many cervical nerves are there

Answer 1

8 cervical nerves

7 vertebrae

Question 2

Cervical nerves
thoracic nerves
lumbar nerves
sacral nerves
coccygeal nerves
total

Answer 2

8-C
12-T
5-L
5-S
1-C
total 31 pairs of spinal nerves

Question 3

each spinal nerves has what two root

Answer 3

anterior and posterior root

Question 4

the anterior nerve roots join to form

Answer 4

plexuses

Question 5

name the 4 plexuses

Answer 5

Cervical plexus
Brachial plexus
Lumbar plexus
Sacral plexus

Question 6

what does the posterior root form

Answer 6

ganglia

Question 7

Cervical plexus

Answer 7

formed by anterior divisions of the upper 4 cervical nerves

Question 8

Brachial plexus

Answer 8

formed by the anterior divisions of C5,6,7,C8, and T1 nerves.

Question 9

Lumbar plexus

Answer 9

formed by the anterior division of L1-4

Question 10

Sacral plexus

Answer 10

formed by the roots of lumbar 4 - 5 and sacral 1-3 nerves.

Question 11

Brachial Plexus- “Break Down”

Answer 11

5 Roots 
3 Trunks
6 Divisions
3 Cords
Terminal branches (nerves)

Question 12

what are the 3 distinct trunks-

what muscle are they between??

Answer 12

superior (C5-6), Middle (C7) , and inferior (C8-T1) Between ant & middle scalene muscle

Question 13

where do the trunks lie?

Answer 13

Trunks pass over lateral border of 1st rib under clavicle and divides into anterior and posterior divisions

Question 14

where do the Divisions lie?

how many are there?

Answer 14

6 divisions: At lateral edge of the 1st rib, behind the clavicle, the trunks divide into
3 anterior divisions
3 posterior divisions

Question 15

what are the cords named after?

how many cords are there

Answer 15

named after their relationship to the axillary artery

3

Question 16

name the 3 cords

Answer 16

lateral cord
posterior cord
medial cord

Question 17

lateral cord is formed from

Answer 17

union of anterior divisions of upper and middle trunks

Question 18

Posterior cord

Answer 18

all 3 posterior divisions

Question 19

Medial cord

Answer 19

continuation of the anterior division of the inferior trunk.

Question 20

lateral cord-what nerves does it supply

Answer 20

gives off lateral branch of the median nerve and terminates as musculocutaneous

Question 21

Medial cord -what nerves does it supply

Answer 21

gives off medial branch of the median nerve and terminates as the ulnar nerve

Question 22

Posterior cord what nerves does it supply

Answer 22

gives off the axillary nerve and terminates as the radial nerve

Question 23

slide 16

Answer 23

slide 16

Question 24

indications for inter scalene approach

Answer 24

procedures on the shoulder, proximal upper arm

Question 25

indications for supraclavicular

Answer 25

entire arm including hand

Question 26

indications for infraclavicular

Answer 26

procedures of the hand, forearm, elbow, and not good for upper arm.

Question 27

axillary approach indications

Answer 27

procedures up to elbow

Question 28

advantages for interscalene

Answer 28

most appropriate for shoulder surgery reduced risk (small risk) of pneumothorax clear landmarks even in obese patients.

Question 29

disadvantages for interscalene

Answer 29

essential to elicit paresthesias

Question 30

for interscalene block what block may need to be supplementary

Answer 30

Supplementary ulnar block may be required

Question 31

interscalene not recommended for?

Answer 31

Not recommended for hand surgery or any surgery below the level of the elbow

Question 32

interscalene block-

Answer 32

Unless large volumes are used, lower trunk anesthesia may be missed

Question 33

what block is used for reduction of the sublimated shoulder joint

Answer 33

interscalene block

Question 34

what roots are most densely blocked in interscalene blocks

Answer 34

roots c5-c7

Question 35

indications for interscalene

Answer 35

Surgical procedures on the clavicle, shoulder, elbow and upper arm with the exception of the medial aspect of the arm For complete surgical anesthesia of shoulder, superficial cervical plexus block may need to be supplemented

Question 36

interscalene - used when other approaches are made difficult or undesirable by anatomic problems

Answer 36

When other approaches to the brachial plexus are made difficult or undesirable by anatomic or pathologic problems (obesity or severe emphysema)

Question 37

interscalene- pain conditions

Answer 37

Pain conditions in the shoulder-arm area (reflex dystrophy, shoulder joint arthrosis, pain due to neoplasm, vessel pathology or injury)

Question 38

interscalene spread

Answer 38

Anesthesia extends to the caudal portion of the cervical plexus and the cranial portion of the brachial plexus.

Question 39

interscalene-not appropriate for surgeries-

Answer 39

Thus, this block is not appropriate for surgeries distal to the elbow

Question 40

interscalene Contraindications/Considerations

Answer 40

Contralateral phrenic or recurrent nerve paralysis (patients with severe pulmonary disease) Contralateral pneumothorax Patients who require bilateral blocks Respiratory compromise

Question 41

Interscalene - Technique

Answer 41

Supine with head slightly elevated and turned 30 degrees or less to contralateral side Palpate the interscalene groove External jugular vein often crosses the interscalene groove (at the level of the cricoid cartilage), can have patient lift head up and push against resistance to help identify the groove Use US if available

Question 42

what length needle is used for interscalene technique

Answer 42

5cm

Question 43

interscalene needle is aimed

Answer 43

slightly medial and caudal angle

Question 44

needle aimed- where for interscalene

Answer 44

Needle is aimed at the transverse process of C6 (medially, caudally)

Question 45

continue advancing the needle until a motor response is elicited at what two muscles

Answer 45

deltoid | bicips

Question 46

how much la is injected in interscalene

Answer 46

20-30ml of la

Question 47

side effects- horners syndrome

Answer 47

(myosis (variant of miosis), ptosis, and anhidrosis (inability to sweat),

Question 48

Side Effects/Complications: interscalene | phrenic nerve

Answer 48

(ipsilateral phrenic nerve paralysis) | Can lead to respiratory failure in pts. with inadequate pulmonary reserve. (C3-C5)

Question 49

side effects/complications- interscalene | Recurrent laryngeal nerve block

Answer 49

(Hoarseness) | In a pt with contralateral vocal cord paralysis, respiratory distress could occur

Question 50

interscalene- hematoma can do what

Answer 50

Compression of the lumen of the carotid artery

Question 51

interscalene Complications:

Answer 51

``` Intravascular injection into a vessel in the neck, particularly the vertebral artery, and diffusion of the local anesthetic solution through the wall of the vertebral artery (CNS intoxication) Subarachnoid injection (total spinal) Epidural injection (high epidural) pneumothorax ```