Hadzic's Peripheral Nerve Blocks 3e PDF

 NEW YORK SCHOOL OF REGIONAL ANESTHESIA Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia Hadzic_FM_00i-xvi.indd 1...

 NEW YORK SCHOOL OF REGIONAL ANESTHESIA Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia Hadzic_FM_00i-xvi.indd 1 14/06/21 10:35 PM  NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information con- tained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product informa- tion sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Hadzic_FM_00i-xvi.indd 2 14/06/21 10:35 PM  NEW YORK SCHOOL OF REGIONAL ANESTHESIA Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia THIRD EDITION Editors Ana M. Lopez, MD, PhD, DESA Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium Angela Lucia Balocco, MD Research Associate NYSORA, The New York School of Regional Anesthesia Anesthesia Resident, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium Catherine Vandepitte, MD, PhD Research Associate NYSORA, The New York School of Regional Anesthesia Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium Admir Hadzic, MD, PhD Director NYSORA, The New York School of Regional Anesthesia Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium Visiting Professor, Department of Anesthesiology, Katholieke Universiteit Leuven (KUL), Belgium Honorary Professor, University of Ljubljana, Slovenia Doctor Honoris Causa, Karol Marcinkowski University of Medical Sciences, Poznan, Poland New York Chicago San Francisco Lisbon London Madrid Mexico City New Delhi San Juan Seoul Singapore Sydney Toronto Hadzic_FM_00i-xvi.indd 3 14/06/21 10:35 PM Copyright © 2022 by McGraw Hill. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-183894-8 MHID: 0-07-183894-5 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-183893-1, MHID: 0-07-183893-7. eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corpo- rate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com. TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WAR- RANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its opera- tion will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/ or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.  DEDICATION We dedicate this book to Jerry Vloka, MD, PhD in recognition of his pioneering contributions to regional anesthesia and immense inspiration for generations of students and scholars of anesthesiology. Hadzic_FM_00i-xvi.indd 5 14/06/21 10:35 PM  This page intentionally left blank 9781260470055_PTCE_PASS3.indb 2  CONTENTS Contributors ix 15. Infraclavicular Brachial Plexus Block 161 Foreword xiii 16. Costoclavicular Brachial Plexus Block 169 Acknowledgments xv 17. Axillary Brachial Plexus Block 177 18. Blocks for Analgesia of the Shoulder: Phrenic Nerve Sparing Blocks 185 SECTION 1 19. Blocks About the Elbow 195 FOUNDATIONS 20. Wrist Block 205 1. Functional Regional Anesthesia Anatomy 3 2. Local Anesthetics: Clinical Pharmacology and Selection 33 SECTION 4 3. Equipment for Peripheral Nerve Blocks 47 LOWER EXTREMITY BLOCKS 4. Electrical Nerve Stimulation 57 21. Lumbar Plexus Block 217 5. Optimizing Ultrasound Image 67 22. Fascia Iliaca Block 229 6. Monitoring and Documentation 23. Blocks for Hip Analgesia 239 in Regional Anesthesia 75 24. Femoral Nerve Block 247 7. Indications for Peripheral Nerve Blocks 89 25. Subsartorial Blocks: Saphenous Nerve, 8. Continuous Peripheral Nerve Blocks 101 Adductor Canal, and Femoral 9. Local Anesthetic Systemic Toxicity and Triangle Blocks 255 Allergy to Local Anesthetics 107 26. Lateral Femoral Cutaneous 10. Neurologic Complications of Nerve Block 265 Peripheral Nerve Blocks 117 27. Obturator Nerve Block 271 11. Preparation for Regional Anesthesia and 28. Proximal Sciatic Nerve Block 281 Perioperative Management 123 29. Popliteal Sciatic Block 291 30. Genicular Nerves Block 299 SECTION 2 31. iPACK Block 305 HEAD AND NECK BLOCKS 32. Ankle Block 313 12. Cervical Plexus Block 131 SECTION 5 SECTION 3 TRUNK AND ABDOMINAL UPPER EXTREMITY BLOCKS WALL BLOCKS 13. Interscalene Brachial Plexus Block 143 33. Intercostal Nerve Block 325 14. Supraclavicular Brachial Plexus Block 153 34. Pectoral Nerves Block 333 Hadzic_FM_00i-xvi.indd 7 14/06/21 10:35 PM  viii Contents 35. Serratus Plane Block 341 39. Rectus Sheath Block 379 36. Paravertebral Block 349 40. Quadratus Lumborum Blocks 385 37. Erector Spinae Plane Block 359 38. Transversus Abdominis Plane Blocks 367 Index 395 Hadzic_FM_00i-xvi.indd 8 14/06/21 10:35 PM  CONTRIBUTORS David Alvarez, MD Javier Domenech de la Lastra, MD, DESA Department of Anesthesiology Department of Anesthesiology Hospital Universitari de Bellvitge Hospital Clinic de Barcelona Barcelona, Spain Barcelona, Spain (Chapter 20) (Chapter 16) Angela Lucia Balocco, MD Robin De Meirsman, MD Department of Anesthesiology Department of Anesthesiology Ziekenhuis Oost-Limburg UZ Leuven Genk, Belgium Leuven, Belgium (Chapters 9, 11, 19, 31, 35, 37, 38, 39, and 40) (Chapter 34) Jonas Bruggen, MD Dimitri Dylst, MD Department of Anesthesiology Department of Anesthesiology UZ Leuven Ziekenhuis Oost-Limburg Leuven, Belgium Genk, Belgium (Chapter 21) (Chapter 17) Robbert Buck, MD Christopher J. Edwards, MD Department of Anesthesiology Department of Anesthesiology UZ Antwerpen Wake Forest Baptist Medical Center Antwerpen, Belgium Winston Salem, North Carolina (Chapter 12) United States of America (Chapter 36) Eveline Claes, MD Department of Anesthesiology Gert-Jan Eerdekens, MD AZ Diest Department of Anesthesiology Diest, Belgium UZ Leuven (Chapter 10) Leuven, Belgium (Chapters 17 and 40) Tomás Cuñat, MD, DESA Department of Anesthesiology Victor Frutos, MD Hospital Clinic de Barcelona Department of Anesthesiology and Pain Clinics Barcelona, Spain Hospital Universitari Germans Trias i Pujol (Chapter 30) Badalona, Spain (Chapter 1) Lotte Cuyx, MD Department of Anesthesiology Jeff Gadsden, MD UZ Leuven Department of Anesthesiology Leuven, Belgium Duke University Hospital (Chapter 38) Durham, North Carolina United States of America Olivier De Fré, MD (Chapter 10) Anesthesiology Department AZ Herentals Levin Garip, MD Herentals, Belgium Department of Anesthesiology (Chapter 2) UZ Leuven Leuven, Belgium (Chapter 2) Hadzic_FM_00i-xvi.indd 9 14/06/21 10:35 PM  x Contributors Admir Hadzic, MD, PhD Leen Janssen, MD Director, The New York School of Regional Anesthesia Department of Anesthesiology New York, United States of America UZ Antwerpen Department of Anesthesiology Antwerpen, Belgium Ziekenhuis Oost-Limburg (Chapter 5) Genk, Belgium (Chapters 3, 4, 10, and 11) Manoj K. Karmakar, MD Director of Pediatric Anesthesia Rawad Hamzi, MD Chinese University of Hong Kong Department of Anesthesia and Pain Management Prince of Wales Hospital Wake Forest Baptist Medical Center Sha Tin, Hong Kong, China Winston Salem, North Carolina, (Chapter 21) United States of America (Chapter 33) Bram Keunen, MD Department of Anesthesiology Tyler Heijnen, MD Ziekenhuis Oost-Limburg Department of Anesthesiology Genk, Belgium Ziekenhuis Oost-Limburg (Chapter 15) Genk, Belgium (Chapter 18) Samantha Kransingh, FCA, FANZCA South Canterbury District Health Board Jelena Heirbaut, MD Timaru, New Zealand Department of Anesthesiology (Chapters 5 and 22) UZ Antwerpen Antwerpen, Belgium (Chapter 4) Queenayda A. D. Kroon, MD Department of Anesthesia and Pain Management Jore Hendrikx, MD University Medical Centre Maastricht Department of Anesthesiology Maastricht, The Netherlands UZ Leuven (Chapter 33) Leuven, Belgium (Chapter 31) Annelies Langenaeken, MD Department of Anesthesiology Lotte Hendrix, MD UZ Leuven Department of Anesthesiology Leuven, Belgium UZ Leuven (Chapter 29) Leuven, Belgium (Chapter 13) Raphaël Lapré, MD Department of Anesthesiology Daryl S. Henshaw, MD AZ Rivierenland Department of Anesthesiology and Pain Management Reet, Belgium Wake Forest Baptist Medical Center (Chapter 2) Winston Salem, North Carolina United States of America (Chapter 36) Ana Lopez, MD, PhD Department of Anesthesiology Peter Hulsbosch, MD Ziekenhuis Oost-Limburg Department of Anesthesiology Genk, Belgium Regionaal Ziekenhuis Heilig Hart (Chapters 1, 11, 12, 16, 18, 20, 21, and 32) Leuven, Belgium (Chapter 15) Sofie Louage, MD Department of Anesthesiology J. Douglas Jaffe, MD AZ Glorieux Department of Anesthesiology and Pain Management Ronse, Belgium Wake Forest Baptist Medical Center (Chapters 27, 28, and 29) Winston Salem, North Carolina United States of America (Chapter 33) Hadzic_FM_00i-xvi.indd 10 14/06/21 10:35 PM  Contributors xi Leander Mancel, MD Filiep Soetens, MD Department of Anesthesiology Department of Anesthesiology UZ Leuven AZ Turnhout Leuven, Belgium Turnhout, Belgium (Chapter 6) (Chapters 2 and 9) Berend Marcus, MD Sam Van Boxstael, MD Department of Anesthesiology Department of Anesthesiology UZ Leuven Ziekenhuis Oost-Limburg Leuven, Belgium Genk, Belgium (Chapter 7) (Chapters 24, 25, and 26) Evi Mellebeek, MD Imré Van Herreweghe, MD Department of Anesthesiology Department of Anesthesiology Ziekenhuis Oost-Limburg AZ Turnhout Genk, Belgium Turnhout, Belgium (Chapter 24) (Chapters 2 and 7) Felipe Muñoz-Leyva, MD Astrid Van Lantschoot, MD Department of Anesthesia and Pain Management Department of Anesthesiology University Health Network, University of Toronto, Ziekenhuis Oost-Limburg Toronto Western Hospital Genk, Belgium Toronto, Ontario, Canada (Chapters 34 and 35) (Chapters 9 and 37) Kathleen Van Loon, MD Gwendolyne Peeters, MD Department of Anesthesiology Department of Anesthesiology UZ Leuven UZ Gent Leuven, Belgium Gent, Belgium (Chapter 9) (Chapter 9) Jill Vanhaeren, MSc Xavier Sala-Blanch, MD Research Associate Department of Anesthesiology The New York School of Regional Anesthesia Hospital Clinic de Barcelona New York, United States of America Barcelona, Spain (Chapter 39) (Chapters 1 and 23) Catherine Vandepitte, MD, PhD Amar Salti, MD, EDRA Department of Anesthesiology Department of Anesthesia and Pain Medicine Ziekenhuis Oost-Limburg Sheikh Khalifa Medical City Genk, Belgium Abu Dhabi, United Arab Emirates (Chapters 6, 8, 11, 15, 17, 19, and 28) (Chapter 22 and 27) Stefanie Vanhoenacker, MD Ruben Schreurs, MD Department of Anesthesiology Department of Anesthesiology Sint-Jozefskliniek Izegem Ziekenhuis Oost-Limburg Izegem, Belgium Genk, Belgium (Chapter 14) (Chapter 25) Thibaut Vanneste, MD Jeroen Smet, MD Department of Anesthesiology Department of Anesthesiology Ziekenhuis Oost-Limburg UZ Gent Genk, Belgium Gent, Belgium (Chapters 13, 14, 23, and 30) (Chapter 3) Hadzic_FM_00i-xvi.indd 11 14/06/21 10:35 PM  xii Contributors Rob Vervoort, MD Daquan Xu Department of Anesthesiology Associate Researcher UZ Leuven The New York School of Regional Anesthesia Leuven, Belgium New York, United States of America (Chapter 8) (Chapter 5) Hadzic_FM_00i-xvi.indd 12 14/06/21 10:35 PM  FOREWORD The third edition of this standard textbook on ultrasound NYSORA’s Reverse Ultrasound Anatomy™ (RUA) images nerve blocks is released during a unique period in human his- feature functional anatomy or block techniques with clear tory. The COVID-19 pandemic and the threats that the disease instructions on the principles and goals of each given tech- poses to both patients and healthcare workers have substan- nique. These cognitive aids entailed countless hours of work tially changed perioperative practice. During the pandemic, and collaboration between NYSORA’s creative and edito- regional anesthesia was established as the preferred method rial teams to develop highly didactic creatives that facilitate over general anesthesia whenever possible. Nerve blocks pre- understanding of the anatomy, fascial planes, and principles serve respiratory function and avoid aerosolization during of nerve blockade. RUA helps students memorize sono- intubation and extubation and, hence, viral transmission to anatomy patterns, which is essential for ultrasound imaging. other patients and healthcare workers. As an example, the use The knowledge of the sonoanatomy patterns substantially of nerve blocks as the preferred surgical anesthesia method increases ultrasound proficiency and skills retention. Wher- during the pandemic allowed many limb surgeries to be car- ever applicable, clinical images of the patient’s position, ried out with decreased exposure to healthcare workers and ultrasound transducer placement, and anatomical detail are less burden on post-anesthesia care units (PACUs) and utili- featured. Recent relevant literature was added to the “Sug- zation of hospital beds. With regional anesthesia, patients can gested Reading” for readers who like to explore the original leave acute postoperative care facilities faster and avoid admis- sources of the information presented. We chose this approach sion to the limited hospitalization beds. In our center, using in an effort to provide the most practical, pragmatic informa- regional anesthesia and nerve blocks as the main anesthetic tion and relieve the content from massive literature citations. choice allowed elective orthopedic surgery in many patients. Readers should be advised that this book is not meant to be The use of ultrasound-guided local regional anesthesia (LRA) an encyclopedic listing of all techniques and their variations. has increased exponentially in the last few years. The traditional Rather, our textbook should be viewed as a compendium of techniques have been refined and a number of new approaches well-established knowledge, didactically organized for learn- have been devised to better suit the evolving clinical practice. ing, and transferring knowledge to students of anesthesiology. Nerve blocks are an essential component of multimodal analge- With this approach, the textbook aims to help standardize, and sia in enhanced recovery after surgery (ERAS) protocols. Their implement well-established techniques, indications, pharma- use enhances analgesia and reduces or eliminates the use of opi- cology, monitoring, and the documentation of nerve blocks. oids in the postoperative period. Some traditional nerve block Instead of burdening the reader with experimental block tech- techniques have been substituted by more selective techniques niques with unproven clinical benefit, we aimed to include to minimize motor block and facilitate early rehabilitation and the most clinically useful nerve block, fascial, and infiltration recovery. New ultrasound-guided fascial plane techniques, dis- techniques with proven efficacy and clinical applicability. tal nerve blocks, and selective periarticular injections also are Information about perioperative management and local anes- increasingly being used to yield a better balance between effi- thetic toxicity treatment was also added, and/or fully revised. cacy, simplicity, safety, and sensory-motor block ratio. Because patients commonly present with a vague history of This third edition of NYSORA’s textbook is substantially allergy to local anesthetics, the new edition also features highly updated and revised to include the many new developments practical algorithms to facilitate decision-making and manage- in regional anesthesia and trends in clinical practice. The new ment of allergy to local anesthetics. edition features entirely new artwork, new clinical images, We are confident that this textbook will continue to be one and new fascial plane and infiltration techniques. All in all, of the primary resources on peripheral nerve blocks in medi- some 500 new algorithms, illustrations, ultrasound images, cal practices worldwide. clinical photographs, and cognitive aids were included to Sincerely, facilitate learning. In addition to anesthesiologists, the highly didactic and organized technique descriptions and func- Drs Hadzic, Lopez, Balocco, and Vandepitte tional anatomy principles will be valuable to all anesthesia providers, acute and chronic pain specialists, as well as inter- Free access to online videos at www.accessanesthesiology.com. ventional pain, musculoskeletal medicine, and emergency Search for this title in the library and select “View All Videos” department physicians. in the Multimedia widget on the landing page of the book. Hadzic_FM_00i-xvi.indd 13 14/06/21 10:35 PM  This page intentionally left blank 9781260470055_PTCE_PASS3.indb 2  ACKNOWLEDGMENTS This book would not be possible without the extraordinary football teams; innovators; and above all incredibly skilled people who contributed their time and talent and undying and passionate surgeons. It has been an absolute pleasure commitment to create an educational masterpiece. Many building the orthopedic anesthesia service with you. A short thanks to Drs Ana Lopez (senior editor), Angela Lucia glimpse at the website of the department of orthopedic Balocco, and Catherine Vandepitte, the third edition editors. surgery at ZOL is sufficient to get a sense that NYSORA- Their combination of commitment, knowledge, research, EUROPE at ZOL is flanked by true giants of orthopedic sur- and clinical expertise is apparent on every page of this book. gery (https://www.zol.be/raadplegingen/orthopedie). Many thanks to the leadership at Ziekenhuis Oost-Limburg Thank you to the NYSORA International Team: Pat Pokorny (ZOL; Genk, Belgium) for their support and for facilitating a (UK), Kusum Dubey (New Delhi), Katherine Hughey-Kubena creative platform in the hospital’s clinical setting. In particu- (USA), Elvira Karovic, Medina Brajkovic, Ismar Ruznjic (B&H), lar, many thanks to the medical director, Dr. Griet Vander Nenad Markovic (SER), Jill Vanhaeren, and Greet van Meir Velpen, and the “can-solve-all” manager, Chantal Desticker. (BE). This is an incredible team of NYSORA’s go-getters. Without your support, this book, and the creation of our cen- Thank you to NYSORA’s illustrator Ismar Ruznjic for ter of excellence for regional anesthesia at ZOL, would not be the new-style illustrations and artwork he imparted to this possible. Thank you to the leadership of the department, espe- edition. Ismar has grown with NYSORA to become one of cially Rene Heylen, Jan Van Zundert, and Pieter De Vooght; the world’s very best anatomy illustrators. their vision led to the creation of one of the best regional A big thank you to our designer and 3-D maestro, Nenad anesthesia centers in the heart of Europe. Thank you to our Markovic, an ultimate perfectionist, whose eye has been con- regional anesthesia team and block nurses Birgit Lohmar, structively critical to many artistic and stylistic aspects of this Joelle Caretta, Ine Vanweert, Kristell Broux, Ilse Cardinaels, book, and NYSORA’s content at large. Sydney Herfs, Elke Janssen, Hüda Erdem, Mohamed Rafiq, Finally, a huge thanks to all the contributors to this book, Danny Baens, and all the operating nurses in the N-Block at as there have been quite a few. Such a volume, packed with so the orthopedic surgery unit. much anatomical information, can always have hidden errors. Many thanks to all top fellows in regional anesthesia. We have relied on our stellar contributors to detect and cor- These young, bright doctors contribute immense value to rect them wherever possible. However, should the readers our teaching mission, and carry on the mission of national find any that we have missed that require correction, please ambassadors of regional anesthesia after graduation. Big forward them to [email protected]. We vouch to improve gratitude to our anesthesia residents who rotate through our upon them and thank you immensely in advance for your service from their mothership Universities: Leuven (KUL), feedback. Gent, Antwerp, and others. Many thanks to all, Our orthopedic surgery department is by all means one of the best in Europe and beyond. Made up of ultra high- Editors achievers; physicians of national, Olympic, and professional Hadzic_FM_00i-xvi.indd 15 14/06/21 10:35 PM  This page intentionally left blank 9781260470055_PTCE_PASS3.indb 2  1 SECTION Foundations Chapter 1 Functional Regional Anesthesia Anatomy 3 Chapter 2 Local Anesthetics: Clinical Pharmacology and Rational Selection 33 Chapter 3 Equipment for Peripheral Nerve Blocks 47 Chapter 4 Electrical Nerve Stimulation 57 Chapter 5 Optimizing Ultrasound Image 67 Chapter 6 Monitoring and Documentation in Regional Anesthesia 75 Chapter 7 Indications for Peripheral Nerve Blocks 89 Chapter 8 Continuous Peripheral Nerve Blocks 101 Chapter 9 Local Anesthetic Systemic Toxicity and Allergy to Local Anesthetics 107 Chapter 10 Neurologic Complications of Peripheral Nerve Blocks 117 Chapter 11 P  reparation for Regional Anesthesia and Perioperative Management 123 Hadzic_Ch01_p001-032.indd 1 10/06/21 3:55 PM  This page intentionally left blank 9781260470055_PTCE_PASS3.indb 2  1 Functional Regional Anesthesia Anatomy Knowledge of anatomy is essential for the practice of regional biotechnology may eventually result in development of the anesthesia and ultrasound-guided regional anesthesia proce- strategies to promote axonal growth and reduce neuronal death. dures. This chapter provides a concise overview of the essential A typical neuron consists of a cell body (soma) with a functional anatomy necessary for the implementation of tradi- large nucleus. The cell body is attached to several branching tional and ultrasound-guided regional anesthesia techniques. processes, called dendrites, and a single axon (Figure 1-2). Figure 1-1 demonstrates the anatomical planes and directions Dendrites receive incoming messages, whereas single axons per used as a conventional approach throughout the book. neuron conduct outgoing messages. In peripheral nerves, axons are long and slender; they are often referred to as nerve fibers. Anatomy of Peripheral Nerves The neuron is the basic functional unit responsible for nerve conduction. Neurons are the longest cells in the body, often as Connective Tissue long as 1 meter. Most neurons have a limited ability to repair The peripheral nerve is composed of three types of fibers: after injury. Advances in the understanding of the neurobi- (1) somatosensory or afferent nerves, (2) motor or effer- ology of nerve regeneration and experimental advances in ent nerves, and (3) autonomic nerves. In a peripheral FIGURE 1-1. Conventional body planes and directions. Red, sagittal; orange, sagittal paramedian; green, transverse; and purple, coronal or axial. Hadzic_Ch01_p001-032.indd 3 10/06/21 3:55 PM  4 SEC TION 1 Foundations FIGURE 1-2. Composition of the neuron. nerve (Figure 1-3), individual axons are enveloped in a loose structures filling the space in between them, such as the and delicate connective tissue, the endoneurium. Groups neurovascular bundles of intermuscular septae. This tissue of axons are arranged within a bundle (nerve fascicle) sur- contributes to the functional mobility of nerves during joint rounded by the perineurium. The perineurium imparts and muscular movement. mechanical strength to the peripheral nerve and functions Of note, the fascicular bundles are not continuous through- as a diffusion barrier to the fascicle, isolating the endo- out the peripheral nerve but divide and anastomose with one neurial space and preserving the ionic milieu of the axon. another as frequently as every few millimeters (Figure 1-4). At each branching point, the perineurium splits with the This arrangement of peripheral nerves helps to explain why fascicle. The fascicles, in turn, are embedded in loose con- intraneural injections, which disrupt this organization, may nective tissue called the interfascicular epineurium, which result in disastrous consequences as opposed to clean needle contains adipose tissue, fibroblasts, mastocytes, blood ves- nerve cuts, which heal more readily. In the vicinity of joints, sels, and lymphatics. The outer layer surrounding the nerve the fascicles are thinner, more numerous, and are likely sur- is the epineurium, a denser collagenous tissue that protects rounded by a greater amount of connective tissue, which the nerve. The paraneurium consists of loose connective reduces the vulnerability of the fascicles to pressure and tissue that holds a stable relationship between adjacent stretching caused by movement. Hadzic_Ch01_p001-032.indd 4 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 5 Blood vessels Axon Perineurium Schwann cell Epifascicular epineurium Endoneurium Mesoneurium Spinal nerve Dorsal root ganglion Ventral root FIGURE 1-3. Organization of the peripheral nerve. Peripheral nerves receive blood supply from the adjacent group of longitudinal capillaries that run within the fascicles blood vessels running along their course. There are two inde- and endoneurium. Neuronal injury after nerve blockade may pendent interconnected vascular systems. The extrinsic sys- be due, at least partly, to the pressure or stretch within con- tem consists of arteries, arterioles, and veins that lie within nective sheaths and the consequent interference with the vas- the epineurium. The intrinsic vascular system comprises a cular supply to the nerve. Hadzic_Ch01_p001-032.indd 5 10/06/21 3:55 PM  6 SEC TION 1 Foundations FIGURE 1-4. Diagram of fascicular arrangement in a peripheral nerve. the dorsal root ganglia and enter the dorsolateral aspect of the Communication Between the spinal cord to form the dorsal root. The motor fibers arise from Central Nervous System and neurons in the ventral horn of the spinal cord and pass through Peripheral Nervous Systems the ventrolateral aspect of the spinal cord to form the ventral The central nervous system (CNS) communicates with the body root. The dorsal and ventral roots converge in the interverte- through spinal nerves, which have sensory and motor compo- bral foramen to form the spinal nerves, which then divide into nents (Figure 1-5). The sensory fibers arise from neurons in dorsal and ventral rami. The dorsal rami innervate muscles, FIGURE 1-5. Schematic transverse section of thoracic vertebra showing the spine and the origin of spinal nerves. Hadzic_Ch01_p001-032.indd 6 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 7 FIGURE 1-6. Anatomy of a typical spinal intercostal nerve. bones, joints, and the skin of the back along the posterior mid- is no C8 vertebra, the C8 nerve passes between the C7 and line. The ventral rami innervate muscles, bones, joints, and the T1 vertebrae. skin of the antero-lateral aspect of the neck, thorax, abdomen, In the thoracic region, the T1 nerve passes between the T1 pelvis, and the extremities (Figure 1-6). and T2 vertebrae. This pattern continues down through the remainder of the spine. The vertebral arch of the fifth sacral and first coccygeal vertebrae is rudimentary. Because of this, the vertebral canal opens inferiorly at the sacral hiatus, Spinal Nerves where the fifth sacral and first coccygeal nerves pass. Roots of There are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, spinal nerves must descend through the vertebral canal before 5 lumbar, 5 sacral, and 1 coccygeal. Spinal nerves pass exiting the vertebral column through the appropriate inter- through the vertebral column at the intervertebral foramina vertebral foramen since the inferior end of the spinal cord (Figure 1-7). The first cervical nerve (C1) passes superior to (conus medullaris) is located at the L1-L2 vertebral level in the C1 vertebra (atlas). The second cervical nerve (C2) passes adults. Collectively, these roots are called the cauda equina. between the C1 (atlas) and C2 (axis) vertebrae. This pattern Outside the vertebral column, ventral rami from cervi- continues down the cervical spine; however, because there cal and lumbosacral spinal levels coalesce to form intricate Hadzic_Ch01_p001-032.indd 7 10/06/21 3:55 PM  8 SEC TION 1 Foundations Thoracic and Abdominal Wall 1 C1 Thoracic Wall 2 C2 3 C3 The intercostal nerves originate from the ventral rami of Cervical 4 5 C4 C5 the first 11 thoracic spinal nerves (T1-T11). Each intercostal 6 C6 nerve becomes part of the neurovascular bundle of the rib 7 and provides sensory and motor innervations (Figure 1-9). C7 8 T1 1 2 T2 T3 Except for the first, each intercostal nerve gives off a lateral 3 T4 cutaneous branch that pierces the overlying muscle near the T5 4 5 T6 midaxillary line. This cutaneous nerve divides into anterior Thoracic 6 T7 and posterior branches, which supply the adjacent skin. The 7 T8 8 T9 intercostal nerves from the second to the sixth space reach 9 T10 the anterior thoracic wall and pierce the superficial fascia 10 11 T11 near the lateral border of the sternum and divide into medial T12 12 and lateral cutaneous branches. L1 1 Most fibers of the anterior ramus of the first thoracic spinal L2 2 nerve join the brachial plexus for distribution to the upper L3 limb. The small first intercostal nerve is the lateral branch Lumbar 3 L4 and supplies only the muscles of the intercostal space, not the 4 L5 overlying skin. In contrast, the lower five intercostal nerves 5 S1 S2 abandon the intercostal space at the costal margin to supply 1 2 S3 S4 the muscles and skin of the abdominal wall. Sacral 3 S5 4 5 Coccygeal Anterior Abdominal Wall The lower six thoracic nerves and the first lumbar nerve FIGURE 1-7. Spinal nerves. innervate the skin, muscles, and parietal peritoneum of the anterior abdominal wall. At the costal margin, the seventh to eleventh thoracic nerves (T7-T11) leave their intercostal networks called plexuses from which nerves extend into the spaces and enter the abdominal wall in a fascial plane between neck, the arms, and the legs. the transversus abdominis and internal oblique muscles. The seventh and eighth intercostal nerves slope upward following Dermatomes, Myotomes, the contour of the costal margin, ninth runs horizontally, and the tenth and eleventh have a downward trajectory. Anteri- and Osteotomes orly, the nerves pierce the rectus abdominis muscle and the A dermatome is the area of the skin supplied by the dor- anterior layer of the rectus sheath to emerge as anterior cuta- sal (sensory) root of a specific spinal nerve (Figure 1-8). In neous branches that supply the overlying skin (Figure 1-9). the trunk, each segment is horizontally disposed, except C1, The subcostal nerve (T12) takes the line of the twelfth rib which does not have a sensory component. The dermatomes across the posterior abdominal wall. It continues around the of the limbs from the fifth cervical to the first thoracic nerve flank and terminates similarly to the lower intercostal nerves. (C5-T1) and from the third lumbar to the second sacral ver- The seventh to twelfth thoracic nerves (T7-T12) give off lat- tebrae (L3-S2) extend like a series of bands from the midline eral cutaneous nerves, which further divide into anterior and of the trunk posteriorly into the limbs. Of note, there is con- posterior branches. The anterior branches supply the skin as siderable overlapping between adjacent dermatomes. far forward as the lateral edge of the rectus abdominis. The A myotome is the segmental innervation of skeletal mus- posterior branches supply the skin overlying the latissimus cle by a ventral root of a specific spinal nerve (Figure 1-8). dorsi. The lateral cutaneous branch of the subcostal nerve is An osteotome is the area of the bone supplied by the sensory distributed to the skin on the side of the buttock. root of the specific spinal nerve. The iliohypogastric and ilioinguinal nerves, both branches Distribution of dermatomes, myotomes, and osteotomes of L1, supply the inferior part of the abdominal wall. The ilio- does not follow the same pattern in some areas, where dif- hypogastric nerve runs above the iliac crest and splits into ferent nerves supply the innervation of deep and superfi- two terminal branches. The lateral cutaneous branch supplies cial structures (Figure 1-8). Regardless, the knowledge of the side of the buttock; the anterior cutaneous branch sup- their distribution is relevant for the application of regional plies the suprapubic region. anesthesia as a guide to decide which block techniques are The ilioinguinal nerve leaves the intermuscular plane by appropriate to provide adequate analgesia and anesthesia piercing the internal oblique muscle above the iliac crest. for specific surgical procedures. It continues between the two oblique muscles to enter the Hadzic_Ch01_p001-032.indd 8 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 9 A B FIGURE 1-8. Distribution of dermatomes, myotomes, and osteotomes: (A) anterior view and (B) posterior view. Hadzic_Ch01_p001-032.indd 9 10/06/21 3:55 PM  10 SEC TION 1 Foundations Dorsal root (sensory root) Ventral root (motor root) Spinal ganglion Meningeal ramus Spinal nerve Dorsal ramus (posterior) with medial ramus and Sympathetic ganglion lateral ramus Lateral cutaneous ramus Ventral cutaneous ramus Ramus communicans Ventral ramus FIGURE 1-9. Course and distribution of an intercostal nerve. inguinal canal through the spermatic cord. Emerging from periphery of the diaphragm. Inflammation of the peritoneum the superficial inguinal ring, it gives cutaneous branches to gives rise to pain in the lower thoracic and abdominal wall. In the skin on the medial side of the root of the thigh, the proxi- contrast, the peritoneum on the central part of the diaphragm mal part of the penis, and the front of the scrotum in males receives sensory branches from the phrenic nerves (C3, C4, and the mons pubis and the anterior part of the labium majus and C5), and irritation in this area may produce pain in the in females. region of the shoulder (the fourth cervical dermatome). Nerve Supply to the Peritoneum Nerve Plexuses The lower thoracic and first lumbar nerves innervate the The ventral rami of the cervical, lumbar, and sacral spinal parietal peritoneum of the abdominal wall. The lower tho- nerves form a neural network known as plexuses. The nerve racic nerves also innervate the peritoneum that covers the fibers from these spinal segments distribute in different Hadzic_Ch01_p001-032.indd 10 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 11 FIGURE 1-10. Organization of the cervical plexus from roots to terminal nerves. terminal nerves. The four major nerve plexuses are the cervi- anterior scalene muscle, passes through the superior tho- cal, brachial, lumbar, and sacral plexus. racic aperture, and descends on the walls of the mediasti- num to innervate the diaphragm (phrenic nerve). Thus, the cervical plexus has a relevant role in maintaining the respira- The Cervical Plexus tory function. Superficial branches from the cervical plexus The cervical plexus originates from the ventral rami of C1 pass around the posterior margin of the sternocleidomas- to C5, which form three loops (Figure 1-10). Deep motor toid muscle and provide sensory innervation to the skin of branches originating from these loops innervate the infra- the lateral scalp, neck, clavicle, shoulder, and upper thorax hyoid and scalene muscles. Fibers from C3 to C5 form the (Figure 1-11). Table 1-1 describes the origin and innerva- phrenic nerve, which descends on the anterior surface of the tion of each nerve of the cervical plexus. Hadzic_Ch01_p001-032.indd 11 10/06/21 3:55 PM  12 SEC TION 1 Foundations FIGURE 1-11. Dissection of the superficial branches of the cervical plexus. TABLE 1-1 Organization and Distribution of the Cervical Plexus NERVES SPINAL SEGMENTS DISTRIBUTION Ansa cervicalis (superior and inferior C1-C3 Five of the extrinsic laryngeal muscles (sternothyroid, branches) sternohyoid, omohyoid, geniohyoid, and thyrohyoid) by way of cranial nerve XII Lesser occipital, transverse cervical, C2-C4 Skin of upper chest, shoulder, neck, and ear supraclavicular, and greater auricular nerves Phrenic nerve C3-C5 Diaphragm Cervical nerves C1-C5 Levator scapulae, scalene muscles, sternocleidomastoid muscles, and trapezius muscles (with cranial nerve XI) Hadzic_Ch01_p001-032.indd 12 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 13 FIGURE 1-12. Organization of the brachial plexus from roots to terminal nerves. The Brachial Plexus (C8-T1) trunks (Figure 1-12). At the level of the clavicle, every trunk gives off an anterior and a posterior division. The ventral rami of spinal nerves C5-T1 form the brachial These divisions rearrange their fibers to form the lateral, plexus, which innervates bones, joints, muscles, and the medial, and posterior cords, which in turn give off the skin of the upper extremity and shoulder girdle. Between peripheral nerves for the upper extremity (Figure 1-13). the anterior and middle scalene muscles, the roots converge Table 1-2 describes the origin and innervation of each nerve to form the superior (C5-C6), middle (C7), and inferior of the brachial plexus. Hadzic_Ch01_p001-032.indd 13 10/06/21 3:55 PM  14 SEC TION 1 Foundations FIGURE 1-13. Dissection of the brachial plexus from the roots in the neck to the axillary fossa. TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 MYOTOMES NERVE (TERMINAL SPINAL MOTOR BRANCH) NERVES TRUNK CORD MUSCLES RESPONSE SCLEROTOMES DERMATOMES Long thoracic C5-C7 Serratus Forward anterior flexion of the arm and contraction of the serratus anterior Dorsal C5 Levator scap- Elevation of scapular ulae, rhom- the scapula boid muscles Nerves to C4-C6 Upper Subclavius Sternoclavicular subclavius joint Hadzic_Ch01_p001-032.indd 14 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 15 TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued) MYOTOMES NERVE (TERMINAL SPINAL MOTOR BRANCH) NERVES TRUNK CORD MUSCLES RESPONSE SCLEROTOMES DERMATOMES Suprascapular C5-C6 Upper Supra- Abduction Glenohumeral spinatus, and lateral and acromiocla- infraspinatus rotation of vicular joints, sub- the shoulder acromial bursa Subscapular C5-C6 Upper Posterior Subscapularis, Adduction Deep surface of (upper and teres major and medial the scapula lower) rotation of the shoulder Thoracodorsal C6-C8 Upper, Posterior Latissimus Extension, middle, dorsi adduction, lower and medial rotation of the shoulder Axillary C5-C6 Upper Posterior Deltoid, teres Abduction Glenohumeral Anterior and minor and lateral anterior and posterior rotation of acromioclavicular shoulder the shoulder joints Radial C5-T1 Upper, Posterior Triceps, Extension of 1st/3rd superior Posterior arm middle, anconeus, the elbow, humerus, elbow and forearm, lower brachioradia- wrist, and joint, radius, ulna, dorsal aspect of lis, extensor fingers, supi- carpus, 1st-3rd the hand (1st-4th carpi radialis nation of metacarpus and fingers) longus and the forearm, phalanges brevis, supina- abduction of tor, extensor the wrist and digitorum thumb communis, extensor digiti minimi, extensor carpi ulnaris, exten- sor indicis, extensor pol- licis longus and brevis, abductor pollicis Lateral C5-C7 Upper, Lateral Pectoralis Glenohumeral pectoral middle minor, pecto- and acromiocla- ralis major vicular joints Musculocuta- C5-C6 Upper Lateral Coracobra- Flexion of the Humerus elbow Lateral forearm neous chialis, biceps elbow and and proximal rim brachii, supination of radioulnar joints brachialis the forearm Hadzic_Ch01_p001-032.indd 15 10/06/21 3:55 PM  16 SEC TION 1 Foundations TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued) MYOTOMES NERVE (TERMINAL SPINAL MOTOR BRANCH) NERVES TRUNK CORD MUSCLES RESPONSE SCLEROTOMES DERMATOMES Median C6-T1 Upper, Lateral, Elbow: Pro- Flexion of Elbow joint Palmar aspect of middle, medial nator teres, the wrist (anterior), radius, the hand (1st-4th lower flexor carpi and 2nd-3rd ulna, 1st-4th fingers) and dor- radialis, pal- fingers, pro- metacarpus and sal aspect of the maris longus nation of the phalanges distal half of the Forearm: forearm 2nd-4th fingers Flexor digitorum superficialis/ profundus, flexor pol- licis longus, pronator quadratus Hand: Thenar muscles, 1st- 2nd lumbrical muscles Medial C8-T1 Lower Medial Pectoralis Clavicle pectoral minor, pecto- ralis major Medial T1 Lower Medial Medial aspect of brachial the arm cutaneous Medial C8-T1 Lower Medial Medial aspect of antebrachial the forearm cutaneous Ulnar C8-T1 Middle Medial Flexor carpi Flexion of the Elbow joint, ulna Medial aspect of ulnaris, flexor wrist and 4th- and medial aspect the hand, 4th-5th digitorum 5th fingers, of the wrist, hand finger profundus adduction of and 4th-5th and interos- the thumb fingers seous (4th- 5th fingers), muscles of the hypothe- nar eminence, adductor pollicis, flexor pollicis brevis Hadzic_Ch01_p001-032.indd 16 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 17 FIGURE 1-14. Organization of the lumbar plexus from roots to terminal nerves. The Lumbar Plexus in the posterior abdominal wall between the psoas major and quadratus lumborum muscles. The main branches The ventral rami of spinal nerves L1-L4 form the lumbar of the lumbar plexus are the iliohypogastric, ilioinguinal, plexus. They divide into anterior and posterior divisions genitofemoral, lateral femoral cutaneous, obturator, and that coalesce to form the terminal nerves (Figure 1-14). femoral nerves (Figure 1-15 and Figure 1-16). Table 1-3 The lumbar plexus innervates the skin, muscles, peritoneal describes the origin and innervation of each nerve of the lining of the lower abdominal wall, and the anteromedial lumbar plexus. aspect of the lower extremities. The plexus runs caudally Hadzic_Ch01_p001-032.indd 17 10/06/21 3:55 PM  18 SEC TION 1 Foundations FIGURE 1-15. Dissection of the lumbar plexus in the pelvic cavity. Lateral femoral cutaneous nerve Inguinal ligament Iliopsoas muscle Femoral nerve Tensor fasciae latae Sartorius muscle Pectineus muscle Femoral artery Femoral vein Adductor longus muscle Great saphenous vein Gracilis muscle FIGURE 1-16. Dissection of the femoral nerve below the inguinal ligament. Hadzic_Ch01_p001-032.indd 18 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 19 TABLE 1-3 Anatomy of the Lumbar Plexus L1-L4 MYOTOMES NERVE (TERMINAL SPINAL MOTOR BRANCH) NERVES MUSCLES RESPONSE SCLEROTOMES DERMATOMES Iliohypogastric T12-L1 Abdominal muscles Contraction of the Skin over inferior (external and internal abdominal wall abdomen and oblique, transverse (inguinal area) buttocks abdominis) Ilioinguinal L1 Internal oblique Contraction of the Skin over superior, abdominal wall medial thigh, and (inguinal area) portions of external genitalia Genitofemoral L1-L2 Cremaster Elevates the scrotum Anteromedial surface of thigh and portions over genitalia Lateral femoral L2-L3 Anterolateral aspect cutaneous of thigh Femoral (anterior/ L2-L4 Sartorius, pectineus Flexion, aduction, Anteromedial aspect superficial branches): and external rotation of thigh anterolateral cutane- of the hip ous, anteromedial cutaneous Femoral (posterior L2-L4 Quadriceps Extension of the Ilium, anterior and Anterior surface of branch): saphe- knee, patellar lateral aspect of thigh, medial surface nous, nerves to the femur, superior artic- of leg, and foot quadriceps ular aspect of tibia; hip and knee joints Obturator L2-L4 Adductors of thigh Adduction of the Ischium, pubis, medial Medial surface of (adductors magnus, thigh, external rota- aspect of femur; hip thigh brevis, and longus); tion of the hip and knee joints gracilis, obturator externus The Sacral Plexus between the greater trochanter and ischial tuberosity in the gluteal area (Figure 1-18). In the proximal thigh, the nerve The ventral rami of spinal nerves L4-L5 and S1-S4 form lies behind the lesser trochanter of the femur and is covered the sacral plexus, which innervates the buttocks, perineum, superficially by the long head of the biceps femoris muscle. posterior aspect of the thigh, and the whole leg below the The two components of the sciatic nerve diverge into two knee, except the sensory territory of the saphenous nerve recognizable nerves as it approaches the popliteal fossa: the (Figure 1-17). The main nerve is the sciatic nerve that leaves common peroneal and the tibial nerves. Table 1-4 describes the pelvis through the greater sciatic foramen and travels the origin and innervation of each nerve of the sacral plexus. Hadzic_Ch01_p001-032.indd 19 10/06/21 3:55 PM  20 SEC TION 1 Foundations FIGURE 1-17. Organization of the sacral plexus from roots to terminal nerves. better understanding of the neuronal components that need Innervation of the Major Joints to be anesthetized to achieve anesthesia for or analgesia after Much of the practice of peripheral nerve blocks involves joint surgery. Table 1-5 summarizes the innervation and orthopedic and joint surgery. Consequently, knowledge of kinetic function of the major muscle groups of the upper the sensory innervation of major joints is important for a and lower extremities. Hadzic_Ch01_p001-032.indd 20 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 21 Gluteus maximus muscle Superior gluteal artery and nerve Tendon of piriform muscle Sacrotuberous ligament Pudendal nerve Sciatic nerve Inferior gluteal nerve Posterior femoral cutaneous nerve Ischial tuberosity FIGURE 1-18. Dissection of the sciatic nerve at the pelvic outlet. TABLE 1-4 Anatomy of the Sacral Plexus L4-S4 NERVE (TERMINAL SPINAL MOTOR MOTOR RESPONSE TO BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES Gluteal (superior/ L4-S2 Abductors of thigh Contraction of the Medial and supe- inferior) (gluteus minimus, buttocks and external rior aspect of the gluteus medius, and rotation of the hip buttocks tensor fasciae latae) and extensor of thigh (gluteus maximus) Posterior femoral S1-S3 Skin of perineum cutaneous and posterior surface of thigh and leg Hadzic_Ch01_p001-032.indd 21 10/06/21 3:55 PM  22 SEC TION 1 Foundations TABLE 1-4 Anatomy of the Sacral Plexus L4-S4 (Continued) NERVE (TERMINAL SPINAL MOTOR MOTOR RESPONSE TO BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES Sciatic Gluteal Three of the hamstrings Extension of hip, flexion Hip joint; ischium, level (semitendinosus and of knee posterior aspect semimembranosus long of the femur head of biceps femoris); adductor magnus (with obturator nerve) Tibial L4-S3 Flexor of knee and Flexion of the knee, plan- Posterior aspect Knee, ankle, and plantar flexors of ankle tar flexion of the foot and of leg, plantar all foot joints; (popliteus, gastrocne- toes, inversion of the foot aspect of foot tibia, fibula, and mius, soleus plantaris, plantar aspect of and tibialis posterior the foot muscles and long head of biceps femoris mus- cle); flexors of toes Common L4-S2 Biceps femoris muscle Flexion of the knee, dorsi Anterior surface Knee, ankle, and peroneal (short head); fibularis flexion of the foot and aspect of leg and all foot joints; (brevis and longus) and toes, eversion of the foot dorsal aspect of proximal tibia and tibialis anterior muscles; foot; skin over fibula and dorsal extensors of toes lateral portion aspect of the foot of foot (through the sural nerve) Pudendal S2-S4 Muscles of perineum, Motor contraction of the External genitalia, including urogenital dia- muscles involved lower third of phragm and external anal the urethra and and urethral sphincter vagina, skin of the muscles; skeletal muscles anal circumfer- (bulbospongiosus, ischio- ence, caudal third cavernosus muscles) of the rectum Nerve to the qua- L4-L5 Quadratus femoris, infe- Adduction and external Hip joint dratus femoris and rior gemellus rotation of the hip inferior gemellus Nerve to obtura- L5-S1 Superior gemellus, Abduction of the hip tori and superior obturator internus gemellus Nerve to piriformis S1-S2 Piriformis Abduction and lateral rotation of the hip Nerves to coccyg- S3-S4 Coccygeus, levator ani Motor contraction of the eus and levator ani muscles involved Hadzic_Ch01_p001-032.indd 22 10/06/21 3:55 PM  Functional Regional Anesthesia Anatomy CHAPTER 1 23 TABLE 1-5 Summary of Movement by Joint UPPER EXTREMITY Shoulder (Glenohumeral) Joint Flexion Biceps brachii—long head Musculocutaneous nerve Coracobrachialis Deltoid Axillary nerve Pectoralis major Medial and lateral pectoral nerve Extension Triceps brachii—long head Radial nerve Latissimus dorsi Thoracodorsal nerve Deltoid Axillary nerve Adduction Latissimus dorsi Thoracodorsal nerve Pectoralis major Medial and lateral pectoral nerves Teres major Lower subscapular nerve Subscapularis Upper and lower subscapular nerve Abduction Supraspinatus Suprascapular nerve Deltoid Axillary nerve Medial rotation Pectoralis major Medial and lateral pectoral nerve Latissimus dorsi Thoracodorsal nerve Teres major Lower subscapular nerve Subscapularis Upper and lower subscapular nerves Lateral rotation Teres minor Axillary nerve Infraspinatus Suprascapular nerve Elbow (Humeroulnar, Humeroradial) Joint Flexion Brachialis Musculocutaneous Biceps brachii—long and short heads Flexor carpi radialis Median nerve Extension Triceps brachii—long lateral, medial head Radial nerve Anconeus Radioulnar Joints Supination Biceps brachii—long and short head Muscul