IPACK BLOCK FOR KNEE ARTHROSCOPY SKIN

The sciatic nerve exits the pelvis through the greater sciatic notch, lateral and posterior to the lesser trochanter of the femur on the posterior aspect of the adductor magnus and deep to the biceps femoris muscle. The sciatic nerve innervates the posterior thigh and knee. 10 The ventral rami of fourth and fifth lumbar nerves and the first, second, and third sacral nerves form the sciatic nerve. The LFC nerve penetrates the inguinal ligament about one centimeter from the anterior superior iliac spine and proceeds down the thigh. It is formed by ventral rami of the second and third lumbar nerves.

IPACK BLOCK FOR KNEE ARTHROSCOPY SKIN

The lateral femoral cutaneous (LFC) nerve provides sensory innervation to the skin of the lateral aspects of the thigh and knee. At the level of the inguinal ligament, the obturator nerve is separated from the femoral nerve by several fascial compartments. While the femoral nerve emerges lateral to psoas major, the obturator emerges medial to it.

It is formed by the anterior divisions of the second, third, and fourth lumbar nerves in the psoas major muscle.

11 The obturator nerve provides sensory and motor innervation of the thigh, and it may contribute sensory articular branches to the knee. It then divides into anterior and posterior divisions before branching as it descends the thigh.10 Two of its terminal branches, the saphenous nerve and nerve to the vastus medialis, provide sensory innervation to the anteromedial knee. At the level of the inguinal ligament, the femoral nerve is typically located lateral to the femoral artery. The nerve runs between the psoas major and the iliacus muscle deep to the fascia iliaca at the level of the inguinal ligament. The femoral nerve innervates the dermatomes over the anterior thigh and knee as well as the femur. The branches of the lumbar plexus include iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral and obturator nerves while the sacral plexus gives rise to the sciatic nerve. The plexus is located between the anterior and posterior masses of the psoas major muscle in line with the intervertebral foramina. 8-10,13,15 The innervation of the knee originates from the lumbosacral plexus, which is formed from the ventral rami of all five lumbar nerves and the first, second, and third sacral nerves. 10-12,15 Regional analgesia for knee surgery involves blocking the femoral and sciatic nerves or their corresponding terminal branches. 5,6Īn understanding of knee innervation is key to safely performing an effective regional anesthetic for surgery. 9 Regional anesthesia, either in the form of a single-injection peripheral nerve block (PNB) or continuous peripheral nerve block (CPNB) with an indwelling catheter, is an attractive adjunct for perioperative multimodal analgesia, and should be considered for this vulnerable patient population. 8 Further, these procedures are more commonly being performed in an outpatient setting, making adequate pain control a priority. 7 These injuries, especially ACL tear, should be surgically managed in a timely manner even in skeletally immature patients, as delaying surgical fixation has been shown to lead to chronic joint instability, premature osteoarthritis and decreased functional status. 5 Acquired or traumatic knee injuries, such as anterior cruciate ligament (ACL) tears, tibial eminence fractures, and meniscal tears are becoming more common as sports participation increases nationally. Patients with congenital knee deformities may be at higher risk of needing subsequent procedures and postoperative pain management may be challenging. Surgical repairs can include tendon lengthening, ligament transfers, and distal femoral extension osteotomies. 1-4 Many of these patients have multi-level joint involvement and may be facing corrective procedures at the hip and ankle, in addition to the knee. Congenital lesions, such as patellofemoral dysfunction as seen in healthy patients and patients with cerebral palsy, or flexion/extension contractures associated with arthrogryposis and pterygium syndrome, are often surgically treated in late childhood, prior to epiphyseal plate closure. Knee pain and injury are responsible for nearly one-fourth of musculoskeletal complaints across all age groups.1 While knee issues are less frequent in young children, the incidence increases in adolescents and young adults who can present with a variety of congenital, developmentally acquired, and traumatic etiologies. Regional Anesthesia for Pediatric Knee Surgeryīy Loren Babirak, MD Elizabeth O’Brien, MD Wallis Muhly, MDĭepartment of Anesthesiology and Critical Care

Ipack block for knee arthroscopy