Regional and Local Anaesthesia

Many operations can also be performed under local anaesthesia without any need for a general anaesthetic. In some types of surgery local anaesthesia can be combined general anaesthesia, not least for the continuation of analgesic treatment after an operation.

The combination of individual regional anaesthetic procedures is also a sensible method that is put to use.

42% of operations in our hospital are carried out under regional anaesthesia, some of which are performed in combination with general anaesthesia.

We would like to briefly explain the main regional anaesthesia procedures that we use in our hospital.

A distinction is drawn between peripheral nerve blocks (nerves somewhat further away from the trunk of the body) and anaesthesia close to the spinal cord such as spinal or peridural anaesthesia.

Points 1 to 4 show the peripheral nerve blocks and points 5 and 6 show anaesthesia close to the spinal cord:

© J. Büttner, G. Meier, Kompendium der peripheren Regionalblockaden, Arcis Verlag GmbH, Munich 2002

Axillary Plexus Anaesthesia
(anaesthesia of the arm via the armpit)

This method is very frequently used in our hospital as it is simple to perform and free of major risks and side effects.

This procedure is often used for operations between the hand and the elbow such as for plastic surgery, hand surgery and trauma surgery.

A specific amount of local anaesthetic is administered near a network of nerves (plexus) in the armpit using a special cannula. After approximately 20 to 30 minutes, the arm is completely anaesthetised and surgery can be performed painlessly. This type of anaesthesia persists for around two to four hours, meaning that the arm also remains anaesthetised after the end of surgery.

This procedure can also be carried out using the catheter method, which involves inserting a thin and  flexible plastic tube near the network of nerves (plexus) in the armpit, which can remain there for a few days. An analgesic pump is subsequently connected to this tube and continuously dispenses a fixed dose of local anaesthetic. This type of anaesthetic has proven to be useful in reducing pain during physiotherapy for patients such as those suffering from Sudeck's atrophy (CRPS).

© J. Büttner, G. Meier, Kompendium der peripheren Regionalblockaden, Arcis Verlag GmbH, Munich 2002

© J. Büttner, G. Meier, Kompendium der peripheren Regionalblockaden, Arcis Verlag GmbH, Munich 2002

Interscalenar Plexus Anaesthesia
(anaesthesia of the shoulder via the neck)

We only perform this procedure in conjunction with general anaesthesia. It is used for shoulder, collarbone or upper arm operations. A local anaesthetic is administered through a small thin cannula between two muscles in the neck near a network of nerves (plexus) and the needle is removed immediately afterwards. The onset of the anaesthetic effect is relatively rapid and generally persists well beyond the general anaesthesia so that the patient also benefits from it after the operation.

This procedure also significantly reduces the need for analgesics during general anaesthesia.

© J. Büttner, G. Meier, Kompendium der peripheren Regionalblockaden, Arcis Verlag GmbH, Munich 2002

Inguinal Femoral Nerve Block and Winnie 3-in-1 Block

We quite often use inguinal nerve (femoral nerve) blocks, for example for wound treatment on the front of the thigh, for analgesic treatment of fractures of the femur or neck of the femur or during mobilisation following fractures of this kind.

Such blocks are also relatively easy to perform and are low in risks and side effects.

In this procedure, a specific quantity of local anaesthetic is administered near the inguinal nerve using a special cannula. This anaesthetic blocks the pain in the area of the anterior and lateral thigh.

In conjunction with the anterior ischiadic nerve block, which is described in the next section, this procedure is very well suited as a catheter method for postoperative analgesic treatment. These analgesic treatment procedures are particularly used during operations requiring insertion of an artificial knee joint. This method may furthermore be combined with general anaesthesia or anaesthesia close to the spinal cord.

© J. Büttner, G. Meier, Kompendium der peripheren Regionalblockaden, Arcis Verlag GmbH, Munich 2002

Anterior Ischiadic Nerve Block (anterior sciatic nerve block)

In order to achieve proper anaesthesia, an anterior approach to the sciatic nerve block must be performed using a nerve stimulator. For this purpose, the anaesthetic needle is connected to a stimulation device which emits low electrical pulses. This triggers muscle twitches, allowing the anaesthetist to determine the right place to administer the local anaesthetic and insert the catheter. We use this technique as a catheter method in conjunction with the femoral nerve block described in point 3 for artificial knee joint operations and then continue it for analgesic treatment. This procedure is currently considered to be the method of choice for these operations in conjunction with general anaesthesia or anaesthesia close to the spinal cord.

Spinal anaesthesia (SPA)

Spinal Anaesthesia (SPA)

Spinal anaesthesia, like peridural anaesthesia, is a method of anaesthesia performed close to the spinal cord, but there is no contact with the spinal cord itself. In adults, the spinal cord ends at the level of the 2nd lumbar vertebra.

The anaesthetic is administered between the 3rd and 4th or the 4th and 5th lumbar vertebrae (see fig. 1).

This procedure can be used in operations on the lower abdomen and the legs.
With the patient in a sitting position, a very thin needle is inserted between two bones of the vertebral column, which can be palpated in the back, making it possible to reach the spinal cavity, which lies inside the vertebral canal.

A small quantity of local anaesthetic is then administered into the spinal cavity. This combines with the spinal fluid, directly anaesthetises the pain fibres and temporarily causes a complete blockage of movement, feeling and pain. Preparations for the operation can then begin after only a few minutes. We often also administer a sedative to induce ’half-sleep’ so that the patient is unaware of the surgery taking place.

Peridural Anaesthesia (PDA)

Like spinal anaesthesia (SPA), peridural anaesthesia (PDA), which is also known as epidural anaesthesia, belongs to the methods of anaesthesia performed close to the spinal cord. Unlike SPA, this does not involved entering the spinal cavity but instead administers the local anaesthetic in the vicinity of the cavity in the peridural space (peri = around; dura = the hard skin surrounding the spinal cavity). It is also possible to insert a catheter (a flexible plastic tube) at this point, through which the analgesic can be administered either in single doses or continuously.

Catheter insertion causes little discomfort because it is carried out under local anaesthetic (see figs. 1-3).

The skin and underlying tissue are first anaesthetised with a local anaesthetic (fig. 1) and the plastic tube is then inserted using a guide cannula (fig. 2). Once it is in the correct position, the cannula is drawn back over the inserted tube (PDC) and only the plastic tube remains (fig. 3).

A small filter is connected to the plastic tube in order to avoid contamination by bacteria. The tube is subsequently secured with plaster strips so that it cannot slip out of place.
The tube is so long that it can be laid over the shoulder and fixed there. It does not cause any discomfort when the patient is lying on his/her back because it is very soft.

This procedure is conventionally used in combination with general anaesthesia for major abdominal surgery or during chest operations, when it is also used for postoperative analgesic treatment.

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Academic teaching hospital of the RWTH technical university, Aachen

Clinic for Anaesthesia and Surgical Intensive Care

Dechant-Deckers-Str. 8
52249 Eschweiler

+49 2403 - 76-1891

St.-Antonius-Hospital gGmbH
Dechant-Deckers-Str. 8
52249 Eschweiler
tel.: 02403 76 - 0
fax: 02403 76 -1119

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