Assessment of Block of the Sciatic Nerve in the Popliteal Fossa

P Pu ur rp po os se e: : Several techniques of tibial nerve (TN) block have been described but require mobilization of the patient. We describe a new landmark, along the internal tibial shaft edge at the midleg level, that allows to block the TN and to insert a catheter with the patient lying supine.M Me et th ho od ds s: : 241 ASA physical status I to III awake, supine patients were studied prospectively. Cutaneous projections of the internal tibial condyle and the internal malleolus were marked and the needle was inserted 45° cephalad in an antero-posterior plane, midway on the line between those two points, 1 cm posterior to the tibial shaft's internal edge. The catheter was introduced in the peri-nervous space using nerve stimulation (< 0.5 mA) on both the Tuohy needle and catheter. Ten millilitres of 2% lidocaine were injected through the catheter. Cutaneous and dermatomal sensory blockade were assessed using cold and pinprick tests while motor block was assessed using a modified Bromage scale. Satisfaction and analgesia scores were noted after surgery for 48 hr. Adverse events were recorded. R Re es su ul lt ts s: : The TN was always blocked, matching the distal L5 cutaneous nerve supply. Blood reflux was present in five patients (needle or catheter). No additional adverse events were noted. During the initial postoperative 48 hr, 0.2% ropivacaine was infused through the catheter (5 mL·hr -1 ) which always provided effective pain relief.C Co on nc cl lu us si io on n: : The midleg technique of TN anesthesia and catheter insertion allows patients to remain in the supine position and results in a high rate of homogeneous anesthesia, a low incidence of side effects and effective continuous analgesia. HE tibial nerve (TN) block is now well accepted for the provision of anesthesia or postoperative analgesia for forefoot surgery in adult patients. 1-3 Several approaches have been described either proximally in the popliteal region 4-9 or at the ankle 2,3 but are associated with an incomplete block. A novel antero-internal landmark for TN block was developed at the midleg level to combine firstly, ease of performance in a supine patient, secondly, a high enough approach to block the whole TN, and thirdly, to allow insertion of a catheter for postoperative analgesia. This new stimulation guided approach to the TN was evaluated Objectif

Section: Objectifmentioning

confidence: 99%

Section: Objectifmentioning

confidence: 99%

mentioning

confidence: 99%

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Le bloc du nerf tibial: évaluation d’une nouvelle approche chez 241 patients

Larrabure

Pandin

Vancutsem

et al. 2005

“…15 Despite these technical modifications, the success rate of total sciatic nerve blockade remained limited. 11,16 The more recent popliteal technique 4,5,17 allows sciatic block involving the tibial and peroneal nerve supplies and easy insertion of a catheter for postoperative analgesia. Unfortunately, this more distal popliteal technique is not adequate to obtain a posterior femoral cutaneous nerve block which is mandatory for tourniquet tolerance.…”

Section: Objectifmentioning

confidence: 99%

Sciatic nerve blockade in the supine position: a novel approach

Pandin

Vandesteene

D’Hollander

2003

P Pu ur rp po os se e: : Sciatic nerve block is useful for surgery below the knee both intra-and postoperatively. Several techniques to insert a catheter at the knee level or higher have been described but need mobilization (lateral decubitus) of the patient. We describe novel landmarks, using a high lateral approach, to block the sciatic nerve without moving the patient.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : One hundred seven ASA I, II and III ASA patients scheduled for major foot or ankle surgery were studied prospectively. With patients awake and lying in the supine position, the catheter was introduced along novel landmarks in the peri-nervous adipose space using specifically designed material and nerve stimulation (< 0.5 mA). After a negative test dose (1% lidocaine with 1/200.000 epinephrine), 10 mL of 0.5% bupivacaine and 10 mL of 2% lidocaine were injected. Thirty minutes after performance of the block, the cutaneous and dermatomal sensory blockade were assessed using cold and pinprick tests while motor block was assessed using a modified Bromage scale. Complications and incidents were recorded. The tibial and superficial peroneal nerve were always blocked, while the deep peroneal and posterofemoral cutaneous nerves were blocked in only 97% and 83% of the patients, respectively. Anesthesia, was always present in the dermatome L5 and in the S1 dermatome in 98% of the patients. No major incidents or complications were noted. Three catheters could not be inserted and the anesthestic solution was injected through the needle.

“…CIATIC nerve block in the popliteal fossa was first described in 1923 1 and recently revisited. [2][3][4] These techniques require a prone position that excludes patients with compromised mobility. Lateral approaches to the sciatic nerve with patients in the supine position have been proposed at the hip 5 and the knee.…”

mentioning

confidence: 99%

Sciatic nerve block in the popliteal fossa: description of a new medial approach

Guntz

Herman

Debizet

et al. 2004

P Pu ur rp po os se e: : Sciatic nerve blocks through lateral approaches in the popliteal fossa have been proposed. We describe a new medial approach to the sciatic nerve at this level.M Me et th ho od ds s: : After an anatomical study on six cadavers, we performed sciatic nerve blocks on 20 patients. A 100-mm insulated needle and a nerve stimulator were used; 20 mL of lidocaine 1.5% with epinephrine were injected.R Re es su ul lt ts s: : Patients lied in the supine position, the thigh flexed, abducted and rotated externally (30° in all directions). The leg was flexed at 130°. In this position, above the adductor tubercle, a depression known as Jobert's fossa is palpated. Through this groove, a medial approach to the sciatic nerve at the level of the popliteal fossa is possible. The mean distance between the adductor tubercle and the puncture site is 6.18 cm (range 4-8 cm) and the mean distance between the skin and the sciatic nerve is 6.62 cm (range 4-9 cm). Mean time to perform the block was 100 sec (range 55-165 sec). Complete motor blockade was obtained after a mean time of 30 min (range 5-60 min) inside the common peroneal nerve area and 43 min (range 15-75 min) inside the tibial nerve area. Motor block was complete in 17 patients and sensory block in 18 patients. No vessel puncture was observed.