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

Abstract

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

Tibial Nerve Block: Supramalleolar or Retromalleolar Approach? A Randomized Trial in 110 Participants

“…These results highlight the greater difficulty in locating the tibial nerve at the supramalleolar level. A study by Larrabure et al [19] also highlights the difficulty in locating the tibial nerve in a more proximal anatomical position. The tibial nerve dermatoma area that presented the greatest difficulty in achieving thermal and pain sensitivity blocking, with both the retromalleolar and the supramalleolar technique, was that of the medial plantar nerve.…”

Description of a novel technique for ultrasound‐guided posterior tibial nerve block

“…To date, an ultrasound-guided posteromedial approach to PTNB has been the methodologic approach most commonly described in the literature for anesthetizing the heel and plantar regions of the foot, principally because the PTN courses posterior to the medial malleolus, with easily palpable landmarks and less tissue to traverse, seemingly making needle placement and maneuverability ideal. 2,3 However, in the authors' clinical experience using the approach described herein, an ultrasound-guided posterolateral PTNB may provide easier needle maneuverability, increased conspicuity of needle placement, and better technical feasibility than the posteromedial approach.…”

“…2 The primary clinical indications for a PTN block include tarsal tunnel syndrome, Baxter's neuropathy, medial plantar neuropathy (Jogger's foot), postoperative analgesia for forefoot surgery, and regional anesthesia for procedures such as plantar fascia injections, needle fasciotomy or tenotomy, and platelet-rich plasma injections. 2,3 As the precise location of the PTN varies among individuals, especially in patients of large body habitus or with altered anatomy due to prior trauma or surgery, using anatomical landmarks for a palpation-guided injection may be challenging. 4,5 Additionally, although the PTN may trifurcate into its three terminal branches at the tarsal tunnel, the MCN often arises directly from the PTN more proximally.…”