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New landmarks for the anterior approach to the sciatic nerve block: imaging and
clinical study
Van Elstraete AC, Poey C, Lebrun T, Pastureau F. Departments of Anesthesiology and Radiology, Saint-Paul Medical Center, Fort de France, Martinique, France In this study, we assessed the reliability of the inguinal crease and femoral artery as anatomic landmarks for the anterior approach to the sciatic nerve and determined the optimal position of the leg during this approach. An imaging study was conducted before the clinical study. The sciatic nerve was located twice in 20 patients undergoing ankle or foot surgery, once with the leg in the neutral position and once with the leg in the externally rotated position. The patient was lying supine. A 22-gauge, 150-mm insulated b-beveled needle connected to a nerve stimulator was inserted 2.5 cm distal to the inguinal crease and 2.5 cm medial to the femoral artery and was directed posteriorly and laterally with a 10 degrees -15 degrees angle relative to the vertical plane. The sciatic nerve was located in all patients at a depth of 10.6 1.8 cm when the leg was in the neutral position and 10.4 1.5 cm when the leg was in the externally rotated position (not significant). In the neutral position and in the externally rotated position, the time needed to identify anatomic landmarks was 28 15 s and 26 14 s, respectively (not significant), and the time needed to locate the sciatic nerve was 79 53 s and 46 25 s (P < 0.006), respectively. We conclude that the inguinal crease and femoral artery are reliable and effective anatomic landmarks for the anterior approach to the sciatic nerve and that the optimal position of the leg is the externally rotated position. IMPLICATIONS: This new anterior approach to the sciatic nerve using the inguinal crease and femoral artery as landmarks is an easy and reliable technique.
Postoperative analgesia with continuous sciatic nerve block after foot surgery: a prospective, randomized comparison between the popliteal and subgluteal approaches di Benedetto P, Casati A, Bertini L, Fanelli G, Chelly JE. Department of Anesthesiology, CTO Roma, Italy To compare the posterior popliteal and subgluteal continuous sciatic nerve block for anesthesia and acute postoperative pain management after foot surgery, 60 ASA physical status I and II patients undergoing elective orthopedic foot surgery were randomly assigned to either a Subgluteal group (n = 30) or Popliteal group (n = 30). Before surgery and after performing a femoral nerve block with 15 mL of 2% mepivacaine, we performed the sciatic nerve block with 20 mL of 0.75% ropivacaine using either a subgluteal or posterior popliteal approach, and the placement of a catheter came afterward. In the recovery room, the catheter was connected to a patient-controlled analgesia pump to infuse 0.2% ropivacaine (basal infusion rate of 5 mL/h, incremental bolus of 10 mL, and a lockout time of 60 min). There were no technical problems in catheter placement. Intraoperative efficacy of nerve block was similar in the two groups. Postoperative catheter displacement and occlusion were recorded in four patients in the Popliteal group and two patients in the Subgluteal group (P = 0.67). Both approaches provided similar postoperative analgesia. We conclude that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach for continuous sciatic block and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures. IMPLICATIONS: Comparing two different approaches for continuous sciatic nerve block after orthopedic foot surgery, this prospective, randomized study demonstrated that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach, and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures.
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A clinical comparison of psoas compartment and inguinal paravascular blocks combined with sciatic nerve block Tokat O, Turker YG, Uckunkaya N, Yilmazlar A. Department of Anaesthesiology, Uludag University Medical School, Bursa, Turkey. The extent of inguinal paravascular blockade and psoas compartment blockade with sciatic nerve block was evaluated in 60 patients. Volumes of 30 ml and 20 ml 0.35% bupivacaine with 1/200,000 epinephrine were injected for lumbar plexus and sciatic nerve block, respectively. Complete lumbar plexus blockade was achieved in 73% of the group who were treated with the psoas compartment technique and 43% of the group who were treated with the inguinal paravascular technique. Sensory blockade of the femoral, lateral femoral cutaneous and obturator nerves was obtained in 100%, 97% and 77% of the patients in the psoas compartment group, and 93%, 63% and 47% of the patients in the inguinal paravascular group, respectively. Sensory blockade of the lateral femoral cutaneous and obturator nerves was more rapid with psoas compartment block. The study suggests that the psoas compartment block is effective in blocking the femoral, lateral femoral cutaneous and obturator nerves, but the inguinal paravascular block is only effective in blocking the femoral nerve.
Continuous subgluteus sciatic nerve block after orthopedic foot and ankle surgery: comparison of two infusion techniques di Benedetto P, Casati A, Bertini L. Department of Anesthesiology, CTO Roma, Rome, Italy BACKGROUND AND OBJECTIVE: To compare continuous infusion or a patient-controlled technique for postoperative analgesia after foot surgery, using a new subgluteus approach for continuous sciatic nerve block. METHODS: Fifty healthy patients, undergoing orthopedic foot surgery, received a continuous sciatic nerve block using a new subgluteus approach. All blocks were placed with the aid of a nerve stimulator using a 10-cm, 18-gauge insulated Tuohy needle. After either plantar flexion or dorsiflexion of the operated foot was elicited at < or = 0.5 mA, 20 mL of 0.75% ropivacaine was injected incrementally using repeated aspiration tests, then followed by the introduction of a 20-gauge epidural catheter. Postoperatively, 0.2% ropivacaine was infused with either a 10 mL/h continuous infusion (group Continuous, n = 25) or with a 5 mL/h basal rate with 5 mL bolus every 60 minutes (group patient-controlled analgesia [PCA], n = 25). Intraoperative analgesic supplementation, as well as postoperative pain relief, morphine consumption, incidence of complication, and patient satisfaction were recorded by an observer unaware of group assignment. RESULTS: The sciatic catheter was successfully placed in all patients. Intravenous fentanyl supplementation (dose range, 50 to 150 microg) was required in 4 patients in each group, but no patient required general anesthesia. Catheter dislocation was reported in 2 patients (4%). The quality of pain relief was good in both groups, and none experienced complications. Nine patients of the Continuous group (37%) and 7 patients of the PCA group (29%) required rescue morphine analgesia because of pain in the femoral dermatomes (P =.76). Ropivacaine consumption was 240 mL in the Continuous group (range, 200 to 240 mL) and 140 mL in the PCA group (range, 120 to 290 mL) (P =.0005). Patient acceptance was good in both groups. CONCLUSIONS: The continuous subgluteus sciatic nerve block represents an easy and reliable option for postoperative analgesia after foot surgery; using a patient controlled rather than a continuous infusion technique reduces the consumption of local anesthetic solution without affecting the quality of pain relief.
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