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Abstract
Objective: Block of the sciatic nerve at the popliteal fossa can be performed using the
ultrasound machine; it may be proximally or distally to the bifurcation of the sciatic nerve using
lateral, medial, or posterior approaches. It is frequently used for surgeries below the knee specially
the foot and ankle operations.
Purpose: This study compares one and two injections of the sciatic nerve in the popliteal
fossa with ultrasound-guided block in foot or ankle surgeries.
Methods: Forty patients received ultrasound-guided sciatic nerve block with the nerve
stimulator, using the posterior approach. The patients were enrolled into two groups (20 patients
each), group 1: received one injection at 2 cm cephalad to the bifurcation of the sciatic nerve,
and group 2: received two injections caudate to the sciatic bifurcation; one for tibial nerve and
the other for common peroneal nerve. All patients received 20 ml of levobupivacaine 0.5%. The
block performance time, block efficacy, success rate, complications and patient’s satisfaction were
evaluated.
Results: Block the tibial and common peroneal nerves separately (two injections) distal to the
point of bifurcation of the sciatic nerve has a significantly (P<0.05) faster time to complete sensory
block of tibial and common peroneal nerves compared to a pre-bifurcation sciatic nerve block
(one injection). The complete motor block, block time performance, success rate and patient’s
satisfaction were not significantly different between groups (P>0.05).
Conclusion: The block of tibial and common peroneal nerves separately distal to the sciatic
nerve bifurcation is superior to single injection block of sciatic nerve above the bifurcation in the
popliteal fossa as regard complete sensory block time.
Keywords: sciatic nerve block; popliteal fossa; ultrasound-guided.
* MD, Department of Anesthesiology and ICU, Faculty of Medicine, Al-Azhar University, Egypt.
** MD, Department of Anesthesia & ICU ,faculty of medicine , Zagazig University, Egypt.
group 2, the sciatic nerve was identified in a similar and percentage. Nominal non-parametric data were
manner as in group 1, and then traced caudally from analyzed using Chi-Square test. Parametric data
the bifurcation where TN and CPN could be clearly were compared using unpaired t-test. Ordinal non-
identified, then every nerve was injected with 10 ml parametric data were analyzed using Mann-Whitney
levobupivacaine 0.5%. Because most of surgeries U-test. P-values < 0.05 were considered statistically
were performed under proximal tourniquet above the significant.
ankle joint and femoral nerve supply the medial aspect
of the leg and ankle, a saphenous nerve (terminal Results
branch of femoral nerve) block was performed for all
patients. We used below-knee field block approach, All patients completed the study without
with the patient in the supine position by identifying induction of general anesthesia. There was no
and palpation the tibial tuberosity, then Injection of significant difference between groups as regard
10 ml of levobupivacaine 0.5% into the subcutaneous patient’s characteristics, duration of surgery, tourniquet
tissue, beginning at the medial aspect of the tibial
application, and type of surgery (table 1).
tuberosity and ending at the medial border of the tibia
just below its medial condyle, then after 10 minutes Table 1
we evaluated its sensory block by pin prick. TN and Patient’s characteristics and clinical data. Data are expressed
CPN sensory blocks were evaluated with pin prick as mean±SD, number (%).
test on their distribution and it was rated as (0=normal Variable Group 1 Group 2 P
sensation, 1=reduced sensation, and 2=no sensation). (n=20) (n=20) value
The motor block was evaluated using flexion (for Age (years) 35±14 38.7±14 0.6
tibial nerve) or extension (for common peroneal nerve) Weight (kg) 65.5±11 68±7 0.7
of the first toe, and it was rated as (0=normal force, Height (cm) 168.5±8 167±7 0.8
1=reduced force, and 2= total immobility). A score of Sex (male/female) 13/7 15/5 0.5
2/2 was considered a complete sensory-motor block2. ASA (I/II/III) 10/7/3 9/8/3 0.9
The block performance time (time between the initial Duration of surgery 47±1.5 44±2 0.1
skin puncture and the withdrawal of the needle), (minute)
complete sensory and motor blocks (evaluated by an Tourniquet (none/above (8/12) (9/11) 0.74
independent blinded observer) were recorded. During the ankle)
surgery, if the patient complained of pain at the site Duration of Tourniquet 35±1.7 37±5 0.55
of the surgery or tourniquet, fentanyl and midazolam (minute)
were administrated until a maximum dose of 100 mcg Type of Surgery
and 3 mg respectively. If the surgery could not be Foot 9(45%) 8(40%) 0.934
completed under these conditions, a general anesthesia Ankle 5(25%) 5(25%)
Others 6(30%) 7(35%)
was then induced and patient excluded from the
study. Duration of tourniquet, type and duration of
the surgery, and complications including vascular Fentanyl and midazolam IV received intra-
puncture, hematomas, and neurological sequels were operatively, block performance time, and patient’s
recorded. The patients were asked at the end of the satisfaction were comparable between the two groups
procedure to rate their satisfaction with the technique (table 2). The complete sensory block time (sensory
(0=poor, 1=fair, 2=good, 3=excellent). score of 2) in the distribution of the TN and CPN was
significantly increased (P<0.05) in group 1 compared
Statistical Analysis to group 2.
Blood was aspirated but without hematoma
The findings of the groups were statistically formation in two patients, one from each group; another
compared using SPSS version 16 (SPSS Inc., Chicago, one patient in each group complained of paresthesia
IL). Data were expressed as mean±SD, number during the block technique.
M.E.J. ANESTH 23 (2), 2015
174 Magdy H. Eldegwy et. al
nerve at the popliteal level with a posterior approach, as regard fentanyl and midazolam received intra-
at 10 cm from the popliteal skin crease, did not result operatively in all patients, also adverse effects were
in a reduced complete onset time or improved success minimal and comparable which was in agreement of
rate when compared with that obtained with single other studies24,25.
stimulation. March et al6 found that only the superficial
peroneal nerve was blocked earlier in group of double Conclusion
injections than in group of single injection.
Also, the higher rates of complete sensory block Double injections of TN and CPN distal to
in separately block of TN and CPN in our study bifurcation of the sciatic nerve gives faster sensory
in accordance with 3 recent studies demonstrating block onset time compared to single injection of the
enhanced effectiveness of the double injection sciatic nerve proximal to the bifurcation in the popliteal
technique for TN and CPN12,28. fossa.
In our study there were no significant differences
References
1. Marhofer P, Schrogendorfer K, Koinig H, et al: Ultrasonographic 16. Casati A, Baciarello M, Di Cianni S, et al: Effects of ultrasound
guidance improves sensory block and onset time of three in-one guidance on the minimum effective anesthetic volume required to
blocks. Anesth Analg; 85:854-7, 1997. block the femoral nerve. British Journal of Anesthesia; 98:823-7,
2. Casati A, Danelli G, Baciarello M, et al: A prospective randomized 2007.
comparison between ultrasound and nerve stimulation guidance for 17. Casati A, Danelli G, Baciarello M, et al: A prospective randomized
multiple injection axillary brachial plexus block. Anesthesiology; comparison between ultrasound and nerve stimulation guidance for
106:992-6, 2007. multiple injection axillary brachial plexus block. Anesthesiology;
3. Rorie DK, Byer DE, Nelson DO, et al: Assessment of block of the 106:992-6, 2007.
sciatic nerve in the popliteal fossa. Anesth Analg; 59:371-6,1980. 18. Marhofer P, Greher M, Kapral S: Ultrasound guidance in regional
4. McLeod DH, Wong DHW, Claridge RJ, Merrick PM: Lateral anesthesia. British Journal of Anaesthesia; 94:7-17, 2005.
popliteal sciatic nerve block compared with subcutaneous infiltration 19. Foster RH, Markham A: Levobupivacaine: a review of its
for analgesia following foot surgery. Can J Anaesth; 41:673-6, 1994. pharmacology and use as a local anesthetic. Drugs; 59:551-79,
5. Vloka JD, Hadzic A, Lesser JB, et al: A common epineural sheath 2000.
for the nerves in the popliteal fossa and its possible implications for 20. Handoll HH, Koscielniak-Nielsen ZJ: Single, double or multiple
sciatic nerve block. Anesth Analg; 84:387-90, 1997. injection techniques for axillary brachial plexus block for hand,
March X, Pineda O, Garcia MM, et al: The posterior approach 6. wrist or forearm surgery. Cochrane Database Systematic Review;
to the sciatic nerve in the popliteal fossa: a comparison of single- 25:CD003842, 2006.
versus double-injection technique. Anesth Analg; 103:1571-3, 2006. 21. Paqueron X, Bouaziz H, Macalou D, et al: The lateral approach to
7. Rorie DK, Byer DE, Nelson DO, et al: Assessment of block of the the sciatic nerve at the popliteal fossa: one or two injections? Anesth
sciatic nerve in the popliteal fossa. Anesth Analg; 59:371-376, 1980. Analg; 89:1221-5, 1999.
8. Sala-Blanch X, Riva ND, Carrera A, et al: Ultrasound-guided 22. Orebaugh SL, Williams BA, Kentor ML: Ultrasound guidance with
popliteal sciatic block with a single injection at the sciatic division nerve stimulation reduces the time necessary for resident peripheral
results in faster block onset than the classical nerve Stimulator nerve blockade. Reg Anesth Pain Med; 32:448-54, 2007.
Technique. Anesth Analg; 114:1121-1127, 2012. 23. Casati A, Baciarello M, Di Cianni S, et al: Effects of ultrasound
9. Yanaru T, Shigematsu K, Higa K, et al: Medial approach to the guidance on the minimum effective anaesthetic volume required to
sciatic nerve at the popliteal fossa in the supine position with block the femoral nerve. British Journal of Anaesthesia; 98:823-7,
ultrasound guidance and nerve stimulator. ISRN Anesthesiology; 2007.
volume Article ID 676823, 3 pages, 2012. 24. Danelli G, Fanelli A, Ghisi D, et al: Ultrasound vs nerve stimulation
10. Singelyn FJ: Single-injection applications for foot and ankle surgery. multiple injection technique for posterior popliteal sciatic nerve
Best Pract Res Clin Anaenesthesoil; 16:247-254, 2002. block. Anaesthesia; 64:638-642, 2009.
11. McCartney CJL, Braune I and Chan VWS: Ultrasound guidance 25. Dufour E, Quennesson P, Van Robais AL, et al: Combined
for a lateral approach to the sciatic nerve in the popliteal fossa. ultrasound and neuro-stimulation guidance for popliteal sciatic
Anaesthesia; 59:1023-1025, 2004. nerve block: a prospective, randomized comparison with neuro-
12. Buys MJ, Arndt CD, Vagh F, Hoard A and Gerstein N: Ultrasound- stimulation alone. Regional Anesthesia; 106:1553-8, 2008.
guided sciatic nerve block in the popliteal fossa using a lateral 26. Perlas A, Brull R, Chan VWS, Nuica A, Abbas S: Ultrasound
approach: onset time comparing separate tibial and common peroneal guidance improves the success of sciatic nerve block at the popliteal
nerve injections versus injecting proximal to the bifurcation. Anesth fossa. Reg Anesth Pain Med; 33:259-65, 2008.
Analg; 110:635-637, 2010. 27. Arcioni R, Palmasani S, et al: Lateral popliteal sciatic nerve block:
13. Handoll HH, Koscielniak-Nielsen ZJ: Single, double or multiple a single injection targeting the tibial branch of the sciatic nerve is as
injection techniques for axillary brachial plexus block for hand, effective as a double-injection technique. Acta Anaesthesiol Scand;
wrist or forearm surgery. Cochrane Database Systematic Review; 51:115-121, 2007.
25:CD003842, 2006. 28. Prasad A, Perlas A, Ramlogan R, Brull R, Chan V: Ultrasound-
14. Paqueron X, Bouaziz H, Macalou D, et al: The lateral approach to guided popliteal block distal to sciatic nerve bifurcation shortens
the sciatic nerve at the popliteal fossa: one or two injections? Anesth onset time: a prospective randomized double-blind study. Reg
Analg; 89:1221-5, 1999. Anesth Pain Med; 35:267-71, 2010.
15. Orebaugh SL, Williams BA, Kentor ML: Ultrasound guidance 29. Germain G, Le´vesque S, Dion N, et al: A Comparison of an
with nerve stimulation reduces the time necessary for with nerve Injection Cephalad or Caudad to the Division of the Sciatic Nerve
stimulation reduces the time necessary for resident peripheral nerve for Ultrasound-Guided Popliteal Block: A Prospective Randomized
blockade. Regional Pain Medicine; 32: 448-54, 2007. Study. Anesth Analg; 114:233-5, 2012.
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References:
1. Talon M. et al., J Burn Care Research 2009; 30: 599-605.
2. MAD (Mucosal Atomization Device) Medical Atomizer in Vitro Spray
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