topics / مواضيع: ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic part 05

ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic part 05

TABLE 12-2 Common Problems During Nerve Localization and the Corrective Action

TIPS

Always assess the risk-benefit ratio of using large volumes and concentrations of long-acting local

anesthetic for interscalene brachial plexus block.

Smaller volumes and concentrations can be used successfully (e.g., 15–20 mL). However failure rate

may be somewhat higher because the spread of local anesthetic can be seen as is the case with

ultrasound guidance.

Block Dynamics and Perioperative Management

When stimulation with a low-intensity current and slow needle advancement are used, interscalene

brachial plexus block is associated with minor patient discomfort. Excessive sedation is not only

unnecessary but also potentially disadvantageous because patient cooperation during landmark

assessment and block performance is beneficial. The administration of benzodiazepines also may

decrease the tone of the scalene and sternocleidomastoid muscles, making their recognition more

difficult. We typically use small doses of midazolam (e.g., 1–2 mg) and/or short acting opioid (e.g.,

alfentanyl 250-500 mcg), so that the patient is comfortable and cooperative during nerve localization.

The onset time of this block is relatively short. The first sign of the blockade is typically a loss of

coordination of the shoulder and arm muscles. This sign is seen sooner than the onset of a sensory

blockade or a temperature change and, when observed within 1 to 2 minutes after injection, is highly

predictive of a successful brachial plexus blockade. In patients undergoing shoulder arthroscopic

procedures, it is important to note that the arthroscopic portals are often inserted outside the

cutaneous distribution of the interscalene block. Local infiltration at the site of the incision by the

surgeon is all that is needed because the entire shoulder joint and deep tissues are anesthetized with

the interscalene block alone.

Education of the patient regarding block effects and side effects is important with interscalene

block. Patients should be instructed to take prescribed oral analgesics and use ice packs before the

block resolves. This regimen is of particular importance with ambulatory patients who may

experience significant pain after discharge if they are unprepared.

TIPS

Due to blockade of neighboring neural structures, many patients develop a hoarse voice (recurrent

laryngeal nerve), mild ipsilateral ptosis and miosis, and nasal congestion (Horner syndrome:

sympathetic chain) following an interscalene block. A proper explanation and reassurance are all that

such patients need.

Interscalene block inevitably results in ipsilateral diaphragmatic paralysis (a phrenic nerve block).

The significance of this is debated, and avoidance of this block is suggested in patients with severe

chronic respiratory disease, especially restrictive lung diseases. Patients with chronic obstructive

pulmonary disease often already have diaphragms that are flattened and inefficient, and the subsequent

paresis is thought to have a limited effect on these individuals.

We avoid the use of this block only in patients whose breathing involves the use of accessory

respiratory muscles.

Appropriate intravenous sedation, communication with the patient, lifting drapes off the patient’s face,

and shielding the ears from noise are all necessary ingredients for success with interscalene blocks in

patients undergoing shoulder surgery.

Continuous Interscalene Block

A continuous interscalene block is a more advanced regional anesthesia technique, and adequate

experience with the single-injection technique is necessary. Paradoxically, although a single-injection

interscalene block is one of the easiest intermediate techniques to perform and master, placement of

the catheter can be one of the more technically challenging procedures. This is because the shallow

position of the brachial plexus does not allow for an easy needle stabilization during catheter

advancement and catheters can easily get dislodged during needle withdrawal. Otherwise, the

technique is similar to the single-injection procedure, apart from a slight difference in the angle of the

needle. This procedure provides excellent analgesia in patients following shoulder, arm, and elbow

surgery.

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

2 × 20-mL syringes containing local anesthetic

Sterile gloves, marking pen, and surface electrode

A 3-mL syringe and 25-gauge needle with local anesthetic for skin infiltration

Peripheral nerve stimulator

Catheter kit (including a 4- to 5-cm large-gauge stimulating needle and catheter)

Kits come in two varieties based on catheter construction: nonstimulating (conventional) and

stimulating catheters. During the placement of a conventional nonstimulating catheter, the stimulating

needle is first advanced until appropriate twitches are obtained. Then, 5 to 10 mL of local anesthetic

or other injectate (e.g., dextrose 5% in water) can be injected to “open up” a space for the catheter to

advance freely without resistance. The catheter is then inserted through the needle approximately 3 to

5 cm beyond the tip of the needle. The needle is withdrawn, the catheter is secured, and the remaining

local anesthetic is injected via the catheter. Stimulating catheters are insulated and have a filament or

core that transmits current to a bare metal tip. After obtaining twitches with the needle, the catheter is

advanced with the nerve stimulator connected until the anesthesiologist is satisfied with the quality of

the motor response. If the twitch is lost, the catheter may be withdrawn until it reappears, and the

catheter is readvanced. This method requires no conducting solution to be injected through the needle

(i.e., local anesthetic, saline) before catheter advancement, or difficulty obtaining a motor response

will result.

Landmarks and Patient Positioning

The patient is in the same position as for the single-injection technique. However, it is imperative that

the anesthesiologist assume an ergonomic position to allow maneuvering during catheter insertion. It

is often easiest for the clinician to stand at the head of the bed to avoid inserting the needle at an

awkward angle because it is desirable to advance the catheter in an inferolateral direction (i.e., the

same direction as the plexus). It is also important that all equipment, including the catheter, be

immediately available and prepared in advance because small movements of the needle that might

occur while trying to prepare the catheter can result in dislodging the needle from its position in the

brachial plexus sheath.

The landmarks for a continuous interscalene brachial plexus block are similar to those for the

single-shot technique:

. Clavicle

. Posterior border of the clavicular head of the sternocleidomastoid muscle

. External jugular vein

Technique

The subcutaneous tissue at the projected site of needle insertion is anesthetized with local anesthetic.

The block needle is attached to a nerve stimulator (1.0 mA, 2 Hz, 0.1 ms). With this technique, the

palpating hand must firmly stabilize the skin to facilitate needle insertion and insertion of the catheter.

A 3- to 5-cm block needle is inserted in the interscalene groove, with a more pronounced caudal

angle than the single-shot technique, and advanced until the brachial plexus twitch is elicited at 0.2 to

0.5 mA. Precautions should be taken to avoid inserting the needle through the external jugular vein

because this invariably results in prolonged oozing from the site of puncture. This can be avoided by

retracting the external jugular vein and inserting the needle slightly in front of or posteriorly to the

external jugular vein. Paying meticulous attention to the position of the needle, the catheter is inserted

no more than 3 to 5 cm beyond the tip of the needle (Figure 12-10).

FIGURE 12-10. Insertion of a catheter into the interscalene space. Insertion of the catheter often

requires lowering of the needle angle to facilitate catheter passage. Catheters are typically inserted 3–

5 cm past the needle tip to prevent inadvertent removal.

TIPS

The most challenging aspect of this technique is stabilization of the needle for catheter insertion after

the brachial plexus is localized.

When the needle encounters the brachial plexus at a very shallow location, it is helpful to have an

assistant advance the catheter in a sterile fashion to ensure that the needle does not move from its

original position.

In patients with less than ideal landmarks, it may be prudent to first use a single-shot needle to localize

the brachial plexus and to determine the needle insertion point and proper angulation before inserting

a large-gauge continuous block needle.

The catheter is secured using an adhesive skin preparation such as benzoin, followed by

application of a clear dressing. Several securing devices are also commercially available. The

infusion port should be clearly marked “continuous nerve block,” and the catheter should be carefully

checked for intravascular placement before administering a bolus or infusion of local anesthetics.

Management of the Continuous Infusion

Continuous infusion is initiated after an initial bolus of dilute local anesthetic is administered through

the needle or catheter. For this purpose, we routinely use 0.2% ropivacaine 15 to 20 mL. Diluted

bupivacaine or levobupivacaine are suitable also but can result in greater motor blockade. Other

adjuvants (clonidine, epinephrine, or opioids) do not appear to be of benefit in continuous nerve

blocks. The infusion is maintained at 5 mL/h when a dose of patient-controlled regional analgesia

(PCRA) (5 mL every 30-60 minutes) is planned. Additional catheter management directions are also

discussed in Chapter 7.

Inpatients should be seen and instructed on the use of PCRA at least once a day. During each visit,

the insertion site should be checked for erythema and swelling and the extent of motor and sensory

blockade documented. The infusion and PCRA dose should be adjusted accordingly. When the patient

complains of breakthrough pain, the extent of the blockade should be checked first. A bolus of dilute

local anesthetic (e.g., 10–15 mL of 0.2% ropivacaine) can be injected to reactivate the catheter.

Increasing the infusion rate alone never results in improvement in analgesia. When the bolus fails to

result in blockade after 30 minutes, the catheter should be considered to have migrated and should be

removed. Alternatively, where equipment and expertise is available, the position of the catheter can

be confirmed ultrasonographically by documenting the location of an injection bolus through the

catheter. Every patient receiving a continuous nerve block infusion should be prescribed an

immediately available alternative pain management protocol because incomplete analgesia and

catheter dislodgment can occur. Complications of interscalane brachial plexus blocks and means of

their prevention are listed in Table 12-3.

TABLE 12-3 Complications and How to Avoid Them

TIPS

Breakthrough pain in patients undergoing continuous infusion is always managed by administering a

bolus of local anesthetic. Increasing the rate of infusion alone is rarely adequate.

For patients on the ward, a small bolus (e.g. 5 mL) of a shorter acting, higher concentration

epinephrine-containing local anesthetic (e.g., 1% mepivacaine or lidocaine with 1:300,000

epinephrine) can be used to test the position of the catheter; failure to obtain a sensory block indicates

catheter migration.

INTERSCALENE BRACHIAL PLEXUS BLOCK: DECISION MAKING ALGORITHM

SUGGESTED READINGS

Adam F, Menigaux C, Sessler DI, Chauvin M. A single preoperative dose of gabapentin (800

milligrams) does not augment postoperative analgesia in patients given interscalene brachial plexus

blocks for arthroscopic shoulder surgery. Anesth Analg. 2006;103:1278-1282.

Agostoni M, Marchesi M, Fanelli G, Reineke R. Analgesic brachial plexus block for reduction of

shoulder dislocation. Reg Anesth. 1996;21:373.

Aguirre J, Ekatodramis G, Ruland P, Borgeat A: Interscalene block should she a block for shoulder and

proximal humerus sugery, and nothing else. J Clin Anesth 2010;22.

Alemanno F, Capozzoli G, Egarter-Vigl E, Gottin L, Alberto B. The middle interscalene block: cadaver

study and clinical assessment. Reg Anesth Pain Med. 2006;31:563-568.

Altintas F, Gumus F, Kaya G, et al. Interscalene brachial plexus block with bupivacaine and

ropivacaine in patients with chronic renal failure: diaphragmatic excursion and pulmonary function

changes. Anesth Analg. 2005;100:1166-1171.

Arcas-Bellas JJ, Cassinello F, Cercos B, del Valle M, Leal V, Alvarez-Rementeria R. Delayed

quadriparesis after an interscalene brachial plexus block and general anesthesia: a differential

diagnosis. Anesth Analg. 2009;109:1341-1343.

Barak M, Iaroshevski D, Poppa E, Ben-Nun A, Katz Y. Low-volume interscalene brachial plexus block

for post-thoracotomy shoulder pain. J Cardiothorac Vasc Anesth. 2007;21:554-557.

Baskan S, Taspinar V, Ozdogan L, Gulsoy KY, Erk G, Dikmen B, Gogus N: Comparison of 0.25%

levobupivacaine and 0.25% bupivacaine for posterior approach interscalene brachial plexus block. J

Anesth 2010;24:38-42.

Baskan S, Taspinar V, Ozdogan L, et al. Comparison of 0.25% levobupivacaine and 0.25% bupivacaine

for posterior approach interscalene brachial plexus block. J Anesth. 2010;24:38-42.

Beaudet V, Williams SR, Tetreault P, Perrault MA. Perioperative interscalene block versus intraarticular injection of local anesthetics for postoperative analgesia in shoulder surgery. Reg Anesth

Pain Med. 2008;33:134-138.

Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block

performed under general anesthesia. Anesthesiology. 2000;93:1541-1544.

Bittar DA. Attempted interscalene block procedures. Anesthesiology. 2001;95:1303-1304.

Blumenthal S, Jutzi H, Borgeat A. Is the interscalene brachial plexus block the best approach? Anesth

Analg. 2006;102:652-653; author reply 653.

Blumenthal S, Nadig M, Borgeat A. Pectoralis major motor for interscalene block: what to do with it?

Reg Anesth Pain Med. 2003;28:155.

Bollini CA, Urmey WF, Vascello L, Cacheiro F. Relationship between evoked motor response and

sensory paresthesia in interscalene brachial plexus block. Reg Anesth Pain Med. 2003;28:384-388.

Borgeat A, Ekatodramis G, Blumenthal S. Interscalene brachial plexus anesthesia with ropivacaine 5

mg/mL and bupivacaine 5 mg/mL: effects on electrocardiogram. Reg Anesth Pain Med. 2004;29:557-

563.

Borgeat A, Ekatodramis G, Gaertner E. Performing an interscalene block during general anesthesia must

be the exception. Anesthesiology. 2001;95:1302-1303.

Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with

interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001;95:875-880.

Borgeat A, Kalberer F, Jacob H, Ruetsch YA, Gerber C. Patient-controlled interscalene analgesia with

ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on hand

motor function. Anesth Analg. 2001;92:218-223.

Brown DL, Bridenbaugh LD. The upper extremity: somatic block. In: Cousins MJ, Bridenbaugh PO,

eds. Neuronal Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA:

Lippincott-Raven; 1988:345-371.

Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia:

contemporary estimates of risk. Anesth Analg. 2007;104:965-974.

Brull R, Wijayatilake DS, Perlas A, et al. Practice patterns related to block selection, nerve

localization and risk disclosure: a survey of the American Society of Regional Anesthesia and Pain

Medicine. Reg Anesth Pain Med. 2008;33:395-403.

Candido KD, Sukhani R, Doty R Jr, et al. Neurologic sequelae after interscalene brachial plexus block

for shoulder/upper arm surgery: the association of patient, anesthetic, and surgical factors to the

incidence and clinical course. Anesth Analg. 2005;100:1489-1495.

Casati A, Borghi B, Fanelli G, et al. Interscalene brachial plexus anesthesia and analgesia for open

shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and

ropivacaine. Anesth Analg. 2003;96:253-259.

Casati A, Chelly JE. Neurological complications after interscalene brachial plexus blockade: what to

make of it? Anesthesiology. 2002;97:279-280.

Casutt M, Ekatodramis G, Maurer K, Borgeat A. Projected complex sensations after interscalene

brachial plexus block. Anesth Analg. 2002;94:1270-1271.

Chelly JE, Greger J, Gebhard R, Casati A. How to prevent catastrophic complications when performing

interscalene blocks. Anesthesiology. 2001;95:1302.

Choquet O, Jochum D, Estebe JP, Dupre LJ, Capdevila X. Motor response following paresthesia during

interscalene block: methodological problems may lead to inappropriate conclusions. Anesthesiology.

2003;98:587-588.

Christ S, Rindfleisch F, Friederich P. Superficial cervical plexus neuropathy after single-injection

interscalene brachial plexus block. Anesth Analg. 2009;109:2008-2011.

Cohen JM, Gray AT: Functional deficits after intraneural injection during interscalene block. Reg

Anesth Pain Med 2010;35:397-399.

Coleman MM, Peng P. Pectorialis major in interscalene brachial plexus blockade. Reg Anesth Pain

Med. 1999;24:190-191.

Crews JC, Rothman TE. Seizure after levobupivacaine for interscalene brachial plexus block. Anesth

Analg. 2003;96:1188-1190.

Culebras X, Van Gessel E, Hoffmeyer P, Gamulin Z. Clonidine combined with a long acting local

anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce

hemodynamic changes. Anesth Analg. 2001;92:199-204.

Delaunay L, Souron V, Lafosse L, Marret E, Toussaint B. Analgesia after arthroscopic rotator cuff

repair: subacromial versus interscalene continuous infusion of ropivacaine. Reg Anesth Pain Med.

2005;30:117-122.

Devera HV, Furukawa KT, Scavone JA, Matson M, Tumber S. Interscalene blocks in anesthetized

pediatric patients. Reg Anesth Pain Med. 2009;34:603-604.

Ekatodramis G, Borgeat A. The “interscalene triangular swelling”: an early sign for successful

interscalene brachial plexus block. Reg Anesth Pain Med. 2000;25:662-663.

Eroglu A, Uzunlar H, Sener M, Akinturk Y, Erciyes N. A clinical comparison of equal concentration

and volume of ropivacaine and bupivacaine for interscalene brachial plexus anesthesia and analgesia

in shoulder surgery. Reg Anesth Pain Med. 2004;29:539-543.

aryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center

performing predominantly regional anesthesia: a prospective study of one hundred thirty-three

patients undergoing shoulder surgery. J Shoulder Elbow Surg. 2006;15:686-690.

Gadsden JC, Tsai T, Iwata T, Somasundarum L, Robards C, Hadžić A. Low interscalene block

provides reliable anesthesia for surgery at or about the elbow. J Clin Anesth. 2009;21:98-102.

Ganesh A. Interscalene brachial plexus block-anatomic considerations. Reg Anesth Pain Med.

2009;34:525.

Hadžić A, Vloka JD, Claudio RE, Hadžić N, Thys DM, Santos AC. Electrical nerve localization:

effects of cutaneous electrode placement and duration of the stimulus on motor response.

Anesthesiology. 2004;100:1526-1530.

Hadžić A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ. The practice of peripheral nerve blocks in

the United States: a national survey [p2e comments]. Reg Anesth Pain Med. 1998;23:241-246.

Hadžić A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia

provides superior same-day recovery over general anesthesia. Anesthesiology. 2005;102: 1001-

1007.

Harrop-Griffiths W, Denny N. Is a deltoid twitch a satisfactory endpoint for all interscalene blocks?

Reg Anesth Pain Med. 2001;26:182-183.

Hermanns H, Braun S, Werdehausen R, Werner A, Lipfert P, Stevens MF. Skin temperature after

interscalene brachial plexus blockade. Reg Anesth Pain Med. 2007;32:481-487.

Hingorani AP, Ascher E, Gupta P, et al. Regional anesthesia: preferred technique for venodilatation in

the creation of upper extremity arteriovenous fistulae. Vascular. 2006;14:23-26.

Homer JR, Davies JM, Amundsen LB. Persistent hiccups after attempted interscalene brachial plexus

block. Reg Anesth Pain Med. 2005;30:574-576.

feld BM, Wright TW, Enneking FK, et al. Total shoulder arthroplasty as an outpatient procedure using

ambulatory perineural local anesthetic infusion: a pilot feasibility study. Anesth Analg.

2005;101:1319-1322.

skandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B. The analgesic effect of interscalene

block using clonidine as an analgesic for shoulder arthroscopy. Anesth Analg. 2003;96:260-262.

skandar H, Wakim N, Benard A, et al. The effects of interscalene brachial plexus block on humeral

arterial blood flow: a Doppler ultrasound study. Anesth Analg. 2005;101:279-281.

afari S, Kalstein AI, Nasrullah HM, Hedayatnia M, Yarmush JM, SchianodiCola J. A randomized,

prospective, double-blind trial comparing 3% chloroprocaine followed by 0.5% bupivacaine to 2%

lidocaine followed by 0.5% bupivacaine for interscalene brachial plexus block. Anesth Analg.

2008;107:1746-1750.

Karaca P, Hadžić A, Yufa M, et al. Painful paresthesiae are infrequent during brachial plexus

localization using low-current peripheral nerve stimulation. Reg Anesth Pain Med. 2003;28:380-383.

Kempen PM, O’Donnell J, Lawler R, Mantha V. Acute respiratory insufficiency during interscalene

plexus block. Anesth Analg. 2000;90:1415-1416.

Klein SM, Nielsen KC, Martin A, et al. Interscalene brachial plexus block with continuous

intraarticular infusion of ropivacaine. Anesth Analg. 2001;93:601-605.

Klein SM, Pietrobon R, Nielsen KC, Warner DS, Greengrass RA, Steele SM. Peripheral nerve

blockade with long-acting local anesthetics: a survey of the Society for Ambulatory Anesthesia.

Anesth Analg. 2002;94: 71-76.

Koorn R, Tenhundfeld Fear KM, Miller C, Boezaart A. The use of cervical paravertebral block as the

sole anesthetic for shoulder surgery in a morbid patient: a case report. Reg Anesth Pain Med.

2004;29:227-229.

Krone SC, Chan VW, Regan J, et al. Analgesic effects of low-dose ropivacaine for interscalene

brachial plexus block for outpatient shoulder surgery—a dose-finding study. Reg Anesth Pain Med.

2001;26:439-443.

Langen KE, Candido KD, King M, Marra G, Winnie AP. The effect of motor activity on the onset and

progression of brachial plexus block with bupivacaine: a randomized prospective study in patients

undergoing arthroscopic shoulder surgery. Anesth Analg. 2008;106:659-663.

Lierz P, Gustorff B, Felleiter P. Pain therapy with interscalene local anesthetic. Anesth Analg.

2001;93:1624.

Liguori GA, Zayas VM, YaDeau JT, et al. Nerve localization techniques for interscalene brachial

plexus blockade: a prospective, randomized comparison of mechanical paresthesia versus electrical

stimulation. Anesth Analg. 2006;103:761-767.

Long TR, Wass CT, Burkle CM. Perioperative interscalene blockade: an overview of its history and

current clinical use. J Clin Anesth. 2002;14:546-556.

Marhofer P, Harrop-Griffiths W, Willschke H, Kirchmair L. Fifteen years of ultrasound guidance in

regional anaesthesia: Part 2—recent developments in block techniques. Br J Anaesth. 2010;104:673-

683.

Maurer K, Ekatodramis G, Rentsch K, Borgeat A. Interscalene and infraclavicular block for bilateral

distal radius fracture. Anesth Analg. 2002;94:450-452.

Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of the brachial plexus and surrounding

compartments, and their possible significance for plexus blocks. Anesthesiology. 2008;108:299-304.

Nadig M, Blumenthal S, Ekatodramis G, Borgeat A. Interscalene brachial plexus anesthesia and

analgesia for open shoulder surgery: what about pharmacokinetics? Anesth Analg. 2003;97: 605-606.

Naik VN, Perlas A, Chandra DB, Chung DY, Chan VW. An assessment tool for brachial plexus regional

anesthesia performance: establishing construct validity and reliability. Reg Anesth Pain Med.

2007;32:41-45.

Neal JM, McDonald SB, Larkin KL, Polissar NL. Suprascapular nerve block prolongs analgesia after

nonarthroscopic shoulder surgery but does not improve outcome. Anesth Analg. 2003;96:982-986.

Orebaugh SL, Williams BA, Vallejo M, Kentor ML. Adverse outcomes associated with stimulatorbased peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med.

2009;34:251-255.

aqueron X, Gentili ME, Willer JC, Coriat P, Riou B. Time sequence of sensory changes after upper

extremity block: swelling sensation is an early and accurate predictor of success. Anesthesiology.

2004;101:162-168.

atel V, Hadzic A, Gadsden J, Gandhi K: An electrocardiopraph artifact caused by peripheral nerve

stimulation during an interscalene brachial plexus nerve block. Reg Anesth Pain Med 2010; 35:118-

Raj PP. Textbook of Regional Anesthesia. London, UK: Churchill Livingstone; 2002.

Reuben SS. Interscalene block superior to general anesthesia. Anesthesiology. 2006;104:207.

Robaux S, Bouaziz H, Boisseau N, Raucoules-Aime M, Laxenaire MC. Persistent phrenic nerve

paralysis following interscalene brachial plexus block. Anesthesiology. 2001;95:1519-1521.

Rose M, Ness TJ. Hypoxia following interscalene block. Reg Anesth Pain Med. 2002;27:94-96.

ardesai AM, Patel R, Denny NM, et al. Interscalene brachial plexus block: can the risk of entering the

spinal canal be reduced? A study of needle angles in volunteers undergoing magnetic resonance

imaging. Anesthesiology. 2006;105:9-13.

ciard D, Matuszczak M, Gebhard R, Kocieniewska D. Interscalene block-, sedation-, lateral

positioning-, and hydralazine-induced hypotension: is it really prudent? Anesthesiology.

2002;97:280-281.

ia S, Sarro F, Lepri A, Bartoli M. The effect of exogenous epinephrine on the incidence of

hypotensive/bradycardic events during shoulder surgery in the sitting position during interscalene

block. Anesth Analg. 2003;97:583-588.

ilverstein WB, Saiyed MU, Brown AR. Interscalene block with a nerve stimulator: a deltoid motor

response is a satisfactory endpoint for successful block. Reg Anesth Pain Med. 2000;25: 356-359.

ingelyn FJ. Difficult insertion of interscalene brachial plexus catheter. Anesth Analg. 2001;92:1074.

ingelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery: a comparison of

intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth

Analg. 2004;99:589-592.

ukhani R, Candido KD. Interscalene brachial plexus block: shoulder paresthesia versus deltoid motor

response: revisiting the anatomy to settle the controversy. Anesth Analg. 2002;95:1818; author reply

1818-1819.

Tonidandel WL, Mayfield JB. Successful interscalene block with a nerve stimulator may also result

after a pectoralis major motor response. Reg Anesth Pain Med. 2002;27:491-493.

Urmey WF. Interscalene block: the truth about twitches. Reg Anesth Pain Med. 2000;25:340-342.

Urmey WF. Is a deltoid twitch a satisfactory endpoint for all interscalene blocks? Reg Anesth Pain

Med. 2001;26:183.

Urmey WF, Stanton J. Inability to consistently elicit a motor response following sensory paresthesia

during interscalene block administration. Anesthesiology. 2002;96:552-554.

Walton JS, Folk JW, Friedman RJ, Dorman BH. Complete brachial plexus palsy after total shoulder

arthroplasty done with interscalene block anesthesia. Reg Anesth Pain Med. 2000;25:318-321.

Weber SC, Parise CA, Jain R. Interscalene block superior to general anesthesia: a discussion of the

conclusions regarding these two anesthesia techniques. Anesthesiology. 2006;104:208.

Whitaker EE, Edelman AL, Wilkens JH, Richman JM: Severe hypotension after interscalene block for

outpatient shoulder surgery: a case report. J Clin Anesth 2010;22:132-134.

White JL. Catastrophic complications of interscalene nerve block. Anesthesiology. 2001;95:1301.

Winnie AP. Interscalene brachial plexus block. Anesth Analg. 1970;49:455-466.

Winnie AP. Plexus Anesthesia, Perivascular Techniques of Brachial Plexus Block. 2nd ed.

Philadelphia, PA: Saunders; 1990.

Wong GY, Brown DL, Miller GM, Cahill DR. Defining the cross-sectional anatomy important to

interscalene brachial plexus block with magnetic resonance imaging. Reg Anesth Pain Med.

1998;23:77-80.

Wurm WH, Concepcion M, Sternlicht A, et al. Preoperative interscalene block for elective shoulder

surgery: loss of benefit over early postoperative block after patient discharge to home. Anesth Analg.

2003;97:1620-1626.

Continuous Interscalene Brachial Plexus Block

Blumenthal S, Nadig M, Borgeat A. The analgesic effect of interscalene block using clonidine as an

analgesic for shoulder arthroscopy: where is the catheter? Anesth Analg. 2003;97:928.

Borgeat A, Aguirre J, Curt A. Case scenario: neurologic complication after continuous interscalene

block. Anesthesiology. 2010;112:742-745.

Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for

continuous interscalene block after shoulder surgery. Anesthesiology. 2003;99:436-442.

Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with

ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery:

effects on diaphragmatic and respiratory function. Anesthesiology. 2000;92:102-108.

Borgeat A, Aguirre J, Curt A: Case scenario: neurologic complication after continuous interscalene

block. Anesthesiology 2010; 112: 742-5.

Capdevila X, Dadure C, Bringuier S, et al. Effect of patient-controlled perineural analgesia on

rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial.

Anesthesiology. 2006;105:566-573.

Capdevila X, Jaber S, Pesonen P, Borgeat A, Eledjam JJ. Acute neck cellulitis and mediastinitis

complicating a continuous interscalene block. Anesth Analg. 2008;107:1419-1421.

Chelly JE, Casati A, Fanelli G. Continuous Peripheral Nerve Block Techniques: An Illustrated Guide.

London, UK: Mosby International; 2001.

Clendenen SR, Robards CB, Wang RD, Greengrass RA. Case report: continuous interscalene block

associated with neck hematoma and postoperative sepsis. Anesth Analg. 2010;110:1236-1238.

Clendenen SR, Robards CB, Wang RD, Greengrass RA: Case report: continuous interscalene block

associated with neck hematoma and postoperative sepsis. Anesth Analg 2010;110: 1236-1238.

Coleman MM, Chan VW. Continuous interscalene brachial plexus block. Can J Anaesth. 1999;46:209-

214.

Despond O, Kohut GN. Broken interscalene brachial plexus catheter: surgical removal or not? Anesth

Analg. 2010;110:643-644.

Dooley J, Fingerman M, Melton S, Klein SM: Contralateral local anesthetic spread from an outpatient

interscalene catheter. Can J Anaesth 2010;10:936-939.

Ekatodramis G, Borgeat A, Huledal G, Jeppsson L, Westman L, Sjovall J. Continuous interscalene

analgesia with ropivacaine 2 mg/ml after major shoulder surgery. Anesthesiology. 2003;98:143-150.

Ekatodramis G, Macaire P, Borgeat A. Prolonged Horner syndrome due to neck hematoma after

continuous interscalene block. Anesthesiology. 2001;95:801-803.

aust A, Fournier R, Hagon O, Hoffmeyer P, Gamulin Z. Partial sensory and motor deficit of ipsilateral

lower limb after continuous interscalene brachial plexus block. Anesth Analg. 2006;102:288-290.

redrickson MJ, Abeyeskera A, Price DJ, Wong AC: Patient-initiated mandatory boluses for

ambulatory continuous interscalene analgesia: an effective strategy for optimizing analgesia and

minimizing side-effects. Br J Anaesth 2011; 106:239-245.

redrickson MJ, Ball CM, Dalgleish AJ. Successful continuous interscalene analgesia for ambulatory

shoulder surgery in a private practice setting. Reg Anesth Pain Med. 2008;33:122-128.

redrickson MJ, Ball CM, Dalgeish AJ: Analgesic effectiveness of a continuous versus single-injection

intersclane block for minor arthroscopic shoulder surgery. Reg Anesth Pain Med 2010;35:28-33.

redrickson MJ, Ball CM, Dalgleish AJ: A prospective randomized comparison of ultrasound guidance

versus neurotimulation for interscalene catheter placement. Reg Anesth Pain Med 2009;34: 590-594.

Hofmann-Kiefer K, Eiser T, Chappell D, Leuschner S, Conzen P, Schwender D. Does patientcontrolled continuous interscalene block improve early functional rehabilitation after open shoulder

surgery? Anesth Analg. 2008;106:991-996.

Horlocker TT, O’Driscoll SW, Dinapoli RP. Recurring brachial plexus neuropathy in a diabetic patient

after shoulder surgery and continuous interscalene block. Anesth Analg. 2000;91:688-690.

Horlocker TT, Weiss WT, Olson CA. Whodunnit: the mysterious case of mediastinitis after continuous

interscalene block. Anesth Analg. 2008;107:1095-1097.

feld BM, Enneking FK. A portable mechanical pump providing over four days of patient-controlled

analgesia by perineural infusion at home. Reg Anesth Pain Med. 2002;27:100-104.

feld BM, Morey TE, Thannikary LJ, Wright TW, Enneking FK. Clonidine added to a continuous

interscalene ropivacaine perineural infusion to improve postoperative analgesia: a randomized,

double-blind, controlled study. Anesth Analg. 2005;100:1172-1178.

feld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus

block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled

study. Anesth Analg. 2003;96:1089-1095.

feld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine

infusion:a comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med.

2004;29:9-16.

feld BM, Vandenborne K, Duncan PW, et al. Ambulatory continuous interscalene nerve blocks

decrease the time to discharge readiness after total shoulder arthroplasty: a randomized, triplemasked, placebo-controlled study. Anesthesiology. 2006;105:999-1007.

Ilfeld BM, Wright TW, Enneking FK, Morey TE. Joint range of motion after total shoulder arthroplasty

with and without a continuous interscalene nerve block: a retrospective, case-control study. Reg

Anesth Pain Med. 2005;30:429-433.

Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous

catheter insertion system and a disposable infusion pump. Anesth Analg. 2000;91:1473-1478.

Le LT, Loland VJ, Mariano ER, et al. Effects of local anesthetic concentration and dose on continuous

interscalene nerve blocks: a dual-center, randomized, observer-masked, controlled study. Reg AnesthPain Med. 2008;33:518-525.

Lehtipalo S, Koskinen LO, Johansson G, Kolmodin J, Biber B. Continuous interscalene brachial plexus

block for postoperative analgesia following shoulder surgery. Acta Anaesthesiol Scand.

1999;43:258-264.

Macfarlane AJ, Brull R. Continuous interscalene block for open shoulder surgery. Anesth Analg.

2008;107:726.

Maurer K, Ekatodramis G, Hodler J, Rentsch K, Perschak H, Borgeat A. Bilateral continuous

interscalene block of brachial plexus for analgesia after bilateral shoulder arthroplasty.

Anesthesiology. 2002;96:762-764.

Pere P, Pitkanen M, Rosenberg PH, et al. Effect of continuous interscalene brachial plexus block on

diaphragm motion and on ventilatory function. Acta Anaesthesiol Scand. 1992; 36:53-57.

Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home:

controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia.

Anesthesiology. 2002;96:1290-1296.

Sandefo I, Bernard JM, Elstraete V, et al. Patient-controlled interscalene analgesia after shoulder

surgery: catheter insertion by the posterior approach. Anesth Analg. 2005;100:1496-1498.

Sardesai AM, Chakrabarti AJ, Denny NM. Lower lobe collapse during continuous interscalene brachialplexus local anesthesia at home. Reg Anesth Pain Med. 2004;29:65-68.

Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder

surgery: continuous versus patient-controlled infusion. Anesth Analg. 1999;89: 1216-1220.

Souron V, Reiland Y, Delaunay L. Pleural effusion and chest pain after continuous interscalene brachial

plexus block. Reg Anesth Pain Med. 2003;28:535-538.

Souron V, Reiland Y, De Traverse A, Delaunay L, Lafosse L. Interpleural migration of an interscalene

catheter. Anesth Analg. 2003;97:1200-1201.

Stevens MF, Werdehausen R, Golla E, et al. Does interscalene catheter placement with stimulating

catheters improve postoperative pain or functional outcome after shoulder surgery? A prospective,

randomized and double-blinded trial. Anesth Analg. 2007;104:442-447.

Vranken JH, van der Vegt MH, Zuurmond WW, Pijl AJ, Dzoljic M. Continuous brachial plexus block at

the cervical level using a posterior approach in the management of neuropathic cancer pain. Reg

Anesth Pain Med. 2001;26:572-575.

Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and adverse effects

associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg.

2007;104:1578-1582.

Supraclavicular Brachial Plexus Block

FIGURE 13-1. Insertion of the needle in the supraclavicular brachial plexus block. The needle is

inserted lateral to the insertion of the clavicular head of the sternocleidomastoid muscle.

Supraclavicular Block

General Considerations

The supraclavicular approach to the brachial plexus characteristically is associated with a rapid

onset of anesthesia and a high success rate. The first percutaneous supraclavicular block was

performed by Kulenkampff in Germany in 1911, reportedly on himself. A few months after, Hirschel

described a method of brachial plexus with an axillary approach. In 1928, Kulenkampff and Persky

published their experiences with a thousand blocks without apparent major complications.

Kulenkampff’s technique required the patient to be in the sitting position. The needle insertion was

above the midpoint of the clavicle in the direction of the spinous process of T2 or T3. Unfortunately,

this medial orientation of the needle was associated with a risk of pneumothorax, which eventually

became the reason for the supraclavicular block to fall into disfavor in many centers. Since then,

many modifications to the original technique were proposed to decrease the risk for pneumothorax.

The technique described in this chapter takes into account the location of the dome of the pleura to

reduce the risk for pneumothorax.

The advantages of a supraclavicular technique over other brachial plexus block approaches are its

rapid onset and complete and predictable anesthesia for entire upper extremity and particularly, hand

surgery. The introduction of ultrasound guidance to regional anesthesia in the last decade has resulted

in significant renewed interest in the clinical application of the supraclavicular block, as well as a

greater understanding of its mechanics.

Functional Anatomy

The supraclavicular block is often called the “spinal anesthesia of the upper extremity” because of its

ubiquitous application for upper extremity surgery. The reasons for its high success rate are in its

anatomic characteristics. The block is performed at the level of the distal trunks and origin of the

divisions, where the brachial plexus is confined to its smallest surface area (Figure 13-2A). The

three trunks carry the entire sensory, motor, and sympathetic innervation of the upper extremity, with

the exception of the uppermost part of the medial side of the arm (T2). The densely packed divisions,

in contrast, carry a similar amount of innervation in a slightly larger surface area, but there is a larger

surface of absorption. Another important anatomic feature of the supraclavicular block is the presence

of the subclavian artery in front of the lower trunk and its divisions (Figure 13-2B). To increase the

chance of blocking C8-T1 dermatomes it may be beneficial to insert the needle in the proximity of the

lower trunk and make it the focal point of in

FIGURE 13-2. (A) Anatomy of brachial plexus about the clavicle. Shown are upper (U), middle (M),

and lower (L) roots of the brachial plexus emerging between anterior (ASM) and middle (MSM)

scalene muscles. Phrenic nerve (PhN) is shown descending on the anterior-medial surface of the

anterior scalene muscle. Other shown anatomic details of importance are vertebral artery (VA),

suprascapular nerve (S), trapezius muscle (TrM), and subclavian artery (SA). Note the intimate

relationship of the brachial plexus trunks to the subclavian artery as they both pass underneath the

clavicle. (B) Relationship of the arterial vasculature and the brachial plexus at the level above the

clavicle.

The sternocleidomastoid muscle inserts on the medial third of the clavicle, the trapezius inserts on

the lateral third, and the neurovascular bundle passes underneath the middle third, which includes the

midpoint of the clavicle. During a supraclavicular block, the pleura potentially can be breached either

at the pleural dome (more likely) or through the first intercostal space.

A practical knowledge of the anatomical position of the pleura is important to decrease the risk of

pneumothorax. The pleural dome is contained within the concavity of the first rib. Because the first

rib crosses under the junction between the medial and middle thirds of the clavicle (Figure 13-3), its

path coincides with the insertion of the sternocleidomastoid muscle, which inserts on the medial third

of the clavicle. Therefore, the lateral insertion of the sternocleidomastoid muscle on the clavicle can

be used as a landmark for the location of the first rib and of the lateral edge of the dome of the pleura.

The first intercostal space, in contrast, is for the most part infraclavicular, and consequently it should

not be reached during a supraclavicular block.

FIGURE 13-3. Radiocontrast image of the mixture of local anesthetic and radiopaque solution

injected in the supraclavicular brachial plexus. The contrast is shown descending from the lower

aspect of the clavicle toward the axillary fossa.

TIPS

With the shoulder pulled down, the entire brachial plexus is located above the clavicle, making it

unnecessary to insert the needle below the clavicle.

The first intercostal space is located below the clavicle for the most part; therefore, it is unlikely to be

breached during a supraclavicular block that is performed above the clavicle, as its name implies.

The dome of the pleura is contained within the concavity of the first rib. The crossing of the first rib

under the clavicle coincides with the lateral insertion of the sternocleidomastoid into the clavicle;

therefore, keeping the needle lateral to this sagittal plane should decrease the risk for pneumothorax.

Distribution of Blockade

The supraclavicular block results in anesthesia of dermatomes C5 through T1, making it suitable for

anesthesia or analgesia of the entire upper extremity distal to the shoulder, including the upper arm

and elbow as well as the forearm, wrist, and hand.

Equipment

Antiseptic solution

Two 20-mL syringes with desired local anesthetic solution

A 3-mL syringe and a 27-gauge needle with local anesthetic for skin infiltration

A 5-cm, 22-gauge, short bevel, insulated needle

Peripheral nerve stimulator

Marking pen and gloves

Landmarks and Patient Positioning

The patient is placed in a semi-sitting position with the head rotated away from the site to be blocked

and the shoulder pulled down. The arm rests comfortably on the side while the wrist, if possible, is

supinated (Figure 13-4). The main landmarks for this block are the lateral insertion of the

sternocleidomastoid muscle onto the clavicle and the clavicle itself.

FIGURE 13-4. Patient position for the supraclavicular brachial plexus block.

Light premedication (e.g., midazolam 1 mg and fentanyl 50 μg IV repeated as necessary) is

beneficial for patient comfort.

Maneuvers to Facilitate Landmarks Identification

To facilitate the recognition of the sternocleidomastoid muscle, the patient can be asked to elevate the

head off the pillow, as shown in Figure 13-5. Once the sternocleidomastoid is identified, a mark is

placed on the clavicle at its lateral insertion, as shown in Figure 13-6.

FIGURE 13-5. Sternocleidomastoid muscle can be accentuated by asking the patient to lift the head

off of the table while glazing away from the side to be blocked.

FIGURE 13-6. Outlining landmarks for supraclavicular brachial plexus block. Shown are the

palpated contours of the sternal and clavicular heads of the sternocleidomastoid muscle.

TIPS

The lateral insertion of the sternocleidomastoid to the clavicle determines the most lateral boundary of

the pleural dome.

This point establishes a parasagittal plane, medial to which the needle should not cross to avoid

placement of the needle toward the pleural dome.

Technique

After identifying the lateral insertion of the sternocleidomastoid muscle on the clavicle, the operator

locates the plexus by palpation, which in adults is found at about 2.5 cm lateral to the

sternocleidomastoid. Once the plexus is found, the point of needle insertion is located immediately

cephalad to the palpating finger, as shown in Figure 13-7.

FIGURE 13-7. Insertion point for the supraclavicular brachial plexus block is outlined

approximately 1–2 cm lateral to the insertion of the clavicular head of the sternocleidomastoid

muscle.

The nerve stimulator is connected to the stimulating needle and set to deliver a 0.8 to 1.0 mA

current at 1 Hz frequency and 0.1 ms of pulse duration.

The needle is inserted first in an anteroposterior direction, almost perpendicularly to the skin with

a slight caudal orientation, as shown in Figure 13-1. The needle is slowly advanced until the upper

trunk is identified by a muscle twitch of the shoulder muscles or up to 1 cm, if there is no response. At

this point, the orientation of the needle is changed to advance it now caudally under the palpating

finger, with a slight posterior angle, as shown in Figure 13-8. This strategy directs the needle from

the vicinity of the upper trunk (shoulder twitch) to the front of the medial trunk (biceps, triceps,

pectoralis twitch) on its way to the lower trunk (fingers twitch).

FIGURE 13-8. Insertion of the needle for the supraclavicular brachial plexus block.

GOAL

The goal of this block is to bring the tip of the needle in the proximity of the lower trunk, which is

manifested by a twitch of the fingers in either flexion or extension.

Once the elicited motor response of the fingers is obtained at 0.5 mA, the injection is carried out

after gentle aspiration. Injecting in the proximity of the lower trunk (motor response of the fingers) is

the most important factor in accomplishing a successful supraclavicular brachial plexus block.

For surgical anesthesia, we commonly select 25 to 35 mL of 1.5% mepivacaine with 1:300,000

epinephrine, for a 3- to 4-hour duration of anesthesia and a variable, but usually short, duration of

analgesia. We use a similar volume of 3% 2-chloroprocaine for a duration of 60 to 90 minutes of

anesthesia for shorter cases. For analgesia, 20 mL of 0.2% ropivacaine with 1:300,000 epinephrine

as an intravascular marker can be selected.

Troubleshooting Maneuvers

If the plexus is not found by palpation at 2.5 cm from the lateral insertion of the sternocleidomastoid:

Verify that the lateral insertion of the sternocleidomastoid on the clavicle is marked correctly. This

insertion is usually vertical into the clavicle, and if an outward curve is noted, it is most likely part of

the omohyoid muscle.

Palpate a few mm more medial or lateral than 2.5 cm.

If the needle in its first perpendicular insertion does not make contact with the upper trunk:

Verify that the nerve stimulator connections and settings are correct.

Failure to elicit a muscle twitch from the middle and lower trunks after eliciting a twitch from the

upper trunk:

This usually means that the orientation plane of the needle, which is advancing caudally, does not

match the frontal orientation plane of the trunks. Bring the needle back to the vicinity of the upper

trunk (shoulder twitch) and increase the posterior orientation of the needle a few degrees.

Contraindications

Supraclavicular block should not be done bilaterally because of the potential risk of respiratory

compromise secondary to pneumothorax or phrenic nerve block. Although this recommendation seems

logical, there is no evidence in the literature that bilateral supraclavicular block is actually

contraindicated. Although phrenic nerve palsy may occur after approximately 50% of supraclavicular

blocks, very few patients are symptomatic.

Regardless, performing the block in patients with chronic respiratory problems, especially those

using accessory respiratory muscles, is a decision that must be made on a case-by-case basis because

any choice of anesthesia, including general anesthesia, will have important implications in these

patients.

TIPS

The risk of an intrafascicular injection can be minimized by using low injection pressures and overall

meticulous technique.

The injection is performed slowly with frequent aspirations while carefully observing the patient and

the monitors for any change or sign of trouble.

If pain or undue pressure is felt at any point during injection, the needle should be withdrawn 1 to 2

mm before a new attempt to inject is made.

NERVE STIMULATOR-GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK:

DECISION-MAKING ALGORITHM

SUGGESTED READINGS

Brown DL, Bridenbaugh LD. The upper extremity: somatic block. In: Cousins MJ, Bridenbaugh PO,

eds. Neuronal Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA:

Lippincott-Raven, 1988;345-371.

Delaunay L, Chelly JE. Blocks at the wrist provide effective anesthesia for carpal tunnel release. Can J

Anaesth. 2001;48:656-660.

Derkash RS, Weaver JK, Berkeley ME, Dawson D. Office carpal tunnel release with wrist block and

wrist tourniquet. Orthopedics. 1996;19:589-590.

Gebhard RE, Al-Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for outpatientcarpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge time. Anesth

Analg. 2002;95:351-355.

Hahn MB, McQuillan PM, Sheplock GJ. Regional Anesthesia: An Atlas of Anatomy and Techniques.

St. Louis, MO: Mosby; 1996.

McCahon R, Bedforth N. Peripheral nerve block at the elbow and wrist. Contin Ed Anaesth Crit Care

Pain. 2007;7:42-44.

Mulroy MF. Regional Anesthesia: An Illustrated Procedural Guide. 3rd ed. Philadelphia, PA:

Lippincott; 2002.

Ramamurthy S, Hickey R. Anesthesia. In: Green DP, Hotchkiss RN, eds. Operative Hand Surgery.

New York, NY: Churchill Livingstone, 1993;25-52.

Cutaneous Nerve Blocks of the Upper Extremity

General Considerations

Cutaneous nerve blocks of the upper extremity are used mainly as a supplement to brachial plexus

blocks. These blocks are simple to learn and perform. They are essentially devoid of complications

and can be useful as complements to major conduction blocks of the upper extremity. Their judicious

use can be used for superficial surgery or to help salvage an incomplete brachial plexus block. The

techniques discussed in this chapter focus primarily on the blocks that are most useful clinically:

blocks of the intercostobrachial nerve and the medial and lateral cutaneous nerves of the forearm,

Figure 17-1.

FIGURE 17-1. Techniques to block the cutaneous nerves of the upper extremity.

Functional Anatomy

Cutaneous nerve blockade is achieved by the injection of local anesthetic into the subcutaneous layers

above the muscle fascia. The subcutaneous tissue contains a variable amount of fat, superficial

nerves, and vessels. Deeper, there is a tough membranous layer, the deep fascia of the upper

extremity, which encloses the muscles of the arm and forearm. Numerous superficial nerves and

vessels penetrate the deep fascia.

The cutaneous innervation of the upper extremity originates from the superficial cervical plexus,

the brachial plexus, and the intercostal nerves (Table 17-1; Figure 17-2A and B). Familiarity with

their relevant anatomy is important to avoid sparing of cutaneous anesthesia during a nerve block

procedure. For example, a brachial plexus block does not anesthetize the intercostobrachial nerve, a

branch of T2 that is responsible for sensation of the skin of the proximal medial arm. Failure to

supplement this may result in discomfort at skin incision during upper extremity surgery. Similarly, a

single-injection axillary brachial plexus block typically does not cover the musculocutaneous nerve

(and its terminal branch, the lateral cutaneous nerve of the forearm). A cutaneous block of this

terminal branch is a more distal alternative to a musculocutaneous nerve block that provides the same

sensory anesthesia.

TABLE 17-1 Origin of the Cutaneous Nerves of the Upper Extremity

FIGURE 17-2. (A) Cutaneous innervation of the upper extremity (front).

FIGURE 17-2. (B) Cutaneous innervation of the upper extremity (back).

Intercostobrachial Nerve Block

Anatomy

The intercostobrachial nerve is the lateral cutaneous branch of the ventral primary ramus of T2. It

provides innervation to the skin of the axilla and the medial aspect of the proximal arm. The

intercostobrachial nerve communicates with the medial cutaneous nerve of the arm, which is a branch

of the brachial plexus (Figure 17-3). Both nerves are anesthetized by subcutaneous infiltration of the

skin of the medial aspect of the arm.

FIGURE 17-3. Anatomy of the terminal nerves of the upper extremity at the level of the axillary

fossa. axillary artery. intercostobrachial nerve. ulnar nerve. median nerve. radial

nerve. musculocutaneous nerve.

Indications

Blocks of these nerves are typically combined with brachial plexus block to achieve more complete

anesthesia of the upper arm.

Technique

A 1.5-in, 25-gauge needle is inserted at the level of the axillary fossa (Figure 17-4A). The entire

width of the medial aspect of the arm is infiltrated with local anesthetic to raise a subcutaneous wheal

of anesthesia.

FIGURE 17-4. (A) Block of the intercostobrachial nerve. (B) Block of the medial cutaneous nerve of

the forearm. (C) Block of the lateral cutaneous nerve of the forearm.

Medial Cutaneous Nerve of the Forearm Block

Anatomy

The medial cutaneous nerve of the forearm originates within the medial cord. This nerve supplies

branches to the skin of the medial side of the forearm (Figure 17-5).

FIGURE 17-5. Medial cutaneous nerve of the arm (arrow).

Indications

The medial antebrachial cutaneous nerve is blocked by infiltration of local anesthetic into the

subcutaneous tissue on the anteromedial and dorsomedial surfaces of the forearm just below the

elbow crease. Along with blockade of the lateral antebrachial cutaneous nerve, this block is

appropriate for the insertion of an arteriovenous graft on the forearm or other superficial procedures

on the volar surface of the forearm.

Technique

A 1.5-in, 25-gauge needle is used to infiltrate local anesthetic subcutaneously over the entire medial

aspect of the arm just below the elbow crease (Figure 17-4B).

Lateral Cutaneous Nerve of the Forearm Block

Anatomy

The lateral cutaneous nerve of the forearm is a cutaneous extension of the musculocutaneous nerve,

which originates from C5 through C7 and separates from the brachial plexus off the lateral cord. The

musculocutaneous nerve runs through the bodies of the coracobrachialis and biceps muscles, emerges

between the biceps and brachioradialis muscles, and pierces the deep brachial fascia just above the

elbow crease lateral to the biceps tendon (Figure 17-6). As soon as the nerve emerges above the

fascia, it becomes the lateral cutaneous nerve of the forearm and descends on the anterolateral surface

of the forearm. The nerve supplies branches to the anterolateral and posterior surfaces of the forearm.

Its distal branches reach the lateral surface of the wrist.

FIGURE 17-6. Lateral cutaneous nerve of the (right) forearm, Biceps muscle,

Brachioradialis muscle.

Indications

Blockade of the lateral cutaneous and medial cutaneous nerves of the forearm results in anesthesia of

the anterior and lateral surfaces of the forearm. This block is suitable for the insertion of

arteriovenous grafts or other superficial procedures on the volar aspect of the forearm. It is also

useful for supplementing an axillary brachial plexus block in which a separate musculocutaneous

nerve block was not performed or failed.

Technique

The nerve can be blocked at the level of the arm (musculocutaneous block; see “Axillary Block” for a

description) or when it emerges at the elbow level. To block the lateral cutaneous nerve of the

forearm at the level of the elbow, a 1.5-in, 25-gauge needle is used to infiltrate local anesthetic

subcutaneously over the entire lateral aspect of the arm just below the elbow crease (Figure 17-4C).

Complications and How to Avoid Them

Complications from cutaneous nerve blocks are few; they are discussed in Table 17-2.

TABLE 17-2 Complications of Cutaneous Blocks and Preventive Techniques

CUTANEOUS NERVE BLOCKS OF THE UPPER EXTREMITY

SUGGESTED READINGS

Agur A, Lee M: Grant’s Atlas of Anatomy. Baltimore, Md: Lippincott Williams & Wilkins, 1999.

Coventry DM, Barker KF, Thomson M: Comparison of two neurostimulation techniques for axillary

brachial plexus blockade. Br J Anaesth 2001; 86: 80-3.

Cuvillon P, Dion N, Deleuze M, Nouvellon E, Mahamat A, L’Hermite J, Boisson C, Vialles N, Ripart J,de La Coussaye JE: Comparison of 3 intensities of stimulation threshold for brachial plexus blocks at

the midhumeral level: a prospective, double-blind, randomized study. Reg Anesth Pain Med 2009;

34: 296-300.

Delaunay L, Chelly JE: Blocks at the wrist provide effective anesthesia for carpal tunnel release. Can J

Anaesth 2001; 48: 656-60.

Deleuze A, Gentili ME, Marret E, Lamonerie L, Bonnet F: A comparison of a single-stimulation lateral

infraclavicular plexus block with a triple-stimulation axillary block. Reg Anesth Pain Med 2003; 28:

89-94.

Gaertner E, Estebe JP, Zamfir A, Cuby C, Macaire P: Infraclavicular plexus block: multiple injection

versus single injection. Reg Anesth Pain Med 2002; 27: 590-4.

Hermanns H, Braun S, Werdehausen R, Werner A, Lipfert P, Stevens MF: Skin temperature after

interscalene brachial plexus blockade. Reg Anesth Pain Med 2007; 32: 481-7.

Jandard C, Gentili ME, Girard F, Ecoffey C, Heck M, Laxenaire MC, Bouaziz H: Infraclavicular block

with lateral approach and nerve stimulation: extent of anesthesia and adverse effects. Reg Anesth PainMed 2002; 27: 37-42.

Jankovic D, Wells C: Regional Nerve Blocks. 2nd ed. Wissenchafts-Verlag Berlin, Blackwell

Scientific Publications 2001.

Macaire P, Choquet O, Jochum D, Travers V, Capdevila X: Nerve blocks at the wrist for carpal tunnel

release revisited: the use of sensory-nerve and motor-nerve stimulation techniques. Reg Anesth Pain

Med 2005; 30: 536-40.

March X, Pardina B, Torres-Bahi S, Navarro M, del Mar Garcia M, Villalonga A: A comparison of a

triple-injection axillary brachial plexus block with the humeral approach. Reg Anesth Pain Med

2003; 28: 504-8.

Oaklander AL, Siegel SM: Cutaneous innervation: form and function. J Am Acad Dermatol 2005; 53:

1027-37.

Pernkopf E: Atlas of Topographical and Applied Human Anatomy. Vol II: Thorax, Abdomen and

Extremities. 2nd ed. Munich, Germany: U&S Saunders, 1980.

Raj P: Textbook of Regional Anesthesia. London, England: Churchill Livingstone 2002.

Salengros JC, Pandin P, Schuind F, Vandesteene A: Intraoperative somatosensory evoked potentials to

facilitate peripheral nerve release. Can J Anaesth 2006; 53: 40-5.

Sia S, Lepri A, Ponzecchi P: Axillary brachial plexus block using peripheral nerve stimulator: a

comparison between double- and triple-injection techniques. Reg Anesth Pain Med 2001; 26: 499-

503.

Viscomi CM, Reese J, Rathmell JP: Medial and lateral antebrachial cutaneous nerve blocks: an easily

learned regional anesthetic for forearm arteriovenous fistula surgery. Reg Anesth 1996; 21: 2-5.

Lumbar Plexus Block

FIGURE 18-1. To accomplish the lumbar plexus block, a needle is inserted perpendicular to the skin

plane, 4 cm lateral to the midline at the level of L3-L5.

General Considerations

The lumbar plexus block (psoas compartment block) is an advanced nerve block technique. Because

the placement of the needle is in the deep muscles, the potential for systemic toxicity is greater than it

is with more superficial techniques. The proximity of the lumbar nerve roots to the epidural space

also carries a risk of epidural spread of the local anesthetic. For these reasons, care should be taken

when selecting the type, volume, and concentration of local anesthetic, particularly in elderly, frail, or

obese patients. The lumbar plexus block provides anesthesia or analgesia to the entire distribution of

the lumbar plexus, including the anterolateral and medial thigh, the knee, and the saphenous nerve

below the knee. When combined with a sciatic nerve block, anesthesia of the entire leg can be

achieved. Because of the complexity of the technique, potential for complications, and existence of

simpler alternatives (e.g. fascia iliaca or femoral blocks), the benefits of lumbar plexus block should

always be weighed against the risks.

Functional Anatomy

The lumbar plexus is composed of five to six peripheral nerves that have their origins in the spinal

roots of L1 to L4, with a contribution from T12 (Figures 18-2 and 18-3). After the roots emerge from

the intervertebral foramina, they divide into anterior and posterior branches. The small posterior

branches supply innervation to the skin of the lower back and paravertebral muscles. The anterior

branches form the lumbar plexus within the substance of the psoas muscle and emerge from the muscle

as individual nerves in the pelvis.

FIGURE 18-2. Anatomy of the lumbar plexus. Roots of the lumbar plexus (arrows) are seen within

the substance of the psoas major muscle (PsMM); the lumbar plexus is exposed through the abdominal

cavity.

FIGURE 18-3. Organization of the Lumbar Plexus into peripheral nerves.

The major branches of the lumbar plexus are the iliohypogastric (L1), ilioinguinal (L1),

genitofemoral nerve (L1/L2), lateral femoral cutaneous nerve (L2/L3), and the femoral and obturator

nerves (L2,3,4). Although not a lumbar nerve root, the T12 spinal nerve contributes to the

iliohypogastric nerve in about 50% of cases.

Distribution of Blockade

The femoral nerve supplies the quadriceps muscle (knee extension), the skin of the anteromedial

thigh, and the medial aspect of the leg below the knee and foot (Figure 18-4 A and B). The obturator

nerve sends motor branches to the adductors of the hip and a variable cutaneous area over the medial

thigh or knee joint. The lateral femoral cutaneous, iliohypogastric, ilioinguinal, and genitofemoral

nerves are superficial sensory nerves.

FIGURE 18-4. (A) Cutaneous distribution of the lumbar plexus to the lower extremity. (B) Motor

innervation of the lumbar plexus to the lower extremity.

Single-Injection Lumbar Plexus Block

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

Two 20-mL syringes with local anesthetic

A 10-mL syringe plus a 25-gauge needle with local anesthetic for skin infiltration

A 10-cm, 21-gauge short-bevel insulated stimulating needle

Peripheral nerve stimulator

Sterile gloves; marking pen

Landmarks and Patient Positioning

The patient is in the lateral decubitus position with a slight forward tilt (Figure 18-5). The foot on the

side to be blocked should be positioned over the dependent leg so that twitches of the quadriceps

muscle and patella can be seen easily. The operator should assume a position from which these

responses are visible. Palpation of the anterior thigh can be useful to make sure the motor response is

indeed that of the quadriceps muscles.

FIGURE 18-5. Patient position for the lumbar plexus block.

TIP

A slight tilt of the pelvis forward allows for a more ergonomic position for the operator.

The anatomical landmarks are as follows (Figure 18-6):

FIGURE 18-6. Landmarks for the lumbar plexus block. The needle insertion site is labeled 3-4 cm

lateral to the intersection of the (horizontal) line passing through spinous processes and iliac crest

(perpendicular) line.

. Iliac crests (intercristal line)

. Spinous processes (midline)

. A point 3–4 cm lateral to the intersection of landmarks 1 and 2 (needle insertion point)

TIPS

Because the gluteal crease tends to sag to a dependent position, it should never be considered as the

midline.

Instead, spinous processes should be relied on to determine the midline more accurately.

Maneuvers to Facilitate Landmark Identification

The identification of the iliac crest can be facilitated by the following maneuvers:

Placing the palpating hand over the ridge of the pelvic bone and pressing firmly against it (Figure 18-

7).

FIGURE 18-7. Technique of palpation of the iliac crest.

To better estimate the location of the iliac crest, the thickness of the adipose tissue over the iliac crest

should be considered.

Pelvic proportions greatly vary among people; thus a visual “reality check” is always performed. If

the estimated iliac crest line appears to be almost at the level of the midtorso or touching the rib cage

(too cranial), make an appropriate adjustment to avoid insertion of the needle too cranially.

Technique

After disinfecting with an antiseptic solution, the skin and paravertebral muscles are anesthetized by

infiltrating local anesthetic subcutaneously at site of needle insertion.

The fingers of the palpating hand are firmly pressed against the paravertebral muscles to stabilize

the landmark and decrease the skin–nerve distance (Figure 18-8). The palpating hand should not be

moved during the entire block procedure so that precise redirections of the angle of needle insertion

can be made, if necessary. The needle is inserted at an angle perpendicular to the skin with the nerve

stimulator set initially to deliver a current of 1.5 mA (1.5 mA, 2 Hz, 0.1–0.3 ms). As the needle is

advanced, local twitches of the paravertebral muscles are obtained first at a depth of a few

centimeters. The needle is advanced further, until twitches of the quadriceps muscle are obtained

(usually at a depth of 6–8 cm). After these twitches are observed, the current should be lowered to

produce stimulation between 0.5 and 1.0 mA. Motor response should not be present at a current less

than 0.5 mA, which could indicate needle placement in the dural sleeve. At this point, 25 to 35 mL of

local anesthetic is injected slowly while avoiding resistance to injection and with frequent

aspirations to rule out inadvertent intravascular needle placement. A resultant, typical spread of the

local anesthetic solution is demonstrated in Figure 18-9.

FIGURE 18-8. Needle insertion for the lumbar plexus block. The needle is inserted to walkoff the

transverse processes and advance the needle 1-2 cm deeper.

FIGURE 18-9. Radiograph demonstrating distribution of the radiopaque solution within the psoas

muscle after a lumbar plexus injection.

GOAL

Visible or palpable twitches of the quadriceps muscle at 0.5 to 1.0 mA.

TIPS

A successful lumbar plexus blockade depends on dispersion of the local anesthetic in a fascial plane

within the psoas muscle where the roots of the plexus are situated.

Stimulation at currents <0.5 mA should not be sought when using this technique. Motor stimulation

with a low current may indicate placement of the needle inside a dural sleeve. An injection inside this

sheath can result in epidural or spinal anesthesia.

TABLE 18-1 Some Common Responses to Nerve Stimulation and Course of Action for Proper

Response

Troubleshooting

When insertion of the needle does not result in quadriceps muscle stimulation, the following

maneuvers should be followed:

. Withdraw the needle to the skin level, redirect it 5° to 10° cranially, and repeat the procedure.

. Withdraw the needle to the skin level, redirect it 5° to 10° caudally, and repeat the procedure.

. Withdraw the needle to the skin level, redirect it 5° to 10° medially, and repeat the procedure.

. Withdraw the needle to the skin level, reinsert it 2 cm caudally or cranially, and repeat the

procedure.

TIPS

Lumbar plexus block carries a higher risk of local anesthetic toxicity than most other nerve block

techniques because of its deep location and the close proximity of muscles.

Consider using a less toxic local anesthetic (e.g., 3% chloroprocaine) or mixtures of two local

anesthetics (e.g., mepivacaine or lidocaine with ropivacaine) to decrease the total dose of more toxic,

long-acting local anesthetic.

Block Dynamics and Perioperative Management

A lumbar plexus block can be associated with significant patient discomfort because the needle

passes through multiple muscle planes. Adequate sedation and analgesia are necessary to ensure a

still and cooperative patient. We often use midazolam 4 to 6 mg after the patient is positioned and

alfentanil 500 to 750 μg just before needle insertion. A typical onset time for this block is 20 to 30

minutes, depending on the type, concentration, and volume of local anesthetic and the level at which

the needle is placed. The first sign of the onset of blockade is usually a loss of sensation in the

saphenous nerve territory (medial skin below the knee).

Continuous Lumbar Plexus Block

A continuous lumbar plexus blockade is an advanced regional anesthesia technique, and adequate

experience with the single-injection technique is a prerequisite to ensure its efficacy and safety.

Otherwise, the technique is quite similar to the single-injection procedure, except that a Tuohy-style

needle is preferred. The needle opening should be directed caudad and laterally to facilitate threading

of the catheter in the direction of the plexus. The technique can be used for postoperative pain

management in patients undergoing hip, femur, and knee surgery.

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

Two 20-mL syringes containing local anesthetic

Sterile gloves, marking pen, and surface electrode

A syringe plus 25-gauge needle with local anesthetic for skin infiltration

Peripheral nerve stimulator

Catheter kit (including a 8- to 10-cm large-gauge stimulating needle and catheter)

Landmarks and Patient Positioning

As for the single-injection technique, the patient is positioned in the lateral decubitus position with

the side to be blocked up and with a slightly forward pelvic tilt (Figure 18-4). An assistant helps

maintain flexion of the spine, as in positioning a patient for an epidural or spinal block in the lateral

position.

The landmarks for a continuous lumbar plexus block are the same as for the single-injection

technique (Figure 18-6):

. Iliac crests (intercristal line)

. Midline (spinous processes)

. Needle insertion site 4 cm lateral to the intersection of landmarks 1 and 2

Technique

The skin and subcutaneous tissues are anesthetized with local anesthetic. The needle is attached to the

nerve stimulator (1.5 mA, 2 Hz). The palpating hand should be firmly pressed and anchored against

the paraspinal muscles to facilitate needle insertion and redirection of the needle when necessary. An

8–10-cm Tuohy-style continuous block needle is inserted at a perpendicular angle and advanced until

the quadriceps muscle contractions are obtained at 0.5 to 1.0 mA. A 5–10 mL of local anesthetic or

other injectate (e.g., D5W) is injected to “open up” a tissue space and facilitate catheter advancement.

The catheter is threaded through the needle for approximately 5 cm beyond the tip of the needle

(Figure 18-10). The needle is withdrawn, the catheter secured, and the remaining anesthetic is

injected via the catheter. Before administration of the local anesthetic, the needle and/or catheter are

checked for inadvertent intravascular and intrathecal placement. This is done by performing an

aspiration test and administering a test dose of epinephrine-containing local anesthetic.

FIGURE 18-10. Insertion of the catheter in the lumbar plexus. The catheter is inserted approximately

5 cm beyond the needle tip.

Continuous Infusion

Continuous infusion is always initiated after an initial bolus of dilute local anesthetic through the

needle or catheter. For this purpose, 0.2% ropivacaine (15 to 20 mL) is used most commonly. The

infusion is maintained at 5 mL/h with 5 mL/h patient-controlled regional analgesia bolus dose.

TIPS

Breakthrough pain in patients receiving a continuous infusion is always managed by administering a

bolus of local anesthetic. Simply increasing the rate of infusion is rarely adequate.

For patients on the ward, a shorter-acting local anesthetic (e.g., 1% mepivacaine) is useful to test the

functionality of the catheter.

Complications and How to Avoid Them

The lumbar plexus block is an advanced nerve block technique that carries a potential for serious

complications if proper precautions are not strictly followed. Some complications and methods to

decrease the risk of them are listed in Table 18-2.

TABLE 18-2 Complications of Lumbar Plexus Block and How To Avoid Them

LUMBAR PLEXUS BLOCK

SUGGESTED READINGS

Altermatt F, Cortinez LI, Munoz H. Plasma levels of levobupivacaine after combined posterior lumbar

plexus and sciatic nerve blocks. Anesth Analg. 2006;102:1597.

Asakura Y, Kandatsu N, Kato N, Sato Y, Fujiwara Y, Komatsu T. Ultra-sound guided sciatic nerve

block combined with lumbar plexus block for infra-inguinal artery bypass graft surgery. Acta

Anaesthesiol Scand. 2008;52:721-722.

Aveline C, Bonnet F. Delayed retroperitoneal haematoma after failed lumbar plexus block. Br J

Anaesth. 2004;93:589-591.

Awad IT, Duggan EM. Posterior lumbar plexus block: anatomy, approaches, and techniques. Reg

Anesth Pain Med. 2005;30:143-149.

Bagry H, de la Cuadra Fontaine JC, Asenjo JF, Bracco D, Carli F. Effect of a continuous peripheral

nerve block on the inflammatory response in knee arthroplasty. Reg Anesth Pain Med. 2008;33:17-

23.

Ben-David B, Joshi R, Chelly JE. Sciatic nerve palsy after total hip arthroplasty in a patient receiving

continuous lumbar plexus block. Anesth Analg. 2003;97:1180-1182.

Ben-David B, Lee EM. Lumbar plexus or lumbar paravertebral blocks? Anesthesiology.

2009;110:1196.

Blumenthal S, Ekatodramis G, Borgeat A. Ropivacaine plasma concentrations are similar during

continuous lumbar plexus blockade using two techniques: pharmacokinetics or pharmacodynamics?

Can J Anaesth. 2004;51:851.

Breslin DS, Martin G, Macleod DB, D’Ercole F, Grant SA. Central nervous system toxicity following

the administration of levobupivacaine for lumbar plexus block: a report of two cases. Reg Anesth

Pain Med. 2003;28:144-147.

Brown DL, Bridenbaugh LD. The upper extremity: somatic block. In: Cousins MJ, Bridenbaugh PO,

eds. Neuronal Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA:

Lippincott-Raven; 1988:345-371.

Capdevila X, Biboulet P, Morau D, et al. Continuous three-in-one block for postoperative pain after

lower limb orthopedic surgery: where do the catheters go? Anesth Analg. 2002;94:1001-1006.

Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: success, risks, and outcome.

Reg Anesth Pain Med. 2005;30:150-162.

Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative

analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation.

Anesth Analg. 2002;94:1606-1613.

Cappelleri G, Aldegheri G, Ruggieri F, Carnelli F, Fanelli A, Casati A. Effects of using the posterior or

anterior approaches to the lumbar plexus on the minimum effective anesthetic concentration (MEAC)

of mepivacaine required to block the femoral nerve: a prospective, randomized, up-and-down study.

Reg Anesth Pain Med. 2008;33:10-16.

Chelly JE. Do we really need an interval between administering fondaparinux and removing a lumbar

plexus catheter? Anesth Analg. 2009;108:670-671.

Chelly JE, Casati A, Fanelli G. Continuous Peripheral Nerve Block Techniques: An Illustrated Guide.

London, UK: Mosby International; 2001.

Chelly JE, Szczodry DM, Neumann KJ. International normalized ratio and prothrombin time values

before the removal of a lumbar plexus catheter in patients receiving warfarin after total hip

replacement. Br J Anaesth. 2008;101:250-254.

Cotter JT, Nielsen KC, Guller U, et al. Increased body mass index and ASA physical status IV are risk

factors for block failure in ambulatory surgery—an analysis of 9,342 blocks. Can J Anaesth.

2004;51:810-816.

Cucchiaro G, Ganesh A. The effects of clonidine on postoperative analgesia after peripheral nerve

blockade in children. Anesth Analg. 2007;104:532-537.

De Biasi P, Lupescu R, Burgun G, Lascurain P, Gaertner E. Continuous lumbar plexus block: use of

radiography to determine catheter tip location. Reg Anesth Pain Med. 2003;28:135-139.

e Leeuw MA, Perez RG. Posterior lumbar plexus block in postoperative analgesia for total hip

arthroplasty. A comparative study between 0.5% bupivacaine with epinephrine and 0.5%

ropivacaine. Rev Bras Anestesiol 2010;60:215-216, 124-125.

e Visme V, Picart F, Le Jouan R, Legrand A, Savry C, Morin V. Combined lumbar and sacral plexus

block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Reg Anesth

Pain Med. 2000;25:158-162.

Duarte LT, Beraldo PS, Saraiva RA. Epidural lumbar block or lumbar plexus block combined with

general anesthesia: efficacy and hemodynamic effects on total hip arthroplasty. Rev Bras Anestesiol.

2009;59:649-664.

Duarte LT, Beraldo PS, Saraiva RA. Effects of epidural analgesia and continuous lumbar plexus block

on functional rehabilitation after total hip arthroplasty [in Portuguese]. Rev Bras Anestesiol.

2009;59:531-544.

Duarte LT, Paes FC, Fernandes Mdo C, Saraiva RA. Posterior lumbar plexus block in postoperative

analgesia for total hip arthroplasty: a comparative study between 0.5% bupivacaine with epinephrine

and 0.5% ropivacaine. Rev Bras Anestesiol. 2009;59:273-285.

Ekatodramis G, Grimm K, Borgeat A. The effect of lumbar plexus block on blood loss and

postoperative pain. Anesthesiology. 2001;94:716-717.

arny J, Drolet P, Girard M. Anatomy of the posterior approach to the lumbar plexus block. Can J

Anaesth. 1994;41:480-485.

arny J, Girard M, Drolet P. Posterior approach to the lumbar plexus combined with a sciatic nerve

block using lidocaine. Can J Anaesth. 1994;41:486-491.

aust AM, Fournier R, Gamulin Z. Perioperative analgesia with posterior continuous lumbar plexus

block for simultaneous ipsilateral total hip and knee arthroplasty. Reg Anesth Pain Med.

2006;31:591.

owler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve

blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J

Anaesth. 2008;100:154-164.

Gadsden JC, Lindenmuth DM, Hadži A, Xu D, Somasundarum L, Flisinski KA. Lumbar plexus block

using high-pressure injection leads to contralateral and epidural spread. Anesthesiology.

2008;109:683-688.

Goroszeniuk T, di Vadi PP. Repeated psoas compartment blocks for the management of long-standing

hip pain. Reg Anesth Pain Med. 2001;26:376-378.

Hadžić A, Karaca PE, Hobeika P, et al. Peripheral nerve blocks result in superior recovery profile

compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976-981.

Hanna MH, Peat SJ, D’Costa F. Lumbar plexus block: an anatomical study. Anaesthesia. 1993;8:675-

678.

Heller AR, Fuchs A, Rossel T, et al. Precision of traditional approaches for lumbar plexus block:

impact and management of interindividual anatomic variability. Anesthesiology. 2009;111:525-532.

Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic nerve block for

reduction of hip fracture in a patient with severe aortic stenosis. Can J Anaesth. 2002;49:946-950.

Horlocker TT, Hebl JR, Kinney MA, Cabanela ME. Opioid-free analgesia following total knee

arthroplasty—a multimodal approach using continuous lumbar plexus (psoas compartment) block,

acetaminophen, and ketorolac. Reg Anesth Pain Med. 2002;27:105-108.

Hsu DT. Delayed retroperitoneal haematoma after failed lumbar plexus block. Br J Anaesth.

2005;94:395.

Huet O, Eyrolle LJ, Mazoit JX, Ozier YM. Cardiac arrest after injection of ropivacaine for posterior

lumbar plexus blockade. Anesthesiology. 2003;99:1451-1453.

feld BM, Ball ST, Gearen PF, et al. Ambulatory continuous posterior lumbar plexus nerve blocks after

hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology.

2008;109:491-501.

feld BM, Ball ST, Gearen PF, et al. Health-related quality of life after hip arthroplasty with and

without an extended-duration continuous posterior lumbar plexus nerve block: a prospective, 1-year

follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg. 2009;109:586-

591.

ohr M. The right thing in the right place: lumbar plexus block in children. Anesthesiology.

2005;102:865.

Kaloul I, Guay J, Cote C, Fallaha M. The posterior lumbar plexus (psoas compartment) block and the

three-in-one femoral nerve block provide similar postoperative analgesia after total knee

replacement. Can J Anaesth. 2004;51:45-51.

Kaloul I, Guay J, Cote C, Halwagi A, Varin F. Ropivacaine plasma concentrations are similar during

continuous lumbar plexus blockade using the anterior three-in-one and the posterior psoas

compartment techniques. Can J Anaesth. 2004;51:52-56.

Karmakar MK, Ho AM, Li X, Kwok WH, Tsang K, Ngan Kee WD. Ultrasound-guided lumbar plexus

block through the acoustic window of the lumbar ultrasound trident. Br J Anaesth. 2008;100:533-537.

Kirchmair L, Enna B, Mitterschiffthaler G, et al. Lumbar plexus in children. A sonographic study and its

relevance to pediatric regional anesthesia. Anesthesiology. 2004;101:445-450.

Kirchmair L, Entner T, Wissel J, Moriggl B, Kapral S, Mitterschiffthaler G. A study of the

paravertebral anatomy for ultrasound-guided posterior lumbar plexus block. Anesth Analg.

2001;93:477-481.

Kirchmair L, Lirk P, Colvin J, Mitterschiffthaler G, Moriggl B. Lumbar plexus and psoas major muscle:

not always as expected. Reg Anesth Pain Med. 2008;33:109-114.

Klein SM, Greengrass RA, Grant SA, Higgins LD, Nielsen KC, Steele SM. Ambulatory surgery for

multi-ligament knee reconstruction with continuous dual catheter peripheral nerve blockade. Can J

Anaesth. 2001;48:375-378.

Laguillo Cadenas JL, Martinez Navas A, de la Tabla Gonzalez RO, Ramos Curado P, Echevarria

Moreno M. Combined posterior lumbar plexus and sacral block for emergency surgery to treat hip

fracture [in Spanish]. Rev Esp Anestesiol Reanim. 2009;56:385-388.

Lang S. Posterior lumbar plexus block. Can J Anaesth. 1994;41: 1238-1239.

Litz RJ, Vicent O, Wiessner D, Heller AR. Misplacement of a psoas compartment catheter in the

subarachnoid space. Reg Anesth Pain Med. 2004;29:60-64.

Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after

ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in

a child. Anesth Analg. 2008;106:1572-1574.

Mannion S. Epidural spread depends on the approach used for posterior lumbar plexus block. Can J

Anaesth. 2004;51:516-517.

Mannion S, Barrett J, Kelly D, Murphy DB, Shorten GD. A description of the spread of injectate after

psoas compartment block using magnetic resonance imaging. Reg Anesth Pain Med. 2005;30:567-

571.

Mannion S, O’Callaghan S, Walsh M, Murphy DB, Shorten GD. In with the new, out with the old?

Comparison of two approaches for psoas compartment block. Anesth Analg. 2005;101:259-264.

Marhofer P, Nasel C, Sitzwohl C, Kapral S. Magnetic resonance imaging of the distribution of local

anesthetic during the three-in-one block. Anesth Analg. 2000;90:119-124.

Martin G, Grant SA, Macleod DB, Breslin DS, Brewer RP. Severe phantom leg pain in an amputee

after lumbar plexus block. Reg Anesth Pain Med. 2003;28:475-478.

Mello SS, Saraiva RA, Marques RS, Gasparini JR, Assis CN, Goncalves MH. Posterior lumbar plexus

block in children: a new anatomical landmark. Reg Anesth Pain Med. 2007;32:522-527.

Morau D, Lopez S, Biboulet P, Bernard N, Amar J, Capdevila X. Comparison of continuous 3-in-1 and

fascia Iliaca compartment blocks for postoperative analgesia: feasibility, catheter migration,

distribution of sensory block, and analgesic efficacy. Reg Anesth Pain Med. 2003;28:309-314.

Morin AM, Kratz CD, Eberhart LH, et al. Postoperative analgesia and functional recovery after totalknee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a

continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block.

Reg Anesth Pain Med. 2005;30:434-445.

andin PC, Vandesteene A, d’Hollander AA. Lumbar plexus posterior approach: a catheter placement

description using electrical nerve stimulation. Anesth Analg. 2002;95:1428-1431.

ousman RM, Mansoor Z, Sciard D. Total spinal anesthetic after continuous posterior lumbar plexus

block. Anesthesiology. 2003;98:1281-1282.

Rose GL, McLarney JT. Retained continuous lumbar plexus block catheter. J Clin Anesth.

2009;21:464-465.

ciard D, Matuszczak M, Gebhard R, Greger J, Al-Samsam T, Chelly JE. Continuous posterior lumbar

plexus block for acute postoperative pain control in young children. Anesthesiology. 2001;95:1521-

1523.

Siddiqui ZI, Cepeda MS, Denman W, Schumann R, Carr DB. Continuous lumbar plexus block provides

improved analgesia with fewer side effects compared with systemic opioids after hip arthroplasty: a

randomized controlled trial. Reg Anesth Pain Med. 2007;32:393-398.

Souron V. A complete block of the knee combines both sacral and lumbar plexus blocks. Anesth Analg.

2004;98:1501.

Stevens RD, Van Gessel E, Flory N, Fournier R, Gamulin Z. Lumbar plexus block reduces pain and

blood loss associated with total hip arthroplasty. Anesthesiology. 2000;93:115-121.

Urmey WF, Grossi P. Use of sequential electrical nerve stimuli (SENS) for location of the sciatic nerveand lumbar plexus. Reg Anesth Pain Med. 2006;31:463-469.

Vanterpool S, Steele SM, Nielsen KC, Tucker M, Klein SM. Combined lumbar-plexus and sciaticnerve blocks: an analysis of plasma ropivacaine concentrations. Reg Anesth Pain Med. 2006;31:417-

421.

Watson MW, Mitra D, McLintock TC, Grant SA. Continuous versus single-injection lumbar plexus

blocks: comparison of the effects on morphine use and early recovery after total knee arthroplasty.

Reg Anesth Pain Med. 2005;30:541-547.

Weller RS, Gerancher JC, Crews JC, Wade KL. Extensive retroperitoneal hematoma without

neurologic deficit in two patients who underwent lumbar plexus block and were later anticoagulated.

Anesthesiology. 2003;98:581-585.

Sciatic Block

FIGURE 19.1-1. (A) Needle insertion for the transgluteal (posterior) approach to sciatic nerve

block. (B) Needle insertion for anterior sciatic block.

PART 1: TRANSGLUTEAL APPROACH

General Considerations

The posterior approach to sciatic nerve block has wide clinical applicability for surgery and pain

management of the lower extremity. Consequently, a sciatic block is one of the more commonly used

techniques in our practice. In contrast to a common belief, this block is relatively easy to perform and

associated with a high success rate. It is particularly well-suited for surgery on the knee, calf,

Achilles tendon, ankle, and foot. It provides complete anesthesia of the leg below the knee with the

exception of the medial strip of skin, which is innervated by the saphenous nerve. When combined

with a femoral nerve or lumbar plexus block, anesthesia of the entire lower extremity can be

achieved.

Functional Anatomy

The sciatic nerve is formed from the L4 through S3 roots. These roots form the sacral plexus on the

anterior surface of the lateral sacrum and converge to become the sciatic nerve on the anterior surface

of the piriformis muscle. The sciatic nerve is the largest nerve in the body and measures nearly 2 cm

in breadth at its origin. The course of the nerve can be estimated by drawing a line on the back of the

thigh beginning from the apex of the popliteal fossa to the midpoint of the line joining the ischial

tuberosity to the apex of the greater trochanter. The sciatic nerve also gives off numerous articular

(hip, knee) and muscular branches.

The sciatic nerve exits the pelvis through the greater sciatic foramen below the piriformis and

descends between the greater trochanter of the femur and the ischial tuberosity, superficial to the

external rotators of the hip (obturator internus, the gemelli muscles, and quadratus femoris) (Figures

19.1-2 and 19.1-3). On its medial side, the sciatic nerve is accompanied by the posterior cutaneous

nerve of the thigh and the inferior gluteal artery. The articular branches of the sciatic nerve arise from

the upper part of the nerve and supply the hip joint by perforating the posterior part of its capsule.

Occasionally, these branches are derived directly from the sacral plexus. The muscular branches of

the sciatic nerve are distributed to the biceps femoris, semitendinosus, and semimembranosus

muscles, and to the ischial head of the adductor magnus. The two components of the nerve (tibial and

common peroneal) diverge approximately 4 to 10 cm above the popliteal crease to separately

continue their paths into the lower leg.

FIGURE 19.1-2. The course and motor innervation of the sciatic nerve.

FIGURE 19.1-3. Anatomy of the sciatic nerve at the subgluteal location. sciatic nerve. nerve

branch to the gluteus muscle. ischial bone. greater trochanter. posterior superior iliac spine.

gluteus muscle.

TIPS

There are numerous variations in the course of the sciatic nerve through the gluteal region. In about

15% of the population, the piriformis muscle divides the nerve. The common peroneal component

passes through or above the muscle, and the tibial component passes below it.

The components of the sciatic nerve diverge at a variable distance from the knee joint. By and large,

most nerves diverge at 4 to 10 cm above the popliteal fossa crease.

Distribution of Blockade

A sciatic nerve block results in anesthesia of the skin of the posterior aspect of the thigh, hamstring,

and biceps femoris muscles; part of the hip and knee joint; and the entire leg below the knee with the

exception of the skin of the medial aspect of the lower leg (Figure 19.1-4). Depending on the level of

surgery, the addition of a saphenous or femoral nerve block may be required to provide coverage for

this area.

FIGURE 19.1-4. Sensory innervation of sciatic nerve and its terminal branches.

Single-Injection Sciatic Nerve Block

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

One 20-mL syringe containing local anesthetic

A 3- to 5-mL syringe plus 25-gauge needle with local anesthetic for skin infiltration

A 10-cm, 21-22 gauge short-bevel insulated stimulating needle

Peripheral nerve stimulator

Sterile gloves; marking pen

Landmarks and Patient Positioning

The patient is in the lateral decubitus position tilted slightly forward (Figure 19.1-5). The foot on the

side to be blocked should be positioned over the dependent leg so that elicited motor response of the

foot or toes can be easily observed.

FIGURE 19.1-5. The patient is positioned in a lateral oblique position with the dependent leg

extended and the leg to be blocked flexed in the knee.

TIP

The skin over the gluteal area is easily movable. Therefore, it is important that the patient remains in

the same position in which the landmarks are outlined. A small forward or backward tilt of the pelvis

can result in a significant shift of the landmarks, leading to difficulty localizing the sciatic nerve.

Landmarks for the posterior approach to a sciatic blockade are easily identified in most patients. A

proper palpation technique is important to adhere to because the adipose tissue over the gluteal area

can obscure these bony prominences. The landmarks are outlined with a marking pen:

. Greater trochanter (Figure 19.1-6)

FIGURE 19.1-6. Palpation technique for the greater trochanter.

. Posterior superior iliac spine (PSIS) (Figure 19.1-7)

FIGURE 19.1-7. Palpation technique for posterior superior iliac spine.

. Needle insertion point 4 cm distal to the midpoint between landmarks 1 and 2 (Figure 19.1-8)

FIGURE 19.1-8. The needle insertion site is marked 5 cm posterior on the line passing through the

midpoint between the greater trochanter 1 and the posterior superior iliac spine 2.

A line between the greater trochanter and the PSIS is drawn and divided in half. Another line

passing through the midpoint of this line and perpendicular to it is extended 4 cm caudal and marked

as the needle insertion point.

TIPS

Palpating the greater trochanter: The osseous prominence of the greater trochanter is best approached

from its posterior aspect, Figure 19.1-6.

Palpating the PSIS: The palpating hand is rolled back from the greater trochanter until the fingers meet

the osseous PSIS. This landmark should be labeled on the side facing the great trochanter, Figure

19.1-7.

Identifying the “inner” aspects of the greater trochanter and the posterior-superior iliac spine results in

a shorter line connecting the two and a more accurate approximation of the position of the sciatic

nerve.

Technique

After skin disinfection, local anesthetic is infiltrated subcutaneously at the needle insertion site. The

operator should assume an ergonomic position to allow precise needle maneuvering and monitoring

of the responses to nerve stimulation.

The fingers of the palpating hand should be firmly pressed on the gluteus area to decrease the skin

to nerve distance. Also, the skin between the index and middle fingers should be stretched to allow

greater precision during block placement (Figure 19.1-9). The palpating hand should not be moved

during the entire procedure. Even small movements of the palpating hand can change the position of

the needle insertion site because of the highly movable skin and soft tissues in the gluteal region. The

needle is introduced perpendicular to the spherical skin plane. Initially, the nerve stimulator should

be set to deliver a current intensity of 1.5 mA to allow for the detection of both twitches of the gluteal

muscles as the needle passes through tissue layers and stimulation of the sciatic nerve.

FIGURE 19.1-9. Needle insertion for the transgluteal (posterior) approach to sciatic nerve block.

As the needle is advanced, twitches of the gluteal muscles are observed first. These twitches

merely indicate the needle position is still too shallow. Once the gluteal twitches disappear, brisk

response of the sciatic nerve ensues (hamstring, calf, foot, or toe twitches). After an initial stimulation

of the sciatic nerve is obtained, the stimulating current is gradually decreased until twitches are still

seen or felt at 0.2 to 0.5 mA. Typically, this occurs at a depth of 5 to 8 cm. At this low current

intensity, any observed motor response is from the stimulation of the sciatic nerve, rather than direct

muscle stimulation (false twitch). After negative aspiration for blood, 15 to 20 mL of local anesthetic

is injected slowly. Any resistance to the injection of local anesthetic should prompt cessation of the

injection and withdrawal of the needle by 1 mm before reattempting to inject. Persistent resistance to

injection should prompt complete needle withdrawal and flushing to ensure the patency of the needle

before reattempting the procedure.

GOAL

The aim is to obtain visible or palpable twitches of the hamstrings, calf muscles, foot, or toes at

0.2 to 0.5 mA. Twitches of the hamstring are equally acceptable with the transgluteal approach

because level of the block is proximal to the departure of the nerve branches to the hamstring

muscle.

Troubleshooting

Table 19.1-1 lists some common responses to nerve stimulation and the course of action to take to

obtain the proper response.

TABLE 19.1-1 Some Common Responses to Nerve Stimulation and Course of Action for Proper

Response

TIP

Stimulation at a current intensity <0.5 mA may not be possible in some patients. This may occur in

elderly patients and in patients with long-standing diabetes mellitus, peripheral neuropathy, sepsis, or

severe peripheral vascular disease. In these cases, stimulating currents up to 1.0 mA should be

accepted as long as the motor response is distal, specific and clearly seen or felt.

We do not advise to use epinephrine in sciatic nerve blockade because of the possibility of ischemia

of the sciatic nerve that could result due to the combination of stretching or sitting on the anesthetized

nerve and the long duration of blockade.

Block Dynamics and Perioperative Management

This technique may be associated with patient discomfort because the needle passes through the

gluteus muscles. Adequate sedation and analgesia are important to ensure the patient is still and

tranquil. Typically, we use midazolam 2 to 4 mg after the patient is positioned and alfentanil 500 to

750 μg just before the needle is inserted. A typical onset time for this block is 10 to 25 minutes,

depending on the type, concentration, and volume of local anesthetic used. The first signs of onset of

the blockade are usually a report by the patient that the foot “feels different” or an inability to wiggle

the toes.

TIP

Inadequate skin anesthesia despite an apparently timely onset of the blockade can occur. It can take 30

minutes or more for full sensory-motor anesthesia to develop. However, local infiltration by the

surgeon at the site of the incision is often all that is needed to allow the surgery to proceed until the

block fully sets up.

Continuous Sciatic Nerve Block

Adequate experience with the single-injection technique is necessary to ensure efficacy and safety of

the continuous block. The procedure is quite similar to the single-injection procedure; however, a

slight angulation of the needle caudally is necessary after obtaining the nerve response to facilitate

threading of the catheter. This technique can be used for surgery and postoperative pain management

in patients undergoing a wide variety of lower leg, foot, and ankle surgeries. In our practice, perhaps

the single most important indication for use of this block is for amputation of the lower extremity.

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

One 20-mL syringe containing local anesthetic

Sterile gloves, marking pen, and surface electrode

A 3- to 5-mL syringe plus 25-gauge needle with local anesthetic for skin infiltration

Peripheral nerve stimulator

Catheter kit (including an 8- to 10-cm large-gauge stimulating needle and catheter)

Kits come in two varieties based on catheter construction: nonstimulating (conventional) and

stimulating catheters. During the placement of a nonstimulating catheter, the needle is advanced first

until appropriate twitches are obtained. Then 5 to 10 mL of local anesthetic or other injectate (e.g.,

D5W) is injected to “open up” a space for the catheter to facilitate its insertion. The catheter is

threaded through the needle until approximately 3 to 5 cm is protruding beyond the tip of the needle.

The needle is withdrawn, the catheter secured, and the remaining local anesthetic is injected via the

catheter. Stimulating catheters are insulated and have a filament or core that transmits current to a

bare metal tip. After obtaining twitches via the needle, the catheter is advanced with the nerve

stimulator guidance while the motor response of the foot, calf, or toes is maintained. With the catheter

technique, motor response of ≤1.0 mA is adequate. If the motor response is lost, the catheter can be

withdrawn until it reappears, and the catheter is then readvanced while maintaining the response. This

method requires that only nonconducting solution be injected through the needle (e.g., dextrose) prior

to catheter advancement.

Landmarks and Patient Positioning

Proper patient positioning at the outset and maintenance of this position during performance of a

continuous sciatic nerve blockade is crucial for precise catheter placement.

The patient is placed in the lateral decubitus position similar to the single-injection block. A

slightly forward pelvic tilt prevents “sagging” of the soft tissues in the gluteal area and significantly

facilitates block placement.

The landmarks for a continuous sciatic block are the same as those in the single-injection technique

(Figure 19.1-8):

. Greater trochanter

. Posterior superior iliac spine

. Needle insertion site 4 cm caudal to the midpoint of the line between landmarks 1 and 2

Technique

The continuous sciatic block technique is similar to the single-injection technique. With the patient in

the lateral decubitus position and tilted slightly forward, the landmarks are identified and marked

with the pen. After a thorough cleaning of the area with an antiseptic solution, the skin at the needle

insertion site is infiltrated with local anesthetic. The palpating hand is positioned and fixed around the

site of needle insertion to shorten the skin to nerve distance.

A 10-cm continuous block needle is connected to the nerve stimulator and inserted perpendicularly

to the skin (Figure 19.1-10). The initial intensity of the stimulating current should be 1.0 to 1.5 mA.

FIGURE 19.1-10. Insertion of the catheter for continuous sciatic nerve block.

TIP

It is useful to inject some local anesthetic intramuscularly to prevent pain during advancement of the

needle.

When a stimulating catheter is used, motor response at a current intensity ≤1.0 mA is adequate.

As the needle is advanced, twitches of the gluteus muscle are observed first. Deeper needle

advancement results in stimulation of the sciatic nerve. The principles of nerve stimulation and needle

redirection are identical to those for the single-injection technique. After obtaining the appropriate

twitches, the needle is manipulated until the desired response (twitches of the hamstrings muscles or

foot) is seen or felt using a current of 0.5-1.0 mA. The catheter should be advanced 3-5 cm beyond the

needle tip. The needle is withdrawn back to the skin level, and the catheter advanced simultaneously

to prevent inadvertent removal of the catheter.

The catheter is checked for inadvertent intravascular placement and secured to the buttock using an

adhesive skin preparation such as benzoin or Dermabond, followed by application of a clear

occlusive dressing. The infusion port should be clearly marked “continuous nerve block.”

TIP

When insertion of the catheter proves difficult, lowering the angle of the needle can be helpful.

Continuous Infusion

Continuous infusion is always initiated after administration of an initial bolus of dilute local

anesthetic through the needle or catheter. For this purpose, we routinely use 0.2% ropivacaine 15 to

20 mL. Diluted bupivacaine or levobupivacaine are suitable but can result in more pronounced motor

blockade. The infusion is maintained at 5 to 10 mL/h when a patient-controlled regional analgesic

dose (5 mL every 60 minutes) is planned.

TIPS

Breakthrough pain in patients undergoing a continuous infusion is always managed by administering a

bolus of local anesthetic. Simply increasing the rate of infusion is never adequate.

For patients on the ward, a higher concentration of a shorter acting local anesthetic (e.g., 1%

lidocaine) is useful both to treat the pain quickly and to test the position of the catheter.

When the bolus injection through the catheter fails to result in blockade after 30 minutes, the catheter

should be considered dislodged and should be removed.

Complications and How to Avoid Them

Table 19.1-2 lists some general and specific instructions on possible complications and methods used

to avoid them.

TABLE 19.1-2 Complications of Sciatic Nerve Block and Preventive Techniques

SUGGESTED READINGS

Altermatt F, Cortinez LI, Munoz H. Plasma levels of levobupivacaine after combined posterior lumbar

plexus and sciatic nerve blocks. Anesth Analg. 2006;102(5):1597.

Bailey SL, et al. Sciatic nerve block. A comparison of single versus double injection technique. Reg

Anesth. 1994;19(1):9-13.

Ben-David B, Schmalenberger K, Chelly JE. Analgesia after total knee arthroplasty: is continuous

sciatic blockade needed in addition to continuous femoral blockade? Anesth Analg. 2004;98(3):747-

749.

Bridenbaugh PO, Wedel DJ. The lower extremity: somatic blockade. In: Cousins MJ, Bridenbaugh PO,

eds. Neuronal Blockade in Clinical Anesthesia and Management of Pain. 3rd ed. Philadelphia, PA:

Lippincott-Raven; 1998:375–394.

Brummett CM, et al. Perineural dexmedetomidine added to ropivacaine causes a dose-dependent

increase in the duration of thermal antinociception in sciatic nerve block in rat. Anesthesiology.

2009;111(5):1111-1119.

Candido KD, Sukhani R, McCarthy RJ. Posterior approach to the sciatic nerve: can “common sense”

replace science and logic? Anesthesiology. 2003;99(5):1237-1238.

Capdevila X, Ponrouch M, Choquet O. Continuous peripheral nerve blocks in clinical practice. Curr

Opin Anaesthesiol. 2008;21(5):619-623.

Casati A, et al. A double-blinded, randomized comparison of either 0.5% levobupivacaine or 0.5%

ropivacaine for sciatic nerve block. Anesth Analg. 2002;94(4):987-990.

Casati A, et al. Levobupivacaine 0.2% or 0.125% for continuous sciatic nerve block: a prospective,

randomized, double-blind comparison with 0.2% ropivacaine. Anesth Analg. 2004;99(3):919-923.

Casati A, et al. Using stimulating catheters for continuous sciatic nerve block shortens onset time of

surgical block and minimizes postoperative consumption of pain medication after halux valgus repair

as compared with conventional nonstimulating catheters. Anesth Analg. 2005;101(4):1192-1197.

Chan VW, et al. Ultrasound examination and localization of the sciatic nerve: a volunteer study.

Anesthesiology. 2006; 104(2):309-314.

Crabtree EC, et al. A method to estimate the depth of the sciatic nerve during subgluteal block by using

thigh diameter as a guide. Reg Anesth Pain Med. 2006;31(4):358-362.

Cuvillon P, et al. Comparison of the parasacral approach and the posterior approach, with single- and

double-injection techniques, to block the sciatic nerve. Anesthesiology. 2003;98(6):1436-1441.

Dalens B, Tanguy A, Vanneuville G. Sciatic nerve blocks in children: comparison of the posterior,

anterior, and lateral approaches in 180 pediatric patients. Anesth Analg. 1990;70(2):131-137.

Danelli G, et al. Ultrasound vs nerve stimulation multiple injection technique for posterior popliteal

sciatic nerve block. Anaesthesia. 2009;64(6):638-642.

i Benedetto P, et al. A new posterior approach to the sciatic nerve block: a prospective, randomized

comparison with the classic posterior approach. Anesth Analg. 2001;93(4):1040-1044.

i Benedetto P, et al. Postoperative analgesia with continuous sciatic nerve block after foot surgery: a

prospective, randomized comparison between the popliteal and subgluteal approaches. Anesth Analg.

2002;94(4):996–1000.

i Benedetto P, et al. Continuous sciatic nerve block: how to choose among different proximal

approaches? Gluteal or subgluteal continuous sciatic nerve block. Anesth Analg. 2003;97(1):296-

297.

i Benedetto P, Casati A, Bertini L. Continuous subgluteus sciatic nerve block after orthopedic foot and

ankle surgery: comparison of two infusion techniques. Reg Anesth Pain Med. 2002;27(2): 168-172.

Ericksen ML, Swenson JD, Pace NL. The anatomic relationship of the sciatic nerve to the lesser

trochanter: implications for anterior sciatic nerve block. Anesth Analg. 2002;95(4):1071-1074.

arny J, Girard M, Drolet P. Posterior approach to the lumbar plexus combined with a sciatic nerve

block using lidocaine. Can J Anaesth. 1994;41(6):486-491.

loch H, et al. Computed tomography scanning of the sciatic nerve posterior to the femur: practical

implications for the lateral midfemoral block. Reg Anesth Pain Med. 2003;28(5):445-449.

ournier R, et al. Levobupivacaine 0.5% provides longer analgesia after sciatic nerve block using the

Labat approach than the same dose of ropivacaine in foot and ankle surgery. Anesth Analg.

2010;110(5):1486-1489.

ranco CD. Posterior approach to the sciatic nerve in adults: is euclidean geometry still necessary?

Anesthesiology. 2003;98(3):723-728.

ranco CD, et al. A subgluteal approach to the sciatic nerve in adults at 10 cm from the midline. Reg

Anesth Pain Med. 2006;31(3):215-220.

ranco CD, Tyler SG. Modified subgluteal approach to the sciatic nerve. Anesth Analg.

2003;97(4):1197.

uzier R, et al. Does the sciatic nerve approach influence thigh tourniquet tolerance during below-knee

surgery? Anesth Analg. 2005;100(5):1511-1514.

Gaertner E, et al. Continuous parasacral sciatic block: a radiographic study. Anesth Analg.

2004;98(3):831-834; table of contents.

Hadžić A, et al. The practice of peripheral nerve blocks in the United States: a national survey. Reg

Anesth Pain Med. 1998;23(3):241-246.

Hagon BS, et al. Parasacral sciatic nerve block: does the elicited motor response predict the success

rate? Anesth Analg. 2007;105(1):263-266.

Hanks RK, et al. The effect of age on sciatic nerve block duration. Anesth Analg. 2006;102(2):588-592.

Helayel PE, et al. Urinary incontinence after bilateral parasacral sciatic-nerve block: report of two

cases. Reg Anesth Pain Med. 2006;31(4):368-371.

ochum D, et al. Adding a selective obturator nerve block to the parasacral sciatic nerve block: an

evaluation. Anesth Analg. 2004;99(5):1544-1549.

Kilpatrick AW, Coventry DM, Todd JG. A comparison of two approaches to sciatic nerve block.

Anaesthesia. 1992;47(2):155-157.

Klein SM, et al. Ambulatory surgery for multi-ligament knee reconstruction with continuous dual

catheter peripheral nerve blockade. Can J Anaesth. 2001;48(4):375-378.

Kumar A. Evaluation of a new posterior subgluteus approach to sciatic nerve. Anesth Analg.

2002;95(3):780.

Latzke D, et al. Minimal local anaesthetic volumes for sciatic nerve block: evaluation of ED 99 in

volunteers. Br J Anaesth. 2010;104(2):239-244.

Levesque S, Delbos A. Sciatic nerve block for total-knee replacement: is it really necessary in all

patients? Reg Anesth Pain Med. 2005;30(4):410-411.

Mansour NY, Bennetts FE. An observational study of combined continuous lumbar plexus and singleshot sciatic nerve blocks for post-knee surgery analgesia. Reg Anesth. 1996;21(4):287-291.

Merchan MC, et al. The sciatic nerve block: a new posterior approach to sacral plexus. Reg Anesth

Pain Med. 2002;27(3):333-334.

Moayeri N, Groen GJ. Differences in quantitative architecture of sciatic nerve may explain differences

in potential vulnerability to nerve injury, onset time, and minimum effective anesthetic volume.

Anesthesiology. 2009;111(5):1128-1134.

Morin AM, et al. Postoperative analgesia and functional recovery after total-knee replacement:

comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral

nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg Anesth Pain

Med. 2005;30(5):434-445.

Morrow MJ. The lateral approach to the sciatic nerve. Anesth Analg. 2000;90(3):770.

Nader A, et al, Sensory testing of distal sural and posterior tibial nerves provides early prediction of

surgical anesthesia after single-injection infragluteal-parabiceps sciatic nerve block. Anesth Analg.

2010;110(3):951-957.

Navas AM, de la Tabla Gonzalez RO, Gutierrez TV. Combined femoral-sciatic catheters for

postoperative pain treatment after total knee replacement. Anesth Analg. 2007;105(1):288.

ham Dang C, et al. The value of adding sciatic block to continuous femoral block for analgesia after

total knee replacement. Reg Anesth Pain Med. 2005;30(2):128-133.

Ripart J, et al. Parasacral approach to block the sciatic nerve: a 400-case survey. Reg Anesth Pain

Med., 2005;30(2):193-197.

Robards C, et al. Sciatic nerve catheter placement: success with using the Raj approach. Anesth Analg.

2009;109(3):972-975.

Rodriguez J, et al. Intraneural catheterization of the sciatic nerve in humans: a pilot study. Reg Anesth

Pain Med. 2008;33(4):285-290.

ala-Blanch X, et al. Structural injury to the human sciatic nerve after intraneural needle insertion. Reg

Anesth Pain Med. 2009;34(3):201-205.

ciard D, Lam N, Hussain M. Continuous sciatic nerve block and total-knee arthroplasty. Reg Anesth

Pain Med. 2005;30(4):411-412.

mith BE, Siggins D. Low volume, high concentration block of the sciatic nerve. Anaesthesia.

1988;43(1):8-11.

ouron V, Eyrolle L, Rosencher N. The Mansour’s sacral plexus block: an effective technique for

continuous block. Reg Anesth Pain Med. 2000;25(2):208-209.

ukhani R, et al. Infragluteal-parabiceps sciatic nerve block: an evaluation of a novel approach using a

single-injection technique. Anesth Analg. 2003;96(3):868-873.

ukhani R, et al. Nerve stimulator-assisted evoked motor response predicts the latency and success of a

single-injection sciatic block. Anesth Analg. 2004;99(2):584-588.

uresh S, et al. Anatomical location of the bifurcation of the sciatic nerve in the posterior thigh in

infants and children: a formula derived from MRI imaging for nerve localization. Reg Anesth Pain

Med. 2007;32(4):351-353.

utherland ID. Continuous sciatic nerve infusion: expanded case report describing a new approach. Reg

Anesth Pain Med. 1998;23(5):496-501.

Taboada M, et al. The effects of three different approaches on the onset time of sciatic nerve blocks

with 0.75% ropivacaine. Anesth Analg. 2004;98(1):242-247.

Taboada M, et al. Plantar flexion seems more reliable than dorsiflexion with Labat’s sciatic nerve

block: a prospective, randomized comparison. Anesth Analg. 2005;100(1):250-254.

Taboada M, et al. Does the site of injection distal to the greater trochanter make a difference in lateral

sciatic nerve blockade? Anesth Analg. 2005;101(4):1188-1191.

Taboada M, et al. What is the minimum effective volume of local anesthetic required for sciatic nerve

blockade? A prospective, randomized comparison between a popliteal and a subgluteal approach.

Anesth Analg. 2006;102(2):593-597.

Taboada M, et al. A prospective, randomized comparison between the popliteal and subgluteal

approaches for continuous sciatic nerve block with stimulating catheters. Anesth Analg.

2006;103(1):244-247.

Taboada M, et al. Two unusual cases of urinary incontinence during continuous sciatic nerve block with

stimulating catheters. Anesth Analg. 2009;108(3):1042-1043.

Taboada Muniz M, et al. Low volume and high concentration of local anesthetic is more efficacious

than high volume and low concentration in Labat’s sciatic nerve block: a prospective, randomized

comparison. Anesth Analg. 2008;107(6):2085-2088.

Tobe M, et al. Long-term effect of sciatic nerve block with slow-release lidocaine in a rat model of

postoperative pain. Anesthesiology. 2010;112(6):1473-1481.

Tran D, Clemente A, Finlayson RJ. A review of approaches and techniques for lower extremity nerve

blocks. Can J Anaesth. 2007;54(11):922-934.

Tsai TP, et al. Intensity of the stimulating current may not be a reliable indicator of intraneural needle

placement. Reg Anesth Pain Med. 2008;33(3):207-210.

Urmey WF, Grossi P. Use of sequential electrical nerve stimuli (SENS) for location of the sciatic nerve

and lumbar plexus. Reg Anesth Pain Med. 2006;31(5):463-469.

Vanterpool S, et al. Combined lumbar-plexus and sciatic-nerve blocks: an analysis of plasma

ropivacaine concentrations. Reg Anesth Pain Med. 2006;31(5):417-421.

Voelckel WG, et al. Signs of inflammation after sciatic nerve block in pigs. Anesth Analg.

2005;101(6):1844-1846.

Wang CF, et al. An absorbable local anesthetic matrix provides several days of functional sciatic nerve

blockade. Anesth Analg. 2009;108(3):1027-1033.

Williams BA, et al. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated

with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from

the period 1996–1999. Anesthesiology. 2003;98(5):1206-1213.

Yung E, et al. Bicarbonate plus epinephrine shortens the onset and prolongs the duration of sciatic block

using chloroprocaine followed by bupivacaine in sprague-dawley rats. Reg Anesth Pain Med.

2009;34(3):196-200.

aric D, et al. A comparison of epidural analgesia with combined continuous femoral-sciatic nerve

blocks after total knee replacement. Anesth Analg. 2006;102(4):1240-1246.

PART 2: ANTERIOR APPROACH

General Considerations

The anterior approach to sciatic block is an advanced nerve block technique. The block is well-suited

for surgery on the leg below the knee, particularly on the ankle and foot. It provides complete

anesthesia of the leg below the knee with the exception of the medial strip of skin, which is innervated

by the saphenous nerve. When combined with a femoral nerve block, this procedure results in

anesthesia of the entire knee and leg. It should be noted that the anterior approach may have less

utility compared with the posterior approach. The sciatic nerve is blocked more distally, and a higher

level of skill is required to achieve reliable anesthesia. Consequently, we reserve the use of this

block for patients who cannot be repositioned into the lateral position needed for the posterior

approach. This technique is not ideal for catheter insertion because of the deep location and

perpendicular angle of insertion required to reach the sciatic nerve.

Functional Anatomy

The sciatic nerve is formed from the L4 through S3 roots. The roots of the sacral plexus combine on

the anterior surface of the sacrum and are assembled into the sciatic nerve on the anterior surface of

the piriformis muscle. The course of the nerve can be estimated by drawing a line on the back of the

thigh from the apex of the popliteal fossa to the midpoint of a line joining the ischial tuberosity to the

apex of the greater trochanter. The nerve exits the pelvis through the greater sciatic notch and gives

off numerous articular (hip, knee) and muscular branches. Once in the upper thigh, it continues its

descent behind the lesser trochanter and becomes completely covered by the femur. The only part of

the nerve accessible to blockade through an anterior approach is a short segment slightly above and

below the lesser trochanter. The muscular branches of the sciatic nerve are distributed to the biceps

femoris, semitendinosus, and semimembranosus, and to the ischial head of the adductor magnus.

TIP

Because the level of the blockade with the anterior approach to sciatic block is often below the

departure of the muscular branches, twitches of the hamstring muscles cannot be accepted as a

reliable sign of localization of the main trunk of the sciatic nerve.

Distribution of Blockade

A sciatic nerve block through the anterior approach results in anesthesia of the hamstring muscles

below the blockade and the entire leg below the knee (including the ankle and foot) except for a strip

of skin over the medial aspect. The distal two thirds of the hamstring muscles are also anesthetized.

Neither the posterior cutaneous nerve of the thigh and articular branches of the hip are anesthetized,

nor the skin over the medial aspect of the leg below, because it is innervated by the saphenous nerve,

a branch of the femoral nerve. Consequently, the anterior approach to sciatic block should be chosen

for selected patients undergoing knee or below-knee surgery who also are unable to be positioned for

the posterior approach. A proximal thigh tourniquet should be reconsidered with this technique

because of the risk of prolonged ischemia of the sciatic nerve, particularly when epinephrinecontaining solutions of local anesthetics are used.

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

One 20-mL syringe containing local anesthetic

A 3- to 5-mL syringe plus a 25-gauge needle with local anesthetic for skin infiltration

A 1.5-mm, 22-gauge short-bevel insulated stimulating needle

Peripheral nerve stimulator

Sterile gloves; marking pen

Landmarks and Patient Positioning

The patient is in the supine position with both legs fully extended.

TIP

Placing a pillow underneath the patient’s hips can be useful to optimize access to the groin and

landmarks for the block.

The following landmarks should be outlined routinely using a marking pen:

. Femoral crease (Figure 19.2-1).

FIGURE 19.2-1. Landmarks for anterior sciatic block. Femoral crease is outlined as a line

connecting anterior superior iliac spine (semicircle) and the finger palpating the pubic bone.

. Femoral artery pulse (Figure 19.2-2).

FIGURE 19.2-2. Landmarks for the anterior sciatic nerve block. The index finger is on the pulse of

the femoral artery.

. Needle insertion point is marked 4 to 5 cm distally to the femoral crease on a line passing through the

pulse of the femoral artery and perpendicularly to the femoral crease (Figures 19.2-3 and 19.2-4).

FIGURE 19.2-3. A line passing through the pulse of the femoral artery and perpendicular to the

femoral crease is drawn.

FIGURE 19.2-4. Point of needle insertion is labeled 4-5 cm from the femoral crease on the

perpendicular line that passes through the femoral pulse

TIP

Avoid displacing the soft tissues laterally or medially during palpation of the femoral artery. The skin

and subcutaneous tissue in this area are highly movable, and lateral or medial displacement of the

tissues can skew the femoral artery landmark.

Technique

After cleaning the area with an antiseptic solution, local anesthetic is infiltrated subcutaneously at the

determined needle insertion site. The operator should stand on the side of the patient to be blocked

and have the ipsilateral foot in the line of vision to be able to monitor the patient and the responses to

nerve stimulation.

The fingers of the palpating hand should be firmly pressed against the quadriceps muscle to

decrease the skin-nerve distance and stabilize the needle path. The needle is introduced at an angle

perpendicular to the skin plane (Figure 19.2-5). Initially, the nerve stimulator should be set to deliver

a 1.5-mA current, as with all “deep” blocks. The current of higher intensity results in an exaggerated

motor response, decreasing the chance of missing this twitch of the foot or toes during nerve

localization.. The twitch of the foot or toes typically occurs at a depth of 10 to 12 cm. After obtaining

negative results from an aspiration test for blood, 15 to 20 mL of local anesthetic is slowly injected.

Any resistance to the injection of local anesthetic should prompt cessation of the injection attempt,

followed by slight withdrawal. Persistent resistance to injection should prompt complete needle

withdrawal and flushing of the needle before reattempting the block; see “tips” for more explanation

of the importance of this strategy.

FIGURE 19.2-5. Needle insertion for anterior sciatic block.

TIP

Because the needle transverses muscle planes, it is occasionally obstructed by muscle fibers.

However, when resistance to injection is met, it is never correct to assume the needle is obstructed.

The proper action is to withdraw the needle and check its patency by flushing before reinserting it.

GOAL

Visible or palpable twitches of the calf muscles, foot, or toes at 0.2 to 0.5 mA.

TIPS

• Local twitches of the quadriceps muscle are elicited often during needle advancement. The needle

should be advanced past these twitches.

• Although there is a concern about femoral nerve injury with further needle advancement, this

concern is theoretical. At this level, the femoral nerve is divided into smaller terminal branches

that are mobile and are unlikely to be penetrated by a slowly advancing, short-beveled needle.

• Resting the heel on the bed surface may prevent the foot from twitching even when the sciatic

nerve is stimulated. This can be prevented by placing the ankle on a footrest or by having an

assistant continuously palpate the calf or Achilles’ tendon.

• Because branches to the hamstring muscle may leave the main trunk of the sciatic nerve before the

level of needle insertion, twitches of the hamstring should not be accepted as a reliable sign of

sciatic nerve localization Figure 19.1-2.

• Bone contact is frequently encountered during needle advancement, indicating the needle has

contacted the femur (usually the lesser trochanter) (Figure 19.2-6). When the needle is stopped by

the bone, the following algorithm is used:

FIGURE 19.2-6. Needle pass required to reach the sciatic nerve through the anterior approach. Note

that the lesser trochanter of the femur partially obscures the sciatic nerve. Internal rotation of the

leg (arrow) is beneficial in allowing access of the needle to the sciatic nerve .

Withdraw the needle back to the subcutaneous tissue.

Rotate the foot inward (internal rotation).

Advance the needle to bypass the lesser trochanter. The internal rotation of the leg also rotates

the lesser trochanter posteriorly and away from the path of the needle and often allows passage of

the needle toward the sciatic nerve.

When steps 1-3 fail to facilitate passage of the needle, the needle is withdrawn back to the skin

and reinserted 1-2 cm medial to the initial insertion site and at a slightly medial angulation

(Figure 19.2-7).

FIGURE 19.2-7. When the needle fails to pass by the trochanter minor despite internal leg rotation,

the needle is inserted 1–2 cm medial to the initial insertion and advanced in a slight medial to lateral

direction to reach the sciatic nerve.

Troubleshooting

Some common responses to nerve stimulation and the course of action to take to obtain the proper

response are given in Table 19.2-1.

TABLE 19.2-1 Common Responses to Nerve Stimulation and Course of Action for Proper Response

TIP

We avoid the use of epinephrine for the anterior approach to a sciatic nerve block because of the

perceived risk of nerve ischemia due to the combined effects of the vasoconstrictive action of

epinephrine and application of a tourniquet.

Block Dynamics and Perioperative Management

Performance of the anterior approach to a sciatic block is associated with patient discomfort because

the needle must transverse multiple muscle planes on its way to the sciatic nerve. The administration

of midazolam 2 to 4 mg after the patient is positioned and alfentanil 500–1000 mg just before

infiltration of local anesthetic is beneficial to allay anxiety and decrease discomfort during the

procedure in most patients. A typical onset time for this block is 20 to 30 minutes, depending on the

type, concentration, and volume of local anesthetic used. The first sign of blockade onset is usually a

report by the patient that the foot “feels different” or an inability to wiggle the toes.

TIP

When indicated, the femoral block is performed first, resulting in anesthesia of the skin and muscle

overlying the needle path for the anterior sciatic block and less patient discomfort.

Complications and How to Avoid Them

Table 19.2-2 lists some general and specific instructions on possible complications and methods that

can be used to avoid them.

TABLE 19.2-2 Complications of Anterior Approach to Sciatic Nerve Block and Preventive

Techniques

SUGGESTED READINGS

Barbero C, Fuzier R, Samii K. Anterior approach to the sciatic nerve block: adaptation to the patient’s

height. Anesth Analg. 2004;98(6):1785-1788.

Blumenthal S, Lambert M, Borgeat A. Intraneural injection during anterior approach for sciatic nerve

block: what have we learned and where to go from here? Anesthesiology. 2005;102(6):1283.

Chelly JE, Delaunay L. A new anterior approach to the sciatic nerve block. Anesthesiology.

1999;91(6):1655-1660.

Ericksen ML, Swenson JD, Pace NL. The anatomic relationship of the sciatic nerve to the lesser

trochanter: implications for anterior sciatic nerve block. Anesth Analg. 2002;95(4):1071-1074.

Magora F, Pessachovitch B, Shoham I. Sciatic nerve block by the anterior approach for operations on

the lower extremity. Br J Anaesth. 1974;46(2):121-123.

Mansour NY. Anterior approach revisited and another new sciatic nerve block in the supine position.

Reg Anesth. 1993;18(4):265-266.

McNicol LR. Sciatic nerve block for children. Sciatic nerve block by the anterior approach for

postoperative pain relief. Anaesthesia. 1985;40(5):410-414.

McNicol LR. Anterior approach to sciatic nerve block in children: loss of resistance or nerve

stimulator for identifying the neurovascular compartment. Anesth Analg. 1987;66(11):1199-1200.

Moore CS, Sheppard D, Wildsmith JA. Thigh rotation and the anterior approach to the sciatic nerve: a

magnetic resonance imaging study. Reg Anesth Pain Med. 2004;29(1):32-35.

andin P, et al. The anterior combined approach via a single skin injection site allows lower limb

anesthesia in supine patients. Can J Anaesth. 2003;50(8):801-804.

lante T Jr, Chaubard M, Delbos A. Unintentional transient sciatic nerve block after knee infiltration

with local anesthetics. Reg Anesth Pain Med. 2007;32(6):547-548.

ala-Blanch X, et al. Intraneural injection during anterior approach for sciatic nerve block.

Anesthesiology. 2004;101(4): 1027-1030.

hah S, et al. Neurologic complication after anterior sciatic nerve block. Anesth Analg.

2005;100(5):1515-1517.

Thota RS, et al. The anterior approach to sciatic nerve block using fluoroscopic guidance and radioopaque dye. Anesth Analg. 2007;104(2):461-462.

Tran D, Clemente A, Finlayson RJ, A review of approaches and techniques for lower extremity nerve

blocks. Can J Anaesth. 2007;54(11):922-934.

Tran KM, et al. Intraarticular bupivacaine-clonidine-morphine versus femoral-sciatic nerve block in

pediatric patients undergoing anterior cruciate ligament reconstruction. Anesth Analg.

2005;101(5):1304-1310.

Valade N, et al. Does sciatic parasacral injection spread to the obturator nerve? An anatomic study.

Anesth Analg. 2008;106(2):664-667.

Van Elstraete AC, et al. New landmarks for the anterior approach to the sciatic nerve block: imaging

and clinical study. Anesth Analg. 2002;95(1):214-218.

Vloka JD, et al. Anterior approach to the sciatic nerve block: the effects of leg rotation. Anesth Analg.

2001;92(2):460-462.

Wiegel M, et al. Anterior sciatic nerve block—new landmarks and clinical experience. Acta

Anaesthesiol Scand. 2005;49(4):552-557.

Popliteal Sciatic Block

FIGURE 20.1-1. (A) Needle insertion for the popliteal intertendinous approach. (B) Needle

insertion for lateral approach to popliteal block.

PART 1: INTERTENDINOUS APPROACH

General Considerations

The popliteal block is a block of the sciatic nerve at the level of the popliteal fossa. This block is one

of the most useful blocks in our practice. Common indications include corrective foot surgery, foot

debridement, and Achilles tendon repair. A sound knowledge of the principles of nerve stimulation

and the anatomic characteristics of the connective tissue sheaths of the sciatic nerve in the popliteal

fossa are essential for its successful implementation.

Functional Anatomy

The sciatic nerve is a nerve bundle consisting of two separate nerve trunks, the tibial and the common

peroneal nerves (Figure 20.1-2). A common epineural sheath envelops these two nerves at their

outset in pelvis. As the sciatic nerve descends toward the knee, the two components eventually

diverge in the popliteal fossa to continue their paths separately as the tibial and the common peroneal

nerves. This division of the sciatic nerve usually occurs between 4 and 10 cm proximal to the

popliteal fossa crease. From its divergence from the sciatic nerve, the common peroneal nerve

continues its path downward and laterally, descending along the head and neck of the fibula, Figure

20.1-2. Its major branches in this region are branches to the knee joint and cutaneous branches to the

sural nerve. Its terminal branches are the superficial and deep peroneal nerves. The tibial nerve is the

larger of the two divisions of the sciatic nerve. It continues its path vertically through the popliteal

fossa, and its terminal branches are the medial and lateral plantar nerves, Figure 20.1-2. Its collateral

branches give rise to the medial cutaneous sural nerve, muscular branches to the muscles of the calf,

and articular branches to the ankle joint. It is important to note that the sciatic nerve in the popliteal

fossa is lateral and superficial to the popliteal artery and vein, and it is contained in its own tissue

(epineural) sheath rather than in a common neurovascular tissue sheath. This anatomic characteristic

explains the relatively low risk of systemic toxicity and vascular punctures with a popliteal block

(Figure 20.1-3). However, the proximity of the large vessels, popliteal artery, and vein still makes it

imperative to carefully rule out an intravascular needle placement by careful aspiration and

meticulously slow injection (e.g., ≤20 mL/min).

FIGURE 20.1-2. Anatomy of the sciatic nerve in the popliteal fossa. The sciatic nerve is shown

with its two divisions, tibial and common peroneal nerves. The common sciatic nerve (1) is is

seen between semitendinosus ( , medially) and biceps ( , laterally) muscles enveloped by the thick

epineural sheath .

FIGURE 20.1-3. The spread of the contrast solution after injection into the common epineural sheath

of the sciatic nerve (SN). The sciatic nerve is positioned between the biceps femoris (BF) and

semimembranosus (SM) muscles. An extensive spread within the epineural sheath is seen.

Distribution of Blockade

A popliteal block results in anesthesia of the entire distal two thirds of the lower leg, with the

exception of the skin on the medial aspect. Cutaneous innervation of the medial leg below the knee is

provided by the saphenous nerve, a cutaneous terminal extension of the femoral nerve. When the

surgery is on the medial aspect of the leg, the addition of a saphenous nerve block or local anesthetic

infiltration at the incision site may be required for complete anesthesia. Popliteal block alone is

usually sufficient for tourniquet on the calf because the tourniquet discomfort is the result of pressure

and ischemia of the deep muscle beds and not of the skin and subcutaneous tissues.

Technique

Equipment

A standard regional anesthesia tray is prepared with the following equipment:

Sterile towels and gauze packs

Two 20-mL syringes containing local anesthetic

A 3- to 5-mL syringe plus 25-gauge needle with local anesthetic for skin infiltration

A 50 cm, 22-gauge short-bevel insulated stimulating needle

Peripheral nerve stimulator

Sterile gloves; marking pen

Landmarks and Patient Positioning

The patient is in the prone position. The foot on the side to be blocked should be positioned so that

even the slightest movements of the foot or toes can be easily observed. This is best achieved by

allowing the foot to extend beyond the operating room bed.

Landmarks for the intertendinous approach to a popliteal block are easily recognizable even in

obese patients (Figure 20.1-4):

FIGURE 20.1-4. Landmarks for the popliteal block. popliteal fossa crease. biceps femoris

tendon. semitendinosus semimembranous muscles.

. Popliteal fossa crease

. Tendon of the biceps femoris muscle (laterally)

. Tendons of the semitendinosus and semimembranosus muscles (medially)

Maneuvers to Facilitate Landmark Identification

The anatomic structures are best accentuated by asking the patient to elevate the foot while palpating

muscles against resistance. This allows for easier and more reliable identification of the hamstring

tendons. All three landmarks should be outlined with a marking pen.

TIPS

Relying on tendons rather than on a subjective interpretation of the popliteal fossa “triangle” results in

a more precise and consistent localization of the sciatic nerve.

In obese patients, it is easier to start tracing the tendons cephalad from their attachment at the knee.

The needle insertion point is marked at 7 cm above the popliteal fossa crease at the midpoint

between the two tendons (Figure 20.1-5).

FIGURE 20.1-5. The point of needle insertion (circle) is marked at 7 cm above the popliteal crease

between tendons of semitendinosus and semimembranosus muscles.

Technique

After a thorough cleaning of the injection site with an antiseptic solution, local anesthetic is infiltrated

subcutaneously. The anesthesiologist stands at the side of the patient with the palpating hand on the

biceps femoris muscle. The needle is introduced at the midpoint between the tendons (Figure 20.1-6).

This position allows the anesthesiologist to both observe the responses to nerve stimulation and

monitor the patient. The nerve stimulator should be initially set to deliver a current of 1.5 mA (2 Hz,

0.1 ms) because this higher current allows the detection of inadvertent needle placement into the

hamstring muscles (local twitches). When the needle is inserted in the correct plane, its advancement

should not result in any local muscle twitches; the first response to nerve stimulation is typically that

of the sciatic nerve (a foot twitch).

FIGURE 20.1-6. Needle insertion for the popliteal intertendinous approach. Needle is inserted at the

midpoint between the biceps femoris laterally and semitendinosus muscles medially.

TIPS

Keeping the fingers of the palpating hand on the biceps muscle is important for the early detection of

muscle twitches.

These local twitches are the result of direct muscle stimulation when the needle is placed too laterally

or medially, respectively.

Local twitches of the semitendinosus muscle indicate that the needle has been inserted too medially.

The needle should be withdrawn to skin level and reinserted laterally. Figure 20.1-7

FIGURE 20.1-7. The needle is re-oriented laterally when the contractions of the local twitches of the

semitendinosus and semimembranous muscles are elicited.

When local stimulation of the biceps muscle is felt under the fingers, the needle should be redirected

medially. Figure 20.1-8

FIGURE 20.1-8. The needle is re-oriented medially when local twitches of the biceps femoris

muscle are elicited.

After initial stimulation of the sciatic nerve is obtained, the stimulating current is gradually

decreased until twitches are still seen or felt at 0.2 to 0.5 mA. This typically occurs at a depth of 3 to

5 cm. After obtaining negative results from an aspiration test for blood, 30 to 40 mL of local

anesthetic is slowly injected.

GOAL

The aim is visible or palpable twitches of the foot or toes at 0.2 to 0.5 mA. There are two

common types of foot twitches:

• Common peroneal nerve stimulation results in dorsiflexion and eversion of the foot.

• Stimulation of the tibial nerve results in plantar flexion and inversion of the foot.

• Tibial nerve response is the preferred response.

TIPS

Stimulation at a current intensity <0.5 mA may not be possible in some patients. This is occasionally

(but not frequently) the case in patients with long-standing diabetes mellitus, peripheral neuropathy,

sepsis, or severe peripheral vascular disease. In these cases, stimulating currents up to 1.0 mA can be

accepted as long as the motor response is specific and clearly seen or felt.

Occasionally, a very small (e.g., 1 mm) movement of the needle results in a change in the motor

response from that of the popliteal nerve (plantar flexion of the foot) to that of the common peroneal

nerve (dorsiflexion of the foot). This indicates needle placement at a level before the divergence of

the sciatic nerve and should be accepted as the most reliable sign of localization of the common trunk

of the sciatic nerve.

Troubleshooting

When insertion of the needle does not result in stimulation of the sciatic nerve (foot twitches),

implement the following maneuvers:

. Keep the palpating hand in the same position.

. Withdraw the needle to skin level, redirect it 15° laterally, and reinsert it.

. When step 2 fails to result in sciatic nerve stimulation, withdraw the needle to skin level, reinsert it 1

cm laterally, and repeat the procedure first with perpendicular needle insertion.

. When the step 3 fails, reinsert the needle 15° laterally. These maneuvers should facilitate localization

of the sciatic nerve when it proves to be challenging.

TIPS

When obtaining the motor response is possible only with higher current intensity (≥0.5 mA),

stimulation of the tibial nerve (plantar flexion) is more reliable.

Isolated twitches of the calf muscles should not be accepted because they may result from stimulation

of the sciatic nerve branches to calf muscles outside the sciatic nerve sheath.

Table 20.1-1 lists some common responses to nerve stimulation and the course of action to take to

obtain the proper response.

TABLE 20.1-1 Common Responses to Nerve Stimulation and the Course of Action to Obtain the

Proper Response

Block Dynamics and Perioperative Management

This technique is associated with minor patient discomfort because the needle passes only through the

adipose tissue of the popliteal fossa. Administration of midazolam 1 to 2 mg after the patient is

positioned and alfentanil 250 to 500 μg just before block placement suffice as premedication for most

patients. A typical onset time for this block is 15 to 30 minutes, depending on the type, concentration,

and volume of local anesthetic used. The first signs of the onset of blockade are usually reports by the

patient’s of inability to move their toes or that the foot “feels different.” With this block, sensory

anesthesia of the skin is often the last to develop. Inadequate skin anesthesia despite the apparently

timely onset of the blockade is common and it may take up to 30 minutes to develop. Thus local

infiltration by the surgeon at the site of the incision is often all that is needed to allow the surgery to

proceed.

Continuous Popliteal Block

The technique is similar to a single-injection procedure; however, slight angulation of the needle

cephalad is necessary to facilitate threading the catheter. Securing and maintaining the catheter is easy

and convenient. This technique can be used for surgery and postoperative pain management in patients

undergoing a wide variety of lower leg, foot, and ankle surgeries.

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ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic part 05

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