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LETTER TO EDITOR
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 368-370

Ultrasound-guided adductor and sciatic nerve block: Two in one approach at mid-thigh level


1 Department of Anaesthesia, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Chandni Sinha
112, Block 2, AIIMS Residential Complex, Khagaul, Patna, Bihar
India
Poonam Kumari
Department of Anaesthesia, All India Institute of Medical Sciences, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.206808

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Date of Web Publication29-Jun-2017
 


How to cite this article:
Kumar A, Sinha C, Kumar A, Kumari P. Ultrasound-guided adductor and sciatic nerve block: Two in one approach at mid-thigh level. Saudi J Anaesth 2017;11:368-70

How to cite this URL:
Kumar A, Sinha C, Kumar A, Kumari P. Ultrasound-guided adductor and sciatic nerve block: Two in one approach at mid-thigh level. Saudi J Anaesth [serial online] 2017 [cited 2017 Sep 20];11:368-70. Available from: http://www.saudija.org/text.asp?2017/11/3/368/206808





Sir,

The greater saphenous nerve block in adductor canal is not sufficient to provide complete analgesia in knee joint surgeries as it blocks only anterior group of nerves supplying knee joint. To provide complete postoperative analgesia for knee surgeries, both greater saphenous and sciatic nerve have to be blocked. Here, we describe two in one approach to block both these nerves at anterior mid-thigh level in a patient scheduled for arthroscopic repair of anterior and posterior cruciate ligament [Figure 1].
Figure 1: Sonoanatomy at the mid-thigh level

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A 35-year-old American Society of Anesthesiologists I patient was scheduled for arthroscopic repair of anterior and posterior cruciate ligament under general anesthesia. Ultrasound (USG)-guided block of the sciatic and saphenous nerve was planned for postoperative analgesia. After anesthetizing the patient, he was placed in supine position with the hip and knee on the operative side flexed and the leg externally rotated at approximately 45°. After skin sterilization with an iodine-containing solution, USG curvilinear transducer was first positioned perpendicular to the skin at mid-thigh with one assistant pulling the hamstring medially. The location was then scanned by sliding and tilting the transducer until a clear transverse image of the hyperechoic sciatic nerve located posterior and medial to the femur was obtained. A 100-mm, 21-gauge insulated nerve block needle (Stimuplex A, B. Braun Melsungen AG, Germany) connected to a nerve stimulator (B. Braun Melsungen AG, Germany) was inserted inline to the curvilinear transducer with the sciatic nerve was in the middle of the USG screen. Once the needle approached the nerve, nerve stimulator was switched on with pulse duration of 0.1 ms and stimulating frequency of 2 Hz. Once, foot dorsiflexion and plantarflexion were elicited at 0.5 mA, local anesthetic 15 cc of 0.2% ropivacaine was injected incrementally. The medial to lateral needle trajectory avoided the femoral vessels and the profunda femoral vessels running between the femur and the lateral aspect of the sciatic nerve.[1] After giving sciatic nerve block, needle is redirected from a same puncture site in the same plane to probe through adductor longus muscle into adductor canal. Fifteen milliliter 0.2% ropivacaine was used to block greater saphenous nerve block after negative aspiration.

We have described clinical use of the anterior approach to sciatic nerve block and greater saphenous nerve block in single skin entry point under real-time USG guidance and show that this technique can be used easily and successfully. The anterior approach to the sciatic nerve block is technically challenging due to lack of reliable surface anatomical landmarks.[2] Hence, USG guidance is very useful for this approach. USG-guided anterior sciatic nerve block has been described at the lesser trochanteric level.[3],[4] Due to the deep location of the nerve at this level, the visualization of the nerve is not as good as the posterior approach. However, this approach is very useful for patients who cannot lie lateral/prone due to various reasons. Furthermore, this is an ergonomically easier technique.[4] A block at a lower level, i.e., mid-thigh as described by us is technically easier due to better visualization of the nerve.

A curved transducer placed over the anteromedial aspect of the mid-thigh will reveal the musculature of all three compartments of the thigh: anterior, medial, and posterior. The greater saphenous nerve can be blocked in adductor canal the boundary of which is (1) roof by sartorius, (2) medially by adductor longus/magnus, and (3) laterally by vastus medialis. The USG image of sciatic nerve in cross section is typically seen as an oval-to-circular hyperechoic structure deep to the adductor muscles. From the anterior aspect, the sciatic nerve continues its longitudinal course deep to the adductor magnus muscle, superficial to the biceps femoris muscle, and immediately adjacent to the femur.

We have described a new approach for blocking sciatic and saphenous nerve at the mid-thigh level especially suited for knee surgeries where the patient cannot lie lateral or prone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vloka JD, Hadzic A, April E, Thys DM. Anterior approach to the sciatic nerve block: The effects of leg rotation. Anesth Analg 2001;92:460-2.  Back to cited text no. 1
    
2.
Dolan J. Ultrasound-guided anterior sciatic nerve block in the proximal thigh: An in-plane approach improving the needle view and respecting fascial planes. Br J Anaesth 2013;110:319-20.  Back to cited text no. 2
    
3.
Chan VW, Nova H, Abbas S, McCartney CJ, Perlas A, Xu DQ. Ultrasound examination and localization of the sciatic nerve: A volunteer study. Anesthesiology 2006;104:309-14.  Back to cited text no. 3
    
4.
Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided anterior approach to sciatic nerve block: A comparison with the posterior approach. Anesth Analg 2009;108:660-5.  Back to cited text no. 4
    


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