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LETTERS TO EDITOR
Year : 2023 | Volume
: 17
| Issue : 2 | Page : 304-305
The superficial peroneal nerve block - Novel neurostimulation-guided “SANTU” technique
Santosh K Sharma1, Tuhin Mistry2
1 Department of Anaesthesiology, Baba Raghav Das Medical College, Gorakhpur, Uttar Pradesh, India
2 Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre and Hospitals Pvt Ltd, Coimbatore, Tamil Nadu, India
Correspondence Address:
Tuhin Mistry
Department of Anaesthesiology and Perioperative Care, Ganga Medical Centre and Hospitals Pvt Ltd, Coimbatore
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.sja_662_22
| Date of Submission | 15-Sep-2022 |
| Date of Decision | 16-Sep-2022 |
| Date of Acceptance | 16-Sep-2022 |
| Date of Web Publication | 10-Mar-2023 |
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How to cite this article:
Sharma SK, Mistry T. The superficial peroneal nerve block - Novel neurostimulation-guided “SANTU” technique. Saudi J Anaesth 2023;17:304-5 |
How to cite this URL:
Sharma SK, Mistry T. The superficial peroneal nerve block - Novel neurostimulation-guided “SANTU” technique. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 27];17:304-5. Available from: https://www.saudija.org/text.asp?2023/17/2/304/371456 |
Dear Editor,
The superficial peroneal nerve (SPN, L4-S1) is one of the terminal branches of the common peroneal nerve (CPN). SPN block (SPNB) is performed using either landmark-guided or ultrasound-guided technique as a component of the ankle block. Isolated SPNB is used to provide incision congruent regional anesthesia/analgesia (RA) in surgeries involving the dorsum of the foot. We write this letter to discuss some anatomical facts about SPN and describe a novel peripheral nerve stimulation (PNS)-guided block technique.
The SPN is a mixed nerve.[1] After arising from the CPN, the SPN travels deep to the peroneus longus (PL) muscle in the lateral compartment of the leg. Then, it runs between the PL and the extensor digitorum longus (EDL) muscles proximally and peroneus brevis (PB) and EDL muscles distally [Figure 1]a and [Figure 1]b. SPN pierces the crural fascia and becomes superficial through the peroneal tunnel at the junction of the upper two-thirds and lower one-third of the leg.[2] Proximal to the ankle, SPN divides into the medial and intermediate dorsal cutaneous branches, which innervate the anterolateral aspect of the leg and the greater part of the dorsum of the foot, excluding the first web space. SPN gives motor innervation to the PL and PB muscles. Thus, it is responsible for the eversion of the foot, which is the desired evoked motor response during neurostimulation [Figure 1]c. | Figure 1: Superficial peroneal nerve (SPN) block: (a) Position of the leg and anatomical landmark; (b) Transverse section of the leg at the junction of the proximal two-thirds and distal one-third of the line joining lateral condyle of the tibial (LC) and lateral malleolus (LM); (c) Needle entry point; (d) Placement of the linear transducer over the needle entry point; (e) Ultrasound image of SPN. EDL-extensor digitorum longus, EHL-extensor hallucis longus, TA-tibialis anterior, DPN-deep peroneal nerve, ATV-anterior tibial vessels, PL-peroneus longus, PB-peroneus brevis, TP-tibialis posterior, FHL-flexor hallucis longus, FDL-flexor digitorum longus, PV-peroneal vessels, TN-tibial nerve, PTV-posterior tibial vessels, LSV-long saphenous vein, SL-soleus muscle, AT-Achilles tendon, SN-sural nerve, F-fibula, T-tibia
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PNS-guided SPNB can be performed by stimulating the motor component. The SPN is targeted at the level where it becomes superficial after penetrating the crural fascia. This level was found at about 12 cm proximal to the ankle joint, corresponding to the junction of the upper two-thirds and lower one-third of the leg.[3]
Based on the cadaveric studies, we developed a novel PNS-guided approach, which we describe as the “SANTU” (Santosh-Tuhin) technique of SPNB. The patient lies supine or lateral, and the side to be blocked is kept over a pillow or padded support [Figure 1]a. The lateral condyle of the tibia and the lateral malleolus are identified. A line joining these two points is divided into three parts, and the junction of the proximal two-thirds and distal one-third is marked. At this point, the needle is inserted perpendicular to the skin in the groove between the EDL muscle anteriorly and the PB muscle posteriorly [Figure 1]c. The initial settings are set at the current of 1–1.5 mA, frequency of 1 Hz, and pulse duration of 1 millisecond. The current is gradually decreased to 0.4 mA once the desired response, that is, foot eversion, is achieved. After negative aspiration, 3–5 mL of local anesthetic is injected.
A small artery and vein usually accompany the SPN.[4] An ultrasound image can visualize and confirm the presence of a small pulsatile artery near SPN [Figure 1]d and [Figure 1]e. Hence, regional anesthesiologists must be careful during SPNB to avoid inadvertent vessel injury and systemic injection of LA.
In conclusion, SPN can be blocked using a neurostimulation technique. However, further anatomical and clinical studies are warranted.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Ribak S, Fonseca JR, Tietzmann A, Gama SA, Hirata HH. The Anatomy and morphology of the superficial peroneal nerve. J ReconstrMicrosurg 2016;32:271-5.  |
| 2. | Agthong S, Huanmanop T, Sasivongsbhakdi T, Ruenkhwan K, Piyawacharapun A, Chentanez V. Anatomy of the superficial peroneal nerve related to the harvesting for nerve graft. Surg RadiolAnat 2008;30:145-8. |
| 3. | Valisena S, Gamulin A, Hannouche D. the intraseptal course of the superficial peroneal nerve: An anatomic study. Foot Ankle Int 2021;42:1171-8. |
| 4. | Nagabhooshana S, Vollala VR, Rodrigues V, Rao M. Anomalous superficial peroneal nerve and variant cutaneous innervation of the sural nerve on the dorsum of the foot: A case report. Cases J 2009;2:197. |
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