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ANALGESIA

Intraneural Injection with Low-Current Stimulation During Popliteal Sciatic Nerve Block

Christopher Robards, MD^*, Admir Hadzic, MD, Lakshmanasamy Somasundaram, MD^*, Takashige Iwata, MD^*, Jeff Gadsden, MD^*, Daquan Xu, MD^*, and Xavier Sala-Blanch, MD

From the *Departments of Anesthesia, St. Luke’s and Roosevelt Hospital Center, University Hospital of Columbia University, College of Physicians and Surgeons, New York City, New York; and Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.

Address correspondence and reprint requests to Admir Hadzic, MD, Department of Anesthesiology, St Luke’s and Roosevelt Hospitals, 1111 Amsterdam Ave., New York City, NY 10025. Address e-mail to admir{at}nysora.com.

Abstract

BACKGROUND: Prevention of an intraneural injection of a local anesthetic during peripheral nerve blockade is considered important to avoid neurologic injury. However, the needle-nerve relationship during low-current electrical nerve localization is not well understood.

METHODS: We postulated that intraneural needletip location is common during low-current stimulation popliteal sciatic nerve blockade. Twenty-four consecutive ASA class I-III patients scheduled for foot or ankle surgery under popliteal sciatic nerve block using a combined ultrasound and nerve stimulator-guided technique were prospectively studied. The end point for needle advancement was predetermined to be either an elicited motor response between 0.2 and 0.5 mA (100 µs/2 Hz) or an apparent intraneural location of the needletip as seen on ultrasound, whichever came first. The injection occurred at either end points provided the injection pressure was <20 psi. The injection was considered intraneural when injectate resulted in both the swelling and compartmentalization of the nerve within the epineurium.

RESULTS: Elicited motor response could be obtained only upon entry of the needle into the intraneural space in 20 patients (83.3%). In the remaining four patients (16.7%), a motor response with a stimulating current of 1.5 mA could not be obtained even after the needle entry into the intraneural space. An injection in the intraneural space occurred in all patients who had motor-evoked response at current 0.2–0.4 mA. All 24 blocks resulted in adequate anesthesia for foot surgery. No patient developed postoperative neurologic dysfunction.

CONCLUSION: The absence of motor response to nerve stimulation during popliteal sciatic nerve block does not exclude intraneural needle placement and may lead to additional unnecessary attempts at nerve localization. Additionally, low-current stimulation was associated with a high frequency of intraneural needle placement.