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LETTER TO THE EDITOR

Block of the Posterior Femoral Cutaneous Nerve

UPMC Shadyside-Presbyterian Hospital, Pittsburgh, PA, ChelJE{at}anes.upmc.edu (Chelly) Clinique Generale, Annecy, France (Delauney)

To the Editor:

The article by Barbero et al. (1) provided interesting data complementing our original description of an anterior approach to the sciatic nerve (2). However, their interpretation of our previously published data deserves the following comments: 1) the authors’ representation of our published landmarks was incorrect. Our landmarks are based on the use of the inferior border of the anterosuperior iliac spine (AIS) and the superior angle of the pubic symphysis tubercle. These are the same as those described by the authors. Therefore the AIS-TS lines presented in Figure 1 in their article should be changed. 2) The posterior femoral cutaneous nerve (PFCN) is a branch of the sacral plexus, not a branch of the sciatic nerve. More importantly, it is a sensory nerve (3). Contrary to the authors’ belief, the PFCN does not innervate the gluteal muscle! Therefore, the PFCN block while performing a sciatic nerve block should be considered a consequence of the local anesthetic diffusion toward the PFCN and does not reflect the intensity of the sciatic block. 3) In the Introduction of their article, the authors indicate that with our technique the block of the PFCN was inadequate (?) in 45% of patients, while in the Discussion they refer to a 50% success rate! Does this 5% difference refer to the difference between inadequacy and failure? 4) In our original description (2), we did not report on the extension of this block to the PFCN. After our original publication, a technical description was indeed published (4). In this technical paper, we reported a complete block of PFCN in 9 of 16 patients, and a partial block of PFCN in 6 of 16 (37%). The failure to block the PFCN in the study by Barbero et al. (1) and our studies led to the need for supplemental anesthesia. As indicated in our technical description (4), there is no doubt that the block of the PFCN is important for surgery in the posterior aspect of the thigh, but evidence supporting the need for a complete PFCN block for surgery at the knee and below without and without a tourniquet remains to be established. Thus, in 60 patients undergoing foot surgery with the use of a tourniquet under a femoral and a posterior popliteal block, a supplemental dose of sufentanil (5–10 µg) was required only in one patient (5).

Further studies are required to determine the conditions in which the block of PFCN is required in the presence of a tourniquet for surgery at the knee or below.

References

1. Barbero C, Fuzier, R, Samii K. Anterior approach to the sciatic nerve block: adaptation to the patient’s height. Anesth Analg 2004;98:1785–8.[Abstract/Free Full Text]
2. Chelly JE, Delaunay L. A new anterior approach to the sciatic nerve block. Anesthesiology 1999;91:1655–60.[Web of Science][Medline]
3. McMinn RMH, Hutchings RT. Color atlas of human anatomy: right gluteal region—branches of the sacral plexus. Weert, The Netherlands: Smeets-Weert, 1977:.
4. Delaunay L, Chelly JE. Nouvelle approche antérieure du nerf sciatique. Ann Fr Anesth Reanim 2000;19:121–2.
5. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg 1997;84:383–6.[Abstract]

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