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Department of Anesthesiology, Jacobi Medical Center, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, pranevicius{at}gmail.com (M. Pranevicius, Park, Cowart, Golden) Clinic of Anesthesiology and Intensive Care of Vilnius University, Vilnius, Lithuania (Rucinskas) New York Hospital Queens Weill Medical College of Cornell Universitym New York, NY (O. Pranevicius)
To the Editor:
Metaanalysis of 12 randomized, controlled trials suggests that nerve blocks using multiple injections have a greater success rate than do single-injection techniques (1). They also have a more rapid onset time and require less local anesthetic (2–5).
However, after the initial local anesthetic injection, motor, and paresthesia responses gradually diminish and some fear unintentional injury to the anesthetized nerve while redirecting the needle (6).
To eliminate this risk we propose using two separate needles rather than redirecting the needle during multiple injection nerve blocks. Local anesthetic is not injected until both needles are placed into their final position.
We used a two-needle approach for posterior intertendinous popliteal nerve block (7). The first needle is inserted in the sagittal plane at the middle of the popliteal fossa 9 cm above the popliteal crease and the needle is "walked" laterally until a tibial (plantar flexion) or peroneal (dorsiflexion) response is obtained. The second needle is inserted 2 cm distally along the course of the nerve (Fig. 1). If the first response obtained is that from the tibial nerve, the second needle is aimed laterally to obtain a peroneal nerve response. After stimulation has reconfirmed proper location of the first needle, local anesthetic is injected through both needles after negative aspiration. Saphenous or femoral block may be required for the tourniquet pain or surgery in the dorsum of the foot.
With ultrasound guidance local anesthetic spread can be seen and the needle is redirected to obtain circumneural deposition (8). However nerve stimulation is the most common neurolocation technique.
The two-needle technique retains the advantages of multiple injection nerve blocks, with the only drawback being the cost of an additional needle and the need for a second skin puncture. It eliminates theoretical safety concerns related to multiple injection nerve blocks and may increase their use in regional anesthesia.
REFERENCES
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