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© 2001 International Anesthesia Research Society
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Abstract |
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To evaluate the efficacy and acceptance of a new posterior subgluteus approach to the sciatic nerve, as compared with the classic posterior approach, 128 patients undergoing foot orthopedic procedures were randomly allocated to receive either the classic posterior sciatic nerve block (Group Labat, n = 64) or a modified subgluteus posterior approach (Group subgluteus, n = 64). All blocks were performed with the use of a nerve stimulator (stimulation frequency, 2 Hz; intensity, 1–0.5 mA). In Group subgluteus, a line was drawn from the greater trochanter to the ischial tuberosity; then, from the midpoint of this line, a second line was drawn perpendicularly and extended caudally for 4 cm. The end of this line represented the needle entry. In both groups, a proper sciatic stimulation was elicited at 0.5 mA; then 20 mL of 0.75% ropivacaine was injected. The time from needle insertion to successful sciatic nerve stimulation was 60 s (range, 10–180 s) with the Labat’s approach and 32 s (range, 5–120 s) with the new subgluteus approach (P = 0.0005). The depth of appropriate sciatic stimulation was 45 ± 13 mm (mean ± SD) after 2 (range, 1–7) needle redirections in Group subgluteus and 67 ± 12 mm after 4 (range, 1–10) needle redirections in Group Labat (P = 0.0001 and P = 0.00001, respectively). The failure rate was similar in both groups. Severe discomfort during the procedure was less frequent and acceptance better in Group subgluteus (5 patients [8%] and 60 patients [94%], respectively) than in Group Labat (20 patients [31%] and 49 patients [77%], respectively) (P = 0.0005 and P = 0.005, respectively). We conclude that this new subgluteus posterior approach to the sciatic nerve is an easy and reliable technique and can be considered an effective alternative to the more traditional Labat’s approach.
IMPLICATIONS: Evaluating the efficacy and acceptance of a new approach to the sciatic nerve block, this prospective, randomized study demonstrated that the new subgluteus posterior approach is an easy and reliable technique and can be considered an useful alternative to the more traditional Labat’s approach in patients undergoing foot surgery, facilitating the performance of the sciatic nerve blocks.
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Introduction |
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Regional anesthesia, which has become increasingly popular for lower-limb procedures, improves the quality of postoperative pain relief (1,2). Among regional anesthesia techniques for the lower limb, the sciatic nerve block is a well established procedure, and it is widely used alone or in association with other nerve blocks (2).
The sciatic nerve converges from the sacral plexus, enters the thigh posteriorly to the femur, and runs toward the popliteal fossa. Accordingly, it can be blocked at different levels along its pathway (2–5). The classic posterior approach of Labat modified by Winnie is the most frequently used approach. However, this approach requires the identification of multiple landmarks, and the stimulating needle has to pass through different layers of muscles, often causing discomfort and pain to the patient during block placement (2,3). With the Raj’s approach, two landmarks are required instead of three; however, the patient is in the supine position with the leg flexed, and this requires additional help to hold the patient’s leg in the appropriate position. The purpose of this article is to describe a new posterior approach to the sciatic nerve at the level of the proximal thigh and compare in a prospective, randomized study the effectiveness, the performance time, and the patients’ acceptance of this new approach with the classic posterior approach.
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Methods |
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The sciatic nerve is a mixed nerve deriving from the sacral plexus, which is formed from the ventral rami of the fourth lumbar to the fourth sacral spinal nerves (6). It is actually composed of two separate nerves, the tibial and common peroneal nerves, enclosed in a common sheath. The nerves entering the plexus converge to form a broad triangle passing through the inferior part of the greater sciatic foramen. Then the sciatic nerve runs over the posterior aspect of the iliac bone and enters the subgluteal space below the piriformis muscle; it passes over the obturator internus, superior and inferior gemelli, and quadratus femoris muscles, reaching the posterior part of the thigh between the greater trochanter of the femur and the ischial tuberosity. Once the sciatic nerve has entered the thigh, it runs toward the popliteal fossa, lying on the external surface of the adductor magnus, within the posterior medial compartment of the thigh. This compartment is limited by the septum intermusculare femoralis mediale and a reinforcement of the posterior fascia of the adductor magnus muscle. Within the popliteal fossa, the two components of the sciatic nerve clearly divide into the larger tibial division, located medially, and the common peroneal nerve, located laterally.
Because of its anatomy, the sciatic nerve can be reached at different levels from the parasacral space to the popliteal fossa, ideally identifying a sciatic line running from the inferior border of the gluteus maximus muscle between the greater trochanter and the ischial tuberosity to the popliteal fossa.
Magnetic resonance imaging shows that as soon as it enters the thigh, the sciatic nerve lies just posteriorly to the lesser trochanter in a region with connective tissue (Fig. 1). It is interesting that at this level, cutaneous landmarks can be easily identified, giving the projection of the sciatic nerve. With the patient placed laterally and the leg to be blocked rolled forward onto the flexed knee, the sulcus between the biceps femoris and semitendinosus muscles can be identified just 3 cm above the lower limit of the gluteus muscle. The depression between these two muscles goes down toward the popliteal fossa and represents the cutaneous projection of the sciatic nerve (sciatic line) (Fig. 2A). If a line is drawn from the greater trochanter to the ischial tuberosity and a second line is drawn perpendicularly from the midpoint and extended caudally for 4 cm, we can identify the needle insertion site for a new posterior approach to the sciatic nerve (Fig. 2A); this is more distal than the classical posterior approach (Fig. 2B).
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After Ethical Committee approval, written informed consent was obtained from all considered patients. One-hundred-twenty-eight patients, scheduled to receive a sciatic nerve block for orthopedic procedures involving the foot, were enrolled. Patients with contraindications to regional anesthesia, patients with respiratory or cardiac disease, diabetes, or peripheral neuropathy, and patients receiving chronic analgesic therapy were excluded.
All patients were premedicated with oral diazepam (10 mg) 30 min before placement of the block; after entering the block room, an IV line was placed at the forearm and a 5 mL · kg-1 · h-1 crystalloid infusion was given IV.
All blocks were performed by anesthesiologists with substantial expertise in both regional anesthesia techniques by using a nerve stimulator (Plexival; Medival, Padua, Italy) and a 10-cm, 20-gauge, short-beveled Teflon-coated stimulating needle (Vygon, Ecouen, France). The stimulation frequency was set at 2 Hz, whereas the intensity of the stimulating current, initially set to deliver 1 mA, was gradually decreased to <0.5 mA after the appropriate muscular response was observed. Paresthesias were never sought.
If indicated by the surgical procedure, a femoral nerve block was placed before the sciatic nerve block. Then the patients were placed in the lateral decubitus position, with the leg to be blocked uppermost and rolled forward and the knee flexed at 90 degrees according to the Sim’s position (2). According to a computer-generated randomization table, patients were then allocated to receive either the classical approach of Labat modified by Winnie (Group Labat, n = 64) or the modified subgluteus posterior approach (Group subgluteus, n = 64).
In Group Labat, a line was drawn from the posterior superior iliac spine to the midpoint of the greater trochanter. A perpendicular line was drawn bisecting this line and intersecting a second line drawn from the greater trochanter to the sacral hiatus. The intersection of these two lines indicated the point of needle entry (Fig. 2B). The stimulating needle was inserted with a 90-degree angle to the skin and advanced until stimulation was obtained of either the tibialis nerve (plantar flexion of the foot) or the common peroneal nerve (dorsiflexion and eversion of the foot). The position of the needle was adjusted to maintain an adequate muscular response with a stimulating current 
0.5 mA; then 20 mL of 0.75% ropivacaine was injected slowly with careful aspiration every 5 mL.
In Group subgluteus, a line was drawn from the greater trochanter to the ischial tuberosity. From the midpoint of this line, a second line was drawn perpendicularly and extended caudally for 4 cm. At this level, a skin depression can be palpated, representing the groove between the biceps femoris and semitendinosus muscles. This point represented the site for needle entry (Fig. 2A). The stimulating needle was inserted with a 90-degree angle to the skin and advanced until sciatic stimulation was observed. The needle position was adjusted, maintaining an adequate muscular twitch with a stimulating current 0.5 mA; then the same volume of 0.75% ropivacaine was injected with aspiration every 5 mL.
Standard monitoring was used throughout the study, including noninvasive arterial blood pressure, heart rate, and pulse oximetry, and sensory and motor blocks were evaluated every 5 min after block placement to assess the adequacy of surgical anesthesia. The patient was judged ready for surgery when he or she showed complete loss of pinprick sensation in both the tibialis and common peroneal nerve distributions with concomitant inability to effectively move the ankle and toes. At that point the surgeon started skin disinfection.
An independent observer, who was not involved in block placement, recorded the time from needle insertion into the skin to successful elicitation of the appropriate motor response (performance time), as well as the time from end of injection to readiness to surgery (onset time), the number of needle redirections required before getting the designated motor response, and the depth at which the sciatic nerve stimulation was elicited. Supplementary IV analgesics and sedation were also recorded by the same independent observer during surgery. The nerve block was considered as 1) adequate, if neither sedation nor analgesics were required during surgery; 2) inadequate, if 50-µg IV boluses of fentanyl were required during surgery; or 3) failed, if general anesthesia was required during surgery.
After the block placement, patients were asked to grade the discomfort experienced during the procedure, by using a three-point scale (1 = not painful; 2 = moderately painful; 3 = extremely painful). Satisfaction with the anesthetic technique was also evaluated 24 h after surgery by using a two-point score: 1 = satisfactory, "If ever operated on again in the future I would accept the same anesthetic procedure"; and 2 = unsatisfactory, "If ever operated on again in the future I would prefer a different anesthetic technique."
To calculate the required study size we took into account both results from a previous pilot study (results presented in part at the Third European Congress of Orthopedic Anesthesia, London, May 31–June 2, 2001) and data reported in the literature (7). We accepted a two-tailed 
error of 5% and a ß error of 20% to detect a 20% difference in the patient’s acceptance of the anesthesia procedure between the classic posterior and new subgluteus approaches to the sciatic nerve (8): on the basis of these figures, the required study size ranged from 50 to 60 patients per group.
Statistical analysis was performed by using the program Systat 7.0 (SPSS Inc, Chicago, IL). Normal distribution of the collected data was evaluated with the Kolmogorov-Smirnov test; continuous variables were then analyzed with either two-sampled Student’s t-tests or the Mann-Whitney U-test, according to the data distribution. Ordinal data were analyzed with the contingency table analysis and Fisher’s exact test. A value of P < 0.05 was considered significant. Continuous variables are presented as mean (± SD) or median (range) according to data distribution, and categoric variables are presented as n (%).
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Results |
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No differences in age (43 ± 17 yr in Group subgluteus and 39 ± 18 yr in Group Labat), weight (73 ± 12 kg in Group subgluteus and 73 ± 12 kg in Group Labat), height (162 ± 6 cm in Group subgluteus and 165 ± 8 cm in Group Labat), male/female ratio (38:26 in Group subgluteus and 35:29 in Group Labat), or ASA physical status were observed between the two groups.
The time from needle insertion to proper sciatic stimulation was 60 s (10–180 s) with the classic posterior approach and 32 s (5–120 s) with the new subgluteus approach (P = 0.0005). Sciatic nerve stimulation was observed at a depth of 45 ± 13 mm after 2 (1–7) needle redirections in Group subgluteus and at a depth of 67 ± 12 mm after 4 (1–10) needle redirections in Group Labat (P = 0.0001 and P = 0.00001, respectively). No differences in the proportion of stimulation of either the tibialis or common peroneal part of the sciatic nerve were reported between the two groups (Fig. 3), but the discomfort during the procedure was markedly less with the new subgluteus approach (Table 1) (P = 0.0005).
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2trend = 18.13; P = 0.0005)
The onset time of sensory and motor blocks was similar in those patients receiving the classic posterior approach (9 min [3–20 min] and 16 min [3–75 min], respectively) and those receiving the new subgluteus approach (8 min [1–25 min] and 14 min [10–50 min], respectively [P = 0.12 and P = 0.59]), without differences in the final distribution of nerve blockade.
Failed nerve block was reported in one patient in Group Labat (1.5%) and four patients in Group subgluteus (6%) (P = 0.36); however, a larger proportion of patients in Group Labat required fentanyl administration to complete surgery (19 patients [30%]) as compared with the Subgluteus group (6 patients [10%]) (P = 0.007), and the median consumption of fentanyl was 50 µg (0–200 µg) in the first group as compared with 0 µg (0–100 µg) in the second one (P = 0.004).
Sixty patients in Group subgluteus (94%) would accept the same anesthesia technique if required in the future for a similar surgical procedure, whereas only 49 patients in Group Labat (77%) would similarly accept the same anesthesia technique in the future (P = 0.005).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Several different proximal approaches to the sciatic nerve have been described in the literature (3–5,9–11); however, the classical posterior approach of Labat is undoubtedly the most often used (10,11). Nonetheless, this approach may be quite painful for the patient, mainly because of the thick layer of muscles through which the stimulating needle passes when seeking the sciatic nerve (2,7). Results of this prospective, randomized study demonstrate that this new subgluteus posterior approach to the sciatic nerve is easier and less painful to the patient as compared with the classical posterior approach of Labat modified by Winnie, and it also results in a better quality of nerve blockade.
The reduced patient discomfort during block placement is probably related to the shallower depth at which the sciatic nerve is identified, because a proper sciatic stimulation was elicited at 4.5 cm as compared with 6.7 cm in Group Labat. This factor and the reduced number of attempts required for successful nerve location probably explain the improved acceptance of the anesthesia procedure. In fact, Fanelli et al. (7), evaluating different nerve blocks performed with a multiple-injection technique with the aid of a nerve stimulator, showed a worse acceptance of the anesthesia technique in those patients receiving sciatic nerve block, mainly because of the withdrawal and redirection of the stimulating needle during block placement to locate the two different branches of the sciatic nerve.
The reduced depth at which the sciatic nerve can be reached with the subgluteus approach could be helpful in obese patients. In fact, the increased amount of adipose tissue in the gluteal region usually makes it quite difficult and unpredictable to identify the sciatic nerve with needles of normal length if the classic posterior approach is used. Further studies are required to compare the efficacy and ease of these two approaches in the obese patient.
The onset time of peripheral nerve blocks is mainly influenced by the clinical properties of the anesthetic solution injected. In this investigation we found a median time for complete blockade of the sciatic nerve of approximately 15 minutes, confirming the data already published on the profile of peripheral nerve blocks performed with ropivacaine (12). Other studies reported a median onset time of posterior sciatic nerve block performed with 0.75% ropivacaine ranging between 10 and 25 minutes (13,14), and similar results have also been demonstrated with other proximal approaches to the sciatic nerve (5). Other authors, evaluating the use of bupivacaine for sciatic nerve block, reported onset times as long as 20–30 minutes (15). The large size of the sciatic nerve may make the onset of blockade less predictable than for other peripheral nerves.
It is interesting that, although no differences in the failure rate of the nerve block were reported between the two groups, patients receiving the classic posterior approach required analgesic supplementation during surgery more frequently compared with the other group. Unfortunately, the independent observer evaluating the evolution of sensory and motor blocks, as well as its intraoperative efficacy, was not blinded to the approach used for sciatic nerve block: this can be considered a shortcoming of our study, because we cannot exclude a bias toward the efficacy of the new subgluteus approach. Nonetheless, the small intermuscular space between the greater trochanter and ischial tuberosity, within which the sciatic nerve is included at the subgluteus level (6), as well as the minimal amount of connective tissue surrounding it, could have improved the nerve impregnation with the local anesthetic solution as compared with the classic posterior approach, explaining the reduced analgesic supplementation observed with the subgluteus approach.
In conclusion, results of this prospective, randomized study demonstrated that the sciatic nerve can be easily blocked by using a new subgluteus posterior approach with a reliable and predictable technique. This new posterior approach to the sciatic nerve can be considered a useful alternative to the classic posterior approach of Labat modified by Winnie, facilitating block placement and improving patient acceptance.
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References |
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- Needoff M, Radford P, Costigan P. Local anesthesia for postoperative pain relief after foot surgery: a prospective clinical trial. Foot Ankle Int 1995; 16: 11–3.[Web of Science][Medline]
- Wedel DJ, Brown DL. Nerve blocks. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill-Livingstone, 1990: 1407–37.
- Labat G. Its technique and clinical applications: regional anaesthesia. 2nd edition. Philadelphia: Saunders, 1924: 45–55.
- Raj PP, Parks RI, Watson TD, Jenkins MT. A new single-position supine approach to sciatic-femoral nerve block. Anesth Analg 1975; 54: 489–93.[Web of Science][Medline]
- Chelly JE, Delaunnay L. A new anterior approach to the sciatic nerve block. Anesthesiology 1999; 91: 1655–60.[Web of Science][Medline]
- McMinn RMH, Hutching RT, eds. Color atlas of human anatomy. Chicago: Year Book Medical Publishers, 1977:296–7.
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Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injections technique for upper and lower limb blockade: failure rate, patient acceptance and neurologic complications. Anesth Analg 1999; 88: 847–52.
[Abstract/Free Full Text] - Browner WS, Black D, Newman B, Hulley SB. Estimating sample size and power. In: Hulley SB, Cummings SR, eds. Designing clinical research: an epidemiologic approach. Baltimore: Williams & Wilkins, 1988: 139–50.
- Beck GP. Anterior approach to sciatic nerve block. Anesthesiology 1963; 24: 222–4.[Web of Science][Medline]
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Dalens B, Tanguy A, Vanneuville G. Sciatic nerve blocks in children: comparison of the posterior, anterior, and lateral approaches in 180 pediatric patients. Anesth Analg 1990; 70: 131–7.
[Abstract/Free Full Text] - Davies MJ, McGlade DP. One hundred sciatic nerve blocks: a comparison of localisation techniques. Anaesth Intensive Care 1993; 21: 76–8.[Web of Science][Medline]
- McClellan KJ, Faulds D. Ropivacaine: an update of its use in regional anaesthesia. Drugs 2000; 60: 1065–93.[Web of Science][Medline]
- Casati A, Borghi B, Fanelli G, Torri G. Ropivacaine or 2% mepivacaine for lower limb peripheral nerve blocks. Anesthesiology 1999; 90: 1047–53.[Web of Science][Medline]
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Casati A, Magistris L, Fanelli G, et al. Low dose clonidine prolongs postoperative analgesia after sciatic-femoral nerve block with 0.75% ropivacaine for foot surgery. Anesth Analg 2000; 91: 388–92.
[Abstract/Free Full Text] - Coventry DM, Todd JG. Alkalinisation of bupivacaine for sciatic nerve blockade. Anaesthesia 1989; 44: 467–70.[Web of Science][Medline]
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