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Popliteal and Saphenous Nerve Blocks, Including Techniques, Indica- Andand Tions and Potential Complications

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Popliteal and Saphenous Nerve Blocks, Including Techniques, Indica- Andand Tions and Potential Complications MedicalContinuing Education CLINICAL PODIATRY Objectives PoplitealPopliteal 1) Explain the details of the popliteal and saphenous nerve blocks, including techniques, indica- andand tions and potential complications. 2) Explain the value of this type of regional anesthetic block, when SaphenousSaphenous general, spinal anesthesia and ankle block anesthesia is contraindicated. Nerve 3) Show the wide range of surgi- Nerve cal procedures that can be done using these techniques. BlocksBlocks 4) Demonstrate the possibilities of incorporating these techniques into residency training programs where lower-extremity surgery is done. 5) Show the value of these blocks This is an as an adjunct to post-operative anal- alternative to gesia. general or spinal 6) Suggest the potential value of anesthesia for these techniques in developing re- gions around the world where gen- surgery of the leg, eral and spinal anesthesia are not ankle and foot. readily available. Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (you save $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 190. Other than those entities cur- rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podia- try Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 190).—Editor By Cornelius M. Donohue III, DPM, Larry Common types of local anesthetic proximal to the ankle as an alterna- R. Goss, DPM, and Larry B. Dyal, DPM, MS blocks performed by foot and ankle tive to general or spinal anesthesia. surgeons include local infiltration, Use of a saphenous nerve block ocal anesthesia has long been digital blocks, ray blocks and ankle (SNB) at the proximal leg segment used for lower extremity sur- blocks. Consideration can be given combined with the terminal sciatic Lgery with immense success. to regional anesthesia at a level Continued on page 184 www.podiatrym.com JUNE/JULY 2004 • PODIATRY MANAGEMENT 183 Nerve Blocks... pared to general anesthesia, they carry fewer inherent risks, especially Continuingnerve block or popliteal fossa for the compromised or chronically ill nerve block (PFNB) results in patient. Many patients who require Medical Education complete anesthesia below the knee surgical intervention are diabetic, hy- for soft tissue and osseous proce- pertensive and have cardiac disease. A dures. Advocacy for more frequent significant number of these patients use of this method of anesthesia, as are not good candidates for general well as anatomical considerations, anesthesia. In addition, compared alternative techniques and surgical with general anesthesia, the neuroen- applications are reviewed. docrine response with regional anes- Incorporation of a terminal sciatic thesia is significantly inhibited due to or popliteal fossa nerve block (PFNB) the blockade of spinothalamic tract Figure 2 and a saphenous nerve block (SNB) afferent impulses and their stimula- has certain advantages over general tion of hypothalamic-pituitary- past with good results; however, it is and spinal anesthesia for surgery of adrenal pathways.1 Intra-operative still not routinely used in the United the leg, ankle and foot. When com- and post-operative hemodynamic dis- States and other countries, both de- turbances are mini- veloped and developing.7, 8, 9 In fact, in mized as a result of 1980, Rorie, et al. reported an 88.2% this blockade. The overall satisfaction rate in a study of value of inhibiting 119 patients.10 Infrequent use of this the neuroendocine block method may be related to lack response can be espe- of resident training, concerns over op- cially appreciated in erating room efficiency and an unpre- the diabetic patient, dictable success rate of the block.11, 12, 13 where the secretion of cortisol and other Anatomical Considerations steroids is mini- Formed from spinal roots L4-S2 mized. Both general and occasionally S3, the sciatic and spinal anesthesia nerve consists of two distinct divi- increase the risk of sions, the tibial nerve (TN) and post-operative com- common peroneal nerve (CPN) plications, including (Figure 1).4 They share a common nausea and vomiting epineural sheath from their origin and prolonged recov- to the popliteal fossa.14 In the ery.2, 3 popliteal fossa, the sciatic nerve is When compared termed the popliteal nerve. At a Figure 1 to spinal anesthesia, variable distance above the this procedure yields popliteal fossa crease, the popliteal no risk of postdural nerve divides into two separate puncture headache, nerves, the TN and CPN. Therefore, and unlike spinal a popliteal nerve block is essentially anesthesia, the anes- the terminal block of the sciatic thetic effect is unilat- nerve at the level of the knee.15 eral. Compared to The TN is the larger of the two more proximal ap- branches and runs parallel and proaches to the sciat- slightly lateral to the midline. Infe- ic nerve block, the riorly, it passes between the heads popliteal block spares of the gastrocnemius muscle.15 The the hamstring mus- CPN follows the tendon of the bi- cles and promotes ceps femoris muscle laterally and immediate post-oper- travels around the fibular head as it ative ambulation. In leaves the popliteal fossa. Both addition, a popliteal nerves innervate the entire leg block can provide below the knee except for the an- prolonged post-oper- teromedial aspects of the leg and ative analgesia and foot, which are innervated by the can be performed in saphenous nerve (L2-L4).16 patients being treated with anticoagulant General Principles therapy.4, 5, 6 Many au- Suggested anatomic landmarks thors have advocated for determining needle insertion Figure 3 this procedure in the Continued on page 185 184 PODIATRY MANAGEMENT • JUNE/JULY 2004 www.podiatrym.com MedicalContinuing Education Nerve Blocks... approach.28 Confirmed by MRI, they The need to position found an accuracy of 75% compared the patient in the prone posi- points for the tibial and common to 25% with the classical approach. tion is the main disadvantage of peroneal blocks have been catego- Hadzic, et al. found that the muscle either of the posterior approach rized into two approaches: the classi- boundaries of the popliteal triangle are techniques to the sciatic nerve block cal and intertendinous methods.17 often difficult to appreciate with any in the popliteal fossa, and may pro- Both of these approaches can be per- reproducible accuracy. Subsequently, hibit its use in certain circumstances. formed with or without a peripheral placement of the needle is often made Conditions such as advanced preg- nerve stimulator (Figure 2). The value too far lateral for contact with the sci- nancy, morbid obesity, spine and of a peripheral nerve stimulator is atic nerve using the classical approach. hemodynamic instability, and me- that it takes advantage of the clinical Subsequent medial redirection of the chanical ventilation are examples that motor activity of the tibial and com- needle for sciatic nerve contact may may prevent the use of the prone po- mon peroneal nerves in locating an carry an increased risk of puncturing sition.31 However, the lateral approach appropriate injection point for the the popliteal vessels, especially when to the sciatic nerve can result in reli- local anesthesia.9, 18, 19, 20, 21, 22, 23 This needles longer than 40 mm are used able anesthesia, comparable to that of technique removes some of the (Figure 4).17, 20 In addition, needles in- the posterior approach. Execution of guesswork from positioning the nee- serted using the classical approach are the block using the lateral approach is dle, because when the peripheral relatively straightforward when the nerve stimulator is not used, the only described technique is followed, al- clinical symptom assisting the clini- though it may take more attempts at cian is the elicitation of paresthesias. As with any nerve localization. In addition to uti- Precise placement of the needle lizing the lateral approach in patients during the popliteal block is impor- anesthesia procedure, who cannot assume the prone posi- tant because of a potential differen- these approaches do tion, this technique provides the op- tial blockade of the tibial and com- tion of performing supplementary mon peroneal nerves. Vloka, et al. carry potential blocks (i.e., saphenous or femoral found that this may be due to a com- complications. nerve blocks) and surgery without the mon epineural sheath.14 Additionally, need for patient repositioning.24, 29, 30 the peripheral nerve stimulator is a valuable tool in the obese patient or Block Technique where there is acute or chronic defor- more prone to transect the body of the Techniques described here are mity of the popliteal region.
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