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

Home , Saphenous nerve, Sciatic nerve block

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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 regions around the world where gen- surgery of the leg, eral and spinal anesthesia are not ankle and foot. readily available.

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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. biceps femoris muscle, which can re- the intertendinous popliteal ap- sult in increased pain during the proce- proach with and without a periph- Classical or Anatomical dure.29 Landmarks for the intertendi- eral nerve stimulator, a lateral Approach nous approach utilize the semimem- popliteal approach with and with- Landmarks for the classical ap- branosus and biceps femoris tendons out a peripheral nerve stimulator proach are formed in the posterior as- only, without the additional variables and the saphenous nerve block, pect of the knee (popliteal fossa), with of the semimembranosus and biceps which is used in conjunction with the borders forming a triangle. Medial femoris muscles as landmarks (Figure either technique. and lateral borders are formed by the 3). The needle is inserted at a midpoint semimembranosus and biceps femoris between the semimembranosus and Intertendinous Popliteal Technique tendons and muscle bellies, respec- biceps femoris tendons 5-6 cm. proxi- (Figures 3, 5, 6 and 7) tively. Identification of the popliteal mal to the popliteal crease. In 1988, 1. The block is performed with cease is marked and a bisection of the Hadzic et al compared a lateral ap- the patient in the prone position. triangle is drawn (Figure 3). In the proach to the classical posterior ap- 2. Landmarks are identified and classical approach, the needle is in- proach, and found no significant dif- marked as previously described. serted 5-6 cm. proximal to the ferences in anesthesia results.30 3. Proper needle placement is popliteal crease and 1 cm marked by extending a 5- lateral to the bisection. 6 cm. vertical line cephalad from the midpoint of Intertendinous the popliteal crease line Approach between the semi-mem- In 2002, Hadzic, et al. branosus and biceps suggested needle place- femoris tendons intersec- ment should be directly tion with that line. between the semimem- 4. A needle is intro- branosus and biceps duced at an angle of ap- femoris tendons.17, 24, 25, 26, 27 proximately 45-60 de- In 1997, Vloka, et al. grees cephalad. demonstrated that the 5. Insert the needle classical approach is sig- to 3-5 cm. depth. nificantly less effective 6. Paresthesias will be than the intertendinous Figure 4 Continued on page 186 www.podiatrym.com JUNE/JULY 2004 • PODIATRY MANAGEMENT 185 Nerve Blocks... 13. Again, common peroneal distribution paresthesias or an ever- Continuing elicited when the needle is in sion of the foot will be elicited de- A peripheral nerve the proximity of nerves. pending on the technique. Medical Education 7. If a peripheral nerve stimula- 14. Perform the same local anes- stimulator is tor is used, the needle with stimula- thetic injection sequence as de- unquestionably a tor should be inserted in the same scribed previously for the tibial manner as described above and the nerve to anesthetize the common reliable tool in a nerve stimulator set at 1.5 mA. peroneal nerve. teaching environment. 8. A motor response will be noted when the tibial nerve is stim- Lateral Popliteal ulated with resultant plantarflexion Technique of the foot clinically observable. 1. The block is performed with saphenous nerve. 9. Continue to lower the am- the patient in the supine position. 1. Palpate the tuberosity of the peres to 0.5 mA; if motor response 2. Identification of the biceps tibia and from this point, draw a is still visible, acceptable proximity femoris tendon and the popliteal line distal and medial at a 45 ° to the nerve has been achieved. crease are marked. angle to the intersection of the an- 10. When paresthesias or a 3. A needle with or without a terior and medial border of the gas- motor response are elicited, (de- nerve stimulator is inserted 5 cm. trocnemius muscle. pending on the technique) inject 1 proximal to the popliteal crease 2. Along this line, inject 10 cc. cc of 1.0 % lidocaine and the pares- and along the anterior border of of local anesthetic into the subcuta- thesias or motor response should the biceps femoris tendon in a neous tissues. cease. slight cephalad direction. 3. The saphenous nerve lies ap- 11. When the paresthesias or 4. Utilizing this approach, the proximately midway between these motor response ceases, infiltrate 9 needle will encounter the common landmarks, passing beneath the cc of 1.0% lidocaine plain or 0.5% peroneal nerve first, eliciting pares- midpoint of this line. bupivacaine, or a mixture of both thesias or an eversion motor re- As with any anesthesia proce- to anesthetize the tibial nerve. sponse. dure, these approaches do carry po- 12. The needle with or without 5. Perform the same local anes- tential complications. Besides the a nerve stimulator is then redirect- thetic injection sequence as de- general risks of local anesthetic ed slightly laterally. scribed previously for the common agents such as toxic and allergic re- peroneal nerve in- actions, one major complication jection with the would be puncture or rupture of intertendinous ap- the popliteal artery or vein.33 An- proach. other potential complication, how- 6. Continue ever uncommon, would be the risk inserting the nee- of puncturing and /or transecting dle or needle with the sciatic nerve, which could cause stimulator until short or long-term paresthesias or tibial nerve distri- permanent autonomic, sensory or bution paresthe- motor deficits throughout the sias or plantarflex- lower extremity.34, 35 Signs and ion motor re- symptoms of infection and sponse is elicited. hematoma must also be monitored. 7. Perform the same local Discussion anesthetic injec- In addressing the historical lack tion sequence as of training in this technique, it is described previ- suggested that anesthesia depart- Figure 5 ously for the tib- ments institute clinical instruction ial nerve injec- for all appropriate staff, including tion with the in- anesthesia, podiatric, orthopedic, tertendinous plastic, vascular and general sur- approach. gery. Operating room efficiency can be facilitated with appropriate plan- Saphenous ning and staff training. Experience Nerve Block has demonstrated that this block Technique can be integrated well into anesthe- (Figure 8)16, 32 sia operating room procedures.19 The final step Use of this relatively safe and suc- in both tech- cessful anesthetic technique with niques includes and without a peripheral nerve Figure 6 anesthetizing the Continued on page 187

186 PODIATRY MANAGEMENT • JUNE/JULY 2004 www.podiatrym.com MedicalContinuing Education Nerve Blocks... guidelines for “blind” unassisted there is significant value nerve block administration. in encouraging its use in stimulator, can result in a high suc- The terminal sciatic and saphe- developing regions of the cess rate for administering regional nous nerve blocks have many ap- world. In many rural, medically anesthesia at this level. plications in lower extremity sur- underserved areas around the A peripheral nerve stimulator is gery distal to the knee (Figure 9). world, early intervention in lower unquestionably a reliable tool in a This technique, supplemented with extremity wounds caused by infec- teaching environment.22 Addition- intravenous monitored anesthesia tion, trauma, ischemia, neuropathy ally, the nerve stimulator can pro- care, has applications not only for and primary ulcerative disease can duce motor activity in patients who incision and drainage and debride- mean the difference between recon- may have diminished or absent ment, but also in reconstruction of struction and restored function and the foot, ankle and leg the alternative, amputation or even threatened by trauma, infec- death from sepsis. tion, ischemia, arthritis, pri- Where general and spinal anes- mary ulcerative disease, neo- thesia are not available, the combi- plasia, neuropathy and con- nation of saphenous and popliteal genital and neuromuscular blocks could be used routinely in deformity.3, 4, 9, 19, 36 Forefoot, modestly equipped medical facili- midfoot, rearfoot, ankle and ties for incision and drainage, de- below-knee amputations can bridement and reconstruction of be performed safely and effi- the distal lower extremity. With ciently using these blocks. In W.H.O. statistics predicting 300 addition, this technique can million cases of Type II diabetes by be used to provide anesthesia the year 2012, the widespread use for application of external of these techniques could potential- Figure 7 fixators to the foot and leg ly translate into prevention of for procedures in- countless lower extremity amputa- elicited paresthesias due to diabetic volving recon- tions around the world annually. or other forms of peripheral neu- struction of the The role of telemedicine for both ropathy or central nervous system diabetic Charcot live and archived instruction in this disease. Even with the nerve stimu- foot and ankle technique can assist in widespread lator, motor neuropathy or signifi- with or without training on a global scale. Where cant muscle atrophy can eliminate additional com- telemedicine is not available, this any visible motor activity used as a ponents of foot technique could be disseminated by guide to anesthetic needle place- and ankle inter- CD teaching material with still and ment. Because of the occasional ab- nal fixation such video components. sent elicitable paresthesias and as screws, plates, In our experience, with over 40 motor activity, the authors encour- pins and staples.8 of these blocks, over the past 2 age more empiric research to deter- Injection of a years, no patient has had to mine reliable modifications of this local anesthetic progress to general anesthesia fol- technique which will define rela- agent at the foot lowing this type of local anesthetic Figuretive 3-dimensional 8 nerve-depth and ankle level block. When considering the risks involved with of spinal and general anesthesia, es- cellulitis is usually avoided to pre- pecially for the chronically ill, this vent seeding of deeper tissues with procedure is a viable alternative. infection. Saphenous and distal sci- The authors advocate more fre- atic nerve blocks have significant quent utilization of this block tech- value in cases such as this because nique when anesthesia is needed the regional anesthesia can be ad- distal to the knee. ministered at a level more proximal to that of the active infection. Summary Post-operative pain manage- The purpose of this article is to ment is an inherent benefit of this advocate more universal clinical use technique, particularly when long of the terminal sciatic and saphe- acting anesthetic agents are used.37 nous nerve blocks, particularly in The value of prolonged analgesia in chronically ill patients. Applications the chronically ill post-operative of this block for surgical procedures patient in preventing complica- below the knee as an alternative to tions is obvious, particularly in pa- general and spinal anesthesia are re- tients suffering from hypertension, viewed. Techniques with and with- diabetes and cardiac disease.6, 7 out the assistance of a peripheral Ease of administering these nerve stimulator are described. Ad- Figure 9 anesthetic blocks suggests that Continued on page 188 www.podiatrym.com JUNE/JULY 2004 • PODIATRY MANAGEMENT 187 Nerve Blocks... 14 Vloka JD, Hadzic A, Lesser JB, Kitain E, Fossa. Anesthesiology 88(6):1480-1486, Geatz H, April EW, Thys DM. A Common 1988. Continuingvocacy for more training ini- Epineural Sheath for the Nerves in the 31 Vloka JD, Hadzic A, Kitain E, Lesser JB, tiatives in hospital settings is Popliteal Fossa and Its Possible Implications Kuroda MM, April EW, Thys DM. Anatomic Medical Education made as well as the technique’s im- for Sciatic Nerve Block. Anesth Analg 84:387- considerations for sciatic nerve block in the plications for post-operative pain 90, 1997. popliteal fossa through the lateral approach. 15 management. The impact of this Sunderland S.:The sciatic nerve and its Reg Anesth 21:414-418, 1996. tibial and common peroneal divisions. 32 Bouaziz H, Benhamou D, Narchi P: A technique in limb preservation on a Anatomical features. Nerves and Nerve In- new approach for the saphenous nerve global scale in underserved regions juries. Edinburgh and London: E. & S. Liv- block. Reg Anesth 21:490, 1996. of the world is discussed. The au- ingstone LTD., 1012-95, 1968. 33 Selander D. Paresthesias or no pares- thors have had good results with 16 Van der Wal M, Lang SA, Yip, RW: thesias? Nerve complications after neural this form of anesthesia with mini- Transsartorial approach for saphenous nerve blockades. Acta Anaesth Belg 39:173-4, 1988. mal adverse effects. ■ block. Can J Anaesth 40:543, 1993. 34 Selander D, Dhuner K-G, Lundborg 17 Hadzic A, Vloka JD, Singson R, Santos G: Peripheral nerve injury due to injec- References AC, Thys DM.: A comparison of intertendi- tion needles used for regional anesthesia: 1 Adriani J. Labat’s Regional nous and classical approaches to popliteal An experimental study of the acute ef- Anesthesia.Techniques and Clinical Applica- nerve block using magnetic resonance imag- fects of needle point trauma. Acta tions., W.B. Saunders Company, Philadel- ing simulation. Anesth Analg 94:1321-4, Anaesth Scand 21:182-8, 1977. phia, pp 317-21, 1967. 2002. 35 Bonner SM, Pridie AK: Sciatic nerve 2 Brown, DL: “Popliteal Block,” in Atlas 18 Benzon, HT, Kim C, Benzon HP, Sil- palsy following juneventful sciatic nerve of Regional Anesthesia, ed by DL Brown, , verstein ME, Jericho B, Prillaman K, Bue- block. Anaesth 52:1206, 1997. WB Saunders, Philadelphia, p 109, 1992. naventura R. Correlation between evoked 36 Sarrafian SK, Ibrahim IN, Breihan JH: 3 Beskin JL, Baxter, DE: Regional anes- motor response of the sciatic nerve and Ankle-foot peripheral nerve block for mid thesia for ambulatory foot and ankle surgery. sensory blockade. Anesthesiolog 87:547- and forefoot surgery. Foot Ankle 4:87, 1983 Orthopedics 10:109, 1987. 552, 1997. 37 McLeod DH, Wong DHW, Vaghadia 4 Hansen E, Eshelman MR, Cracchiolo III 19 Lee TH, Wapner KL, Hecht PJ, Hunt H, Claridge RJ. Lateral popliteal sciatic nerve A. Popliteal fossa neural blockade as the sole PJ: Regional anesthesia in foot and ankle sur- block compared with ankle block for analge- anesthetic technique for outpatient foot and gery. Orthopedics 19:578, 1996. sia following foot surgery. Can J Anaesth ankle surgery. Foot Ankle 21:38-44, 2000. 20 Hadzic A, Vloka JD. Peripheral Nerve 42(9):765-9, 1995. 5 Provenzano DA, Viscusi ER, Adams, SB Stimulator for Unassisted Nerve Blockade. Jr, Kerner, M, Abidi NA. The safety and effica- Anesthesiology 84(6):1528-1529, 1996. cy of the popliteal fossa nerve block for foot 21 Gouverneur JM.: Sciatic nerve block Dr. Donahue is As- and ankle surgery. American Orthopaedic in the popliteal fossa with atraumatic sistant Professor, Foot and Ankle Society 31st Annual Meeting, needles and nerve stimulation. Acta Department of San Francisco, CA, March 2001. Anaesth Belgica 4:391-9, 1985. Surgery at the 6 Rongstad KM, Mann RA, Prieskorn D, 22 Singelyn FJ, Gouverneur JM, Gri- Drexel University Nicholson S, Horton G. Popliteal sciatic bomont BF. Popliteal sciatic nerve block College of Medi- nerve block for postoperative analgesia. Foot aided by a nerve stimulator: a reliable tech- cine, Philadelphia, Ankle 17:378-382, 1996. nique for foot and ankle surgery. Reg Anesth PA and a Fellow of 7 McLeod DH, Wong DH, Claridge RJ, 16:278-81, 1991. the American Col- Merrick PM. Lateral popliteal sciatic nerve 23 Smith BE, Allison A: The use of a low lege of Foot and block compared with subcutaneous infiltra- power nerve stimulator during sciatic nerve Ankle Surgeons. tion for analgesia following foot surgery. Can block. Anaesthesia 42:297, 1987. J Anaesth 41:673-676, 1994. 24 Vloka JD, Hadzic A, Koorn R, Thys Dr. Goss is is Di- 8 Myerson, MS, Ruland, CM, Allon, SM: DM.: Supine approach to the sciatic rector of Surgi- Regional anesthesia for foot and ankle sur- nerve in the popliteal fossa. Can J cal Residency gery. Foot Ankle 13:284, 1992. Anaesth 43(9):964-967, 1996. Program at 9 Nusbaum LM, Hamelberg W: Intra- Beck GP: Anterior approach to sciatic TENET Roxbor- venous regional anesthesia for surgery on the nerve block. Anesthesiology 24:222-224, ough Hospital foot and ankle. Anesthesiology 64:91, 1986 1963. and is Adjunct 10 Rorie DK, Byer DE, Nelson DO, et 26 Kilpatrick AWA, Coventy DM, Todd Clinical Instruc- al.: Assessment of block of the sciatic JG.: A comparison of two approaches to sci- tor at the Tem- nerve in the popliteal fossa. Anesth Analg atic nerve block. Anaesthesia 47:155-7. 1992. ple University 59:371-6, 1980. 27 Singelyn FJ, Aye F, Governeur JM: School of Podia- 11 Hadzic A, Vloka JD, Kuroda MM, Continuous popliteal sciatic nerve block: an tric Medicine, Philadelphia, PA. He is a Koorn R, Birnbach DJ. The practice of pe- original technique to provide postoperative Fellow of the American College of Foot ripheral nerve blocks in the United States: analgesia after foot surgery. Anesth Analg and Ankle Surgeons. A national survey. Reg Anesth 23:241- 84:384, 1997. 246, 1998. 28 Vloka JD, Hadzic A, Singson R, Koorn 12 Hadzic A,Vloka JD, Kuroda MM, R, Thys DM. The popliteal nerve block revis- Dr. Dyal is Chief Koorn R, Birnbach DJ, Thys DM. The use of ited: Results of an MRI study. Anesth Analg Resident at the peripheral nerve blockade in anesthesia prac- 84:344, 1997. podiatric surgi- tice. A national survey. Anesth Analg, 29 Zetlaoui PJ, Bouaziz H: Lateral ap- cal residency at 84:300, 1997. proach to the sciatic nerve in the popliteal TENET Roxbor- 13 Kopacz DJ, Bridenbaugh LD. Are anes- fossa. Anesth Analg 87:79, 1998. ough Hospital, thesia residency programs failing regional 30 Hadzic A, Vloka JD. A Comparison of Philadelphia, anesthesia? The past, present, and future. Reg the Posterior versus Lateral Approaches to PA. Anesth 18(2):84-7, 1993. the Block of the Sciatic Nerve in the Popliteal

188 PODIATRY MANAGEMENT • JUNE/JULY 2004 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 191.

1) The popliteal nerve is the surgery of the leg, foot and 11) One of the side effects of name given to the distal aspect ankle is: spinal anesthesia not caused by of : A) Historically, they have not popliteal and saphenous nerve A) The sciatic nerve been incorporated into resi- blocks is: B) The saphenous nerve dency training programs. A) Postdural headache C) The sural nerve B) There is a high incidence B) Spinothalamic tract block- D) The superficial femoral of block failure. ade nerve C) They are difficult tech- C) Complete anesthesia distal niques to teach. to the knee 2) The popliteal block consists of D) There is limited post-oper- D) DVT 2 components: ative analgesia with these A) Saphenous and sural nerve techniques. 12) One of the many applica- blocks. tions of the popliteal and saphe- B) Tibial and common per- 7) The______approach to nous nerve blocks that has been oneal nerve blocks. the tibial and common peroneal traditionally underutilized is: C) Superfical femoral and tib- nerve blocks has been shown to A) Use of these blocks in de- ial nerve blocks be as effective as the posterior, veloping regions and coun- D) Pudental and common intertendinous approach. tries. peroneal nerve blocks A) Medial B) Abcesses of the knee. B) Anterior C) Hospitals without anesthe- 3) The following anesthetic pro- C) Lateral siologists. cedure does not selectively block D) Retrograde D) Distal bypass procedures. pain impulses to the spinothalamic tract: 8) Which technique reduces the 13) The lateral approach to the A) General risk of neurovascular damage popliteal nerve block, with the B) Tibial nerve block during the popliteal block? patient in the supine position, C) Common peroneal nerve A) Intertendinous approach has the advantage of: block B) Classical approach A) Improved quality of block D) Saphenous nerve block C) Scalene block compared to that in the D) Ankle block prone position. 4) The following is not a compli- B) Less risk of neurovascular cation of a popliteal nerve block: 9) One of the advantages of the damage. A) Puncture of the femoral popliteal and saphenous nerve C) Not having to turn and artery blocks as well as all regional reposition the patient after B) Puncture of popliteal anesthetic blocks is: the block before surgery. artery A) Elevation of the blood D) More proximal distribu- C) Puncture of popliteal vein pressure in hypotensive pa- tion of the block compared to D) Laceration of the tibial tients. that in the prone position. nerve B) Increase of endogenous endorphins. 14) The most valuable asset in 5) A ______is used to locate C) Reduced neuroendocrine using a peripheral nerve stimula- the tibial and common peroneal response in the chronically ill tor when administering a nerves prior to injection of local patient. popliteal block is: anesthesia in the popliteal fossa. D) Reduction of blood sugar A) Elicitation of motor activity A) Sensory action potential levels in the diabetic surgical of the common peroneal and B) Electromyograph patient. tibial nerves. C) Nerve conduction velocity B) Elicitation of motor activity D) Peripheral nerve stimula- 10) Which of the following might of the saphenous nerve. tor be considered a contraindication C) Elicitation of sensory ac- to a popliteal block? tion potentials of the tibial 6) One of the main reasons that A) DVT nerve. the popliteal and saphenous B) Foot infection D) Elicitation of motor activi- nerve blocks are not routinely C) Charcot foot ty of the sural nerve. used for D) Ankle fracture Continued on page 190 www.podiatrym.com JUNE/JULY 2004 • PODIATRY MANAGEMENT 189 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program 15) The popliteal nerve is located______to Welcome to the innovative Continuing Education the popliteal vessels. Program brought to you by Podiatry Management A) Medial Magazine. Our journal has been approved as a B) Lateral C) Anterior sponsor of Continuing Medical Education by the D) Posterior Council on Podiatric Medical Education.

16) The popliteal nerve is composed of: Now it’s even easier and more convenient A) The sural and saphenous nerves. to enroll in PM’s CE program! B) The superficial femoral and tibial nerves. C) The tibial and common peroneal nerves. You can now enroll at any time during the year D) The sural and the superficial peroneal and submit eligible exams at any time during your nerves. enrollment period. PM enrollees are entitled to submit ten exams 17) When using the intertendionous or classical published during their consecutive, twelve–month approach to the popliteal block, the needle should make an angle of ______degrees with the enrollment period. Your enrollment period begins skin of the popliteal region. with the month payment is received. For example, A) 10-20 if your payment is received on September 1, 2003, B) 45-60 your enrollment is valid through August 31, 2004. C) 80-90 D) 0-10 If you’re not enrolled, you may also submit any exam(s) published in PM magazine within the past 18) One of the complications of the classical ap- twelve months. CME articles and examination proach to the popliteal block which is signifi- questions from past issues of Podiatry Man- cantly reduced with the intertendinous ap- agement can be found on the Internet at proach is: A) DVT http://www.podiatrym.com/cme. All lessons B) Infection are approved for 1.5 hours of CE credit. Please read C) Paresthesias the testing, grading and payment instructions to de- D) Risk of puncture of the popliteal vessels cide which method of participation is best for you. 19) One important benefit of a popliteal-saphe- Please call (631) 563-1604 if you have any ques- nous nerve block compared to general anesthe- tions. A personal operator will be happy to assist you. sia is: Each of the 10 lessons will count as 1.5 credits; A) Accelerated wound healing thus a maximum of 15 CME credits may be B) Less time for patient in the operating earned during any 12-month period. You may se- room C) Post-operative analgesia lect any 10 in a 24-month period. D) Better anesthesia The Podiatry Management Magazine CME 20) The sciatic nerve is formed from the spinal program is approved by the Council on Podiatric roots L4-S2 and occasionally S3 and consists of Education in all states where credits in instruction- two distinct divisions: al media are accepted. This article is approved for A) The tibial nerve and the common per- 1.5 Continuing Education Contact Hours (or 0.15 oneal nerve. CEU’s) for each examination successfully completed. B) The superficial femoral nerve and the saphenous nerve. C) The common peroneal nerve and the PM’s CME program is valid in all states sural nerve. except Kentucky. D) The sural nerve and the superficial femoral nerve. Home Study CME credits now See answer sheet on page 191. accepted in Pennsylvania

190 PODIATRY MANAGEMENT • JUNE/JULY 2004 www.podiatrym.com ✄ MedicalContinuing Education Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en- all info. on the front and back of this page and mail with your rolled, please send $17.50 per exam, or $109 to cover all 10 check to: Podiatry Management, P.O. Box 490, East Islip, exams (thus saving $66 over the cost of 10 individual exam fees). NY 11730. Credit cards may be used only if you are faxing or Facsimile Grading phoning in your test answers. To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe- CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro- notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form Phone-In Grading below. For each question, decide which choice is the best an- You may also complete your exam by using the toll-free ser- swer, and circle the letter representing your choice. vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday (4) Complete all other information on the front and back of through Friday. Your CPME certificate will be dated the same day this page. you call and mailed within 48 hours. There is a $2.50 charge for (5) Choose one out of the 3 options for testgrading: mail-in, this service if you are currently enrolled in the annual 10-exam fax, or phone. To select the type of service that best suits your CPME program (and this exam falls within your enrollment peri- needs, please read the following section, “Test Grading Options”. od), and this fee can be charged to your Visa, Mastercard, Ameri- TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your check to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604.

ENROLLMENT FORM & ANSWER SHEET

Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card payment may be used for fax or phone-in grading only. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is a $17.50 check payable to Podiatry Management Magazine for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $109.00 (thus saving me $66 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 191 ✄ (cont’d) www.podiatrym.com 11. A12. B A13. C B A14. D C B A15. D C B A16. D C B A17. D C B A18. D C B A19. D C B A20. D C B A D C B D C D EXAM #6/04 (Donohue, Goss and Dyal) (Donohue, Goss 1. A2. B A3. C B A4. D C B A5. D C B A6. D C B A7. D C B A8. D C B A9. D C B A D C B D C D 10. A B C D Popliteal and Saphenous Nerve and Saphenous Popliteal Blocks LESSON EVALUATION exam Please indicate the date you completed this ______the lesson? How much time did it take you to complete ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well all ______Somewhat ______Not at lesson? What overall grade would you assign this A B C D Degree______Additional comments and suggestions for future exams: ______Circle: ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • JUNE/JULY 2004

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