Lower extremity regional anesthesia: essentials of our current understanding

Tran, De Q.H.; Salinas, Francis V.; Benzon, Honorio T.; Neal, Joseph M.

doi:10.1136/rapm-2018-000019

Cited by 140 publications

(36 citation statements)

References 405 publications

(213 reference statements)

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“…An injection at the midthigh level, commonly described as an adductor canal block, has gained popularity as an efficient motor-sparing alternative to the traditional femoral nerve block (FNB) for postoperative analgesia after total knee arthroplasty (TKA) 1 2. The accurate term for an injection anterolateral to the femoral artery (FA) at the midthigh level (eg, midway between the anterior superior iliac spine (ASIS) and the base of the patella) is a femoral triangle block (FTB), as this point is consistently within the femoral triangle (FT) and not in the anatomical adductor canal 3–6. An injection at the midthigh level efficiently anesthetizes the saphenous nerve (SN) and the medial vastus nerve (MVN).…”

Section: Introductionmentioning

confidence: 99%

Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial

Bjørn

Nielsen

Moriggl

et al. 2019

Reg Anesth Pain Med

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Background and objectives For pain relief after total knee arthroplasty (TKA), an injection at the midthigh level may produce analgesia inferior to that of a femoral nerve block as the anterior femoral cutaneous nerves (intermediate femoral cutaneous nerve (IFCN) and medial femoral cutaneous nerve (MFCN)) are not anesthetized. The IFCN can be selectively anesthetized in the subcutaneous tissue above the sartorius muscle and the MFCN by an injection in the proximal part of the femoral triangle (FT). The primary aim was to investigate the area of cutaneous anesthesia in relation to the surgical incision for TKA and anteromedial knee area after intermediate femoral cutaneous nerve blockade (IFCNB) in combination with an injection in the proximal or distal part of the FT (proximal vs distal femoral triangle block (FTB)). Methods The study was carried out as two separate investigations: first, dissection of nine cadaver sides to verify a technique for IFCNB; second, a volunteer study with 40 healthy volunteers. The surgical midline incision for TKA was drawn bilaterally. All volunteers received an active distal FTB combined with a placebo proximal FTB on one side and vice versa on the other side. All volunteers were randomized to an active IFCNB on one side and placebo IFCNB on the contralateral side. Results Identification of IFCN was successful in all cadaver sides. Fifteen out of 20 volunteers had complete anesthesia of the incision line after IFCNB combined with proximal FTB, which was significantly higher compared with proximal FTB alone and with distal FTB+IFCNB. A gap at the anteromedial knee area was present in 2/20 volunteers with proximal FTB compared with 17/20 with distal FTB when all volunteers had active IFCNB. Conclusion Ultrasound-guided blockade of the IFCN and MFCN anesthetize the surgical midline incision and the anteromedial area of the knee relevant for TKA. In contrast, an injection at the midthigh level produces insufficient cutaneous anesthesia not covering the areas of interest. Trial registration number EudraCT: 2018-004986-15.

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Section: Introductionmentioning

confidence: 99%

Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial

Bjørn

Nielsen

Moriggl

et al. 2019

Reg Anesth Pain Med

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“…The severity of pain observed could have been due to pre‐existing Tarlov cysts, and a sacral catheter may not be routinely required for other patients with similar injuries. We are also unable to compare our technique with others, and have not demonstrated reproducibility, especially given that sacral plexus blockade can be technically challenging . As a large proportion of the pelvis is innervated by branches of the sacral plexus, we have since provided analgesia with sacral plexus blockade for several patients with acetabular fractures.…”

Section: Discussionmentioning

confidence: 99%

“…Although we report a novel indication, ultrasound‐guided sacral plexus blocks have been described for surgical anaesthesia of the hip joint in conjunction with a lumbar plexus block . Parasacral approaches to the sacral plexus and sciatic nerve have also been widely reported . Potential advantages include unilateral analgesia with minimal unilateral motor block, reduced opioid consumption, reduced opioid side‐effects and the facilitation of mobilisation.…”

Section: Discussionmentioning

confidence: 99%

“…Currently, there is no evidence on the complications of continuous ultrasound‐guided sacral plexus blockade. In addition to risks common to all perineural techniques, such as local anaesthetic toxicity and unintentional intravascular injection, rectal perforation has been reported . Given the depth of the target, there is more risk of haematoma with parasacral blockade in comparison with more superficial blocks (such as femoral nerve blockade), due to relatively incompressible blood vessels .…”

Section: Discussionmentioning

confidence: 99%

“…A sacral plexus catheter was inserted using an ultrasound‐guided parasacral technique, targeting the sacral plexus immediately caudal to the posterior inferior iliac spine (PSIS) . She was positioned in the lateral decubitus position, based on a previously described technique .…”

Section: Reportmentioning

confidence: 99%

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Sacral plexus catheter analgesia in a patient with traumatic sacral fractures and Tarlov cysts

Ireland

Womack

Foley

2019

Anaesthesia Reports

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Summary We report the use of a sacral plexus catheter for continuous local anaesthetic infusion in a patient with a unilateral sacral ala fracture following a fall from a horse. Although sacral plexus blockade has been well described for lower limb surgery, an ultrasound‐guided continuous catheter technique for conservatively managed fractures has not been described. Despite appropriate oral analgesia, the patient reported severe pain, particularly in the right gluteal region, which meant she was unable to sit upright or take deep breaths. A sacral plexus catheter was inserted with ultrasound guidance and an initial bolus of 30 ml levobupivicaine 0.25% was delivered followed by infusion of 8 ml.h−1 levobupivicaine 0.125%. Daily follow‐up and assessment were provided by the acute pain team. We judged the procedure to be a success as measured by an improvement in mobilisation, deep breathing, cough and patient satisfaction.

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