Peripheral Nerve Blocks: A Color Atlas, 3rd Edition

60. Continuous Sciatic Nerve Blocks

Maria Matuszczak

Didier Sciard

A. Parasacral Approach

Patient Position: Lateral, with the side to be blocked upright.

Indications: Anesthesia and postoperative analgesia for surgery below the knee; postoperative physiotherapy and complex regional pain syndrome.

Needle Size and Catheter: 18-gauge, 25-, 38-, or 50-mm insulated introducer needle, and a 20- or 21-gauge catheter.

Skin–Nerve Distance: The depth of the sacral plexus at this level has not yet been investigated in children. The plexus can be found at 15- to 50-mm depth.

Volume and Infusion Rate: (Table 60-1); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: The posterior superior iliac spine, and the ischial tuberosity.

Approach and Technique: A line is drawn between the posterior superior iliac spine and the ischial tuberosity; this line is divided in three. In an appropriately anesthetized/sedated child, the needle is introduced perpendicular to the skin, at the junction of the cranial third and the caudal two-thirds of that line. A sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing (Fig. 60-1).

 

Table 60-1. Maximum Initial Bolus Volume of Ropivacaine 0.2%—Parasacral Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

15 mL

17.5 mL

20 mL

22.5 mL

25 mL

25 mL

30 mL

30 mL

Figure 60-1. Parasacral catheter placement.

Tips

1.   The needle is introduced perpendicular to the skin or 30° in the cranial direction.

2.   At this level the sciatic nerve is close to the internal iliac vessels (sciatic vascular trunk).

3.   If there is bone contact, the needle needs to be inserted more caudally on the line between the posterior superior iliac spine and the ischial tuberosity.

4.   A stimulating catheter can be used in older children.

Suggested Readings

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

B. Anterior Approach

Patient Position: Supine, with the leg in a neutral position.

Indications: Anesthesia and postoperative analgesia for surgery below the knee; postoperative physiotherapy and complex regional pain syndrome.

Needle Size and Catheter: 18-gauge, 50- to 150-mm insulated introducer needle, a 20- or 21-gauge catheter.

Skin–Nerve Distance: 3 cm at one year, increasing to 11 cm in adolescents (Fig. 60-2)

Volume and Infusion Rate: (Table 60-2); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: Anterior superior iliac spine, the pubic tubercle (inguinal ligament), and the greater trochanter of the femur.

Approach and Technique: A line is drawn between the anterior superior iliac spine and the pubic tubercle (inguinal ligament line). Next, a parallel line is drawn passing through the greater trochanter. A perpendicular line is drawn at the junction of the medial third and the lateral two-thirds of these lines. The intersection of the perpendicular line and the line passing through the greater trochanter presents the site of needle insertion. In an appropriately anesthetized/sedated child, the insulated needle, connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is introduced perpendicular to the skin. Within 3 to 11 cm, a sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing.

Figure 60-2. Distance skin to sciatic nerve, anterior approach distance.

Table 60-2. Maximum Initial Bolus Volume of Ropivacaine 0.2%—Anterior Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

15 mL

17.5 mL

20 mL

22.5 mL

25 mL

25 mL

30 mL

30 mL

Tips

1.   A femoral nerve stimulation may be elicited within a depth of 1 to 4 cm.

2.   The needle has to be withdrawn very carefully in order not to displace the catheter.

3.   If the femur is contacted the needle has to be introduced more medially.

4.   To the authors' knowledge this approach was not yet used for continuous infusion in smaller children. The youngest patient with continuous infusion was 15 years old (43 kg).

5.   A stimulating catheter can be used in older children.

Suggested Readings

Beck GP. Anterior approach to sciatic nerve block. Anesthesiology 1963;24:222–224.

Chelly JE, Greger J, Howard G. Simple interior approach for sciatic blockade. Reg Anesth 1997;22:114.

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

Raj PP, Parks RI, Watson TD, et al. A new single-position supine approach to sciatic-femoral nerve block. Anesth Analg 1975; 54:489–493.

C. Subgluteal Approach

Patient Position: Lateral, with the side to be blocked upright, and knee flexed.

Indications: Anesthesia and postoperative analgesia for surgery below the knee; postoperative physiotherapy and complex regional pain syndrome.

Needle Size and Catheter: 18-gauge, 25- to 100-mm insulated introducer needle, a 20- or 21-gauge catheter.

Skin–Nerve Distance: 2 cm at one year, increasing up to 6 cm in adolescents (Fig. 60-3).

Volume and Infusion Rate: (Table 60-3); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: The greater trochanter of the femur, and the ischial tuberosity.

Approach and Technique: A line is drawn between the greater trochanter of the femur and the ischial tuberosity. At its midpoint a 2- to 5-cm long, perpendicular, subgluteal line is drawn. The end point of this perpendicular line presents the site of needle insertion. In an appropriately anesthetized/sedated child, the insulated needle, connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is introduced perpendicular to the skin. Within 2 to 6 cm, a sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing (Fig. 60-4).

Figure 60-3. Distance skin to sciatic nerve, subgluteal approach.

Table 60-3. Maximum Initial Bolus Volume of Ropivacaine 0.2%—Subgluteal Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

15 mL

17.5 mL

20 mL

22.5 mL

25 mL

25 mL

30 mL

30 mL

Tips

1.   A groove can be felt between the semitendinous muscle and the biceps femoris muscle; the sciatic nerve is located deep in that groove.

2.   A local stimulation of the biceps femoris muscle can be elicited, but is not sufficient; only a plantar flexion of the foot with flexion of the toes and/or a dorsiflexion and eversion of the foot indicate correct needle placement.

3.   The ultrasound can be used to localize the sciatic nerve, to position the needle, and to verify that the local anesthetic is injected via the catheter around the nerve.

4.   A stimulating catheter can be used in older children.

Figure 60-4. Placement subgluteal catheter.

Suggested Readings

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional anesthesia. Part 1: theoretical background. Paediatr Anaesth 2006;16(10):1008–1018.

Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth 2006;16:1125–1132.

Van Geffen G, Gielen M. Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. Anesth Analg 2006;103(2):328–333.

D. High Lateral Approach

Patient Position: Supine and knee flexed.

Indications: Anesthesia and postoperative analgesia for surgery below the knee; postoperative physiotherapy and complex regional pain syndrome.

Needle Size and Catheter: 18-gauge, 25- to 150-mm insulated introducer needle, a 20- or 21-gauge catheter.

Skin–Nerve Distance: 2 cm at one year, increasing up to 10 cm in adolescents (Fig. 60-5).

Volume and Infusion Rate: (Table 60-4); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Figure 60-5. Distance skin to sciatic nerve, high lateral approach.

 

Table 60-4. Maximum Initial Bolus Volume of Ropivacaine 0.2%—High Lateral Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

15 mL

17.5 mL

20 mL

22.5 mL

25 mL

25 mL

30 mL

30 mL

Anatomic Landmarks: The greater trochanter of the femur, and the long axis of the femur.

Approach and Technique: The greater trochanter of the femur is identified and a line is drawn along the axis of the femur. In an appropriately anesthetized/sedated child, the insulated needle, connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is introduced perpendicular to the skin, at the level of the gluteal fold and 1 to 2 cm below the long axis of the femur. Within 2 to 10 cm, a sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing (Figs. 60-6, 60-7).

Tips

1.   If bone contact occurs, the needle needs to be redirected posteriorly.

2.   Ultrasound can be used to localize the sciatic nerve, to position the needle, and to verify that the local anesthetic is injected via the catheter around the nerve.

3.   Local stimulation of the biceps femoris muscle can be elicited, but is not sufficient; only a plantar flexion of the foot with flexion of the toes and/or a dorsiflexion and eversion of the foot indicate correct needle placement.

4.   A stimulating catheter can be used in older children.

Figure 60-6. Catheter placement, high lateral sciatic.

 

Figure 60-7. Catheter secured, high lateral sciatic approach.

Suggested Readings

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: A prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Ivani G, Codipietro L, Gagliardi F, et al. A long-term continuous infusion via a sciatic catheter in a 3-year-old boy. Paediatr Anaesth 2003;13:718–721.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional anesthesia. Part 1: theoretical background. Paediatr Anaesth 2006;16(10):1008–1018.

Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth 2006;16:1125–1132.

E. Lateral Popliteal Approach

Patient Position: Supine and knee flexed at 45°.

Indications: Anesthesia and postoperative analgesia for surgery below the knee.

Needle Size and Catheter: 18-gauge, 25- to 100-mm insulated introducer needle, a 20- or 21-gauge catheter.

Skin–Nerve Distance: 2 cm at one year, increasing up to 7 cm in adolescents.

Volume and Infusion Rate: (Table 60-5); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: Groove between the biceps femoris muscle and vastus lateralis muscle, and the patella (Fig. 60-8).

Approach and Technique: A pillow is placed under the leg. The groove between the biceps femoris muscle and vastus lateralis muscle is identified and marked, as is the cranial border of the patella. In an appropriately anesthetized/sedated child, the insulated needle, connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is introduced perpendicularly to the skin, at 3 to 10 cm cephalad from the patella border on the line along the groove. Within 2 to 7 cm, a sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing (Fig. 60-9).

Tips

1.   If bone contact occurs, the needle needs to be redirected posteriorly.

2.   Ultrasound can be used to localize the sciatic nerve, to position the needle, and to verify that the local anesthetic is injected via the catheter around the nerve.

3.   A plantar flexion of the foot with flexion of the toes and/or a dorsiflexion and eversion of the foot indicate correct needle placement.

4.   A stimulating catheter can be used in older children.

Table 60-5. Maximum Initial Bolus Volume of Ropivacaine 0.2%—Lateral Popliteal Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

15 mL

17.5 mL

20 mL

22.5 mL

25 mL

25 mL

30 mL

30 mL

 

Figure 60-8. Lateral popliteal approach, landmarks.

Figure 60-9. Catheter placed, lateral sciatic approach.

Suggested Readings

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Hadzic A, Vlogka JD. A comparision of the posterior versus lateral approaches to the block of the sciatic nerve in the popliteal fossa. Anesthesiology 1988;88:1480–1486.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional anesthesia. Part 1: theoretical background. Paediatr Anaesth 2006;16(10):1008–1018.

Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth 2006;16:1125–1132.

Vlodka JD, Hadzic A, Kitain E, et al. Anatomic considerations for sciatic nerve block in the popliteal fossa through the lateral approach. Reg Anesth 1996;21:414–418.

F. Posterior Popliteal Approach

Patient Position: Prone.

Indications: Anesthesia and postoperative analgesia for surgery below the knee.

Needle Size and Catheter: 18-gauge, 25- to 100-mm insulated introducer needle, a 20- or 21-gauge catheter.

Skin–Nerve Distance: 1.5 cm at one year, increasing up to 6 cm in adolescents.

Volume and Infusion Rates: (Table 60-6); maximum initial bolus volume of ropivacaine 0.2%. Dosage of ropivacaine 0.2% for continuous infusion: 0.4 to 0.5 mg/kg/h.

Anatomic Landmarks: The popliteal crease, the semitendinosus and semimembranous tendons medially and the biceps femoris tendon laterally.

Approach and Technique: The leg is flexed to identify the popliteal crease. A line is drawn at the level of the popliteal crease between the semitendinosus and semimembranous tendons medially and the biceps femoris tendon laterally. At its midpoint a perpendicular line is drawn in a cephalad direction; this line divides the popliteal triangle. In an appropriately anesthetized/sedated child, the insulated needle, connected to a nerve stimulator (1.5 mA, 2 Hz, 0.1 ms) is introduced at a 45° angle to the skin, at 2 to 5 cm proximally and 1 cm laterally to the perpendicular line, and advanced in a cephalad direction. Within 1.5 to 6 cm, a sciatic nerve stimulation is elicited. With an appropriate muscle response still present at a current of 0.5 mA and after negative aspiration for blood the appropriate amount of local anesthetic solution is slowly injected. Maintaining the introducer needle in the same position, the catheter is threaded 2 cm beyond the needle tip. The introducer needle is removed and the catheter is secured in place with benzoin and a transparent adhesive dressing (Figs. 60-10, 60-11, 60-12).

Tips

1.   Ultrasound can be used to localize the sciatic nerve, to position the needle, and to verify that the local anesthetic is injected via the catheter around the nerve.

2.   A plantar flexion of the foot with flexion of the toes and/or a dorsiflexion and eversion of the foot indicate correct needle placement.

3.   A stimulating catheter can be used in older children.

Table 60-6. Maximum Initial Bolus Volume of Ropivacaine 0.2%—Posterior Popliteal Approach

kg

2–10 kg

15 kg

20 kg

25 kg

30 kg

40 kg

50 kg

60 kg

70 kg

mL

1 mL/kg

12 mL

15 mL

18 mL

20 mL

22 mL

25 mL

30 mL

30 mL

 

Figure 60-10. Posterior popliteal sciatic approach.

Figure 60-11. Catheter placement.

Figure 60-12. Catheter secured.

Suggested Readings

Dadure C, Bringuier S, Nicolas F, et al. Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study. Anesth Analg 2006;102:744–749.

Dadure C, Capdevila X. Continuous peripheral nerve blocks in children. Best Pract Res Clin Anaesthesiol 2005;19(2):309–321.

Dadure C, Motais F, Ricard C, et al. Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome 1 in children. Anesthesiology 2005;102:387–391.

Dadure C, Pirat Ph, Raux O, et al. Perioperative continuous peripheral nerve blocks with disposable infusion pumps in children: a prospective descriptive study. Anesth Analg 2003;97:687–690.

Dalens B. Regional anesthesia in infants, children, and adolescents. Baltimore: Williams & Wilkins, 1995.

Hadzic A, Vlogka JD. A comparison of the posterior versus lateral approaches to the block of the sciatic nerve in the popliteal fossa. Anesthesiology 1988;88:1480–1486.

Ivani G, Mossetti V. Continuous peripheral nerve blocks. Paediatr Anaesth 2005;15:87–90.

Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional anesthesia. Part 1: theoretical background. Paediatr Anaesth 2006;16(10):1008–1018.

Roberts S. Ultrasonographic guidance in pediatric regional anesthesia. Part 2: techniques. Paediatr Anaesth 2006;16:1125–1132.

Singelyn FJ, Gouverneur JM, Gribomont BF. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg 1997;84:383–386.