Regional anaesthesia is potentially dangerous in anaesthetised

adult patients - con

Barrie Fischer, M.D.

Chestons Cottage
Uphampton, United Kingdom
As the benefits of regional anaesthesia become more widely recognised both
central and peripheral nerve blocks are used with increasing frequency during the
perioperative period. Some RA techniques are traditionally used as the sole
technique but in the majority of cases RA is combined with a light general
anaesthetic. Opinion is divided between those anaesthetists who perform the
regional anaesthetic after induction of the general anaesthetic and those who
advise against this practice on the grounds of safety. A number of medical experts
strongly advise against the practice and yet it remains a common practice in many
countries. Bromage describes the practice as one of the potential causes of
"masked mischief" [1] and together with others has consistently argued against
performing central neural blocks [2,3], in particular thoracic epidurals, on
anaesthetised patients, whereas others positively recommend it in thoracic surgery
[4,5].
A survey by the American Society of Regional Anaesthesia amongst its members
showed that the practice was common in the USA for both adult and paediatric
patients [6] although the response rate was low. A more recent survey by Romer
amongst thoracic anaesthetists in the UK showed that the majority of those who
perform thoracic epidurals, invariably insert them after general anaesthesia has
been induced [7]. The opinions of medical experts rightly carry great weight, so
why do it? Who is right?
The subject has been debated with increasing frequency but with no firm
conclusions as there is a lack of rigorous data to support both sides of the
argument. There is a perception that nerve damage due to regional anaesthesia is
becoming more common and the potential for serious nerve damage focuses
considerable, possibly disproportionate, attention on the risk which cannot be
supported by the scientific data.
In a review of litigation against anaesthetists published in 1994 [8] Aitkenhead
noted a recent rise in the number of claims from patients who have had regional
anaesthesia, whether awake or under anaesthesia but given the weaknesses of
currently available data it is difficult to establish whether any rise in complaints is
due to bad practice, or is just a reflection of increasing usage of RA and a greater
tendency for resorting to litigation.
While researching this topic for an editorial [9] I contacted the two major Medical
Defence Organisations in the United Kingdom for a medico-legal perspective. Both
organisations are currently unaware of any cases of neurological damage
occurring where the sole risk factor was general anaesthesia being induced prior to
the block being performed. The Medical Defence Union has a risk management
analysis of cases where general anaesthesia preceded regional anaesthesia
(spinal or epidural block) and serious neurological damage subsequently occurred.
The prime risk factor was poor patient management where the standard of care fell
below acceptable standards. Separate analysis of morbidity due to regional
anaesthesia alone (spinal, epidural, thoracic sympathetic block, brachial plexus
and paravertebral block) showed a similar profile of patient outcomes and risk
factors i.e. poor patient management. Neither organisation views the administration
of a general anaesthetic before a regional anaesthetic as inherently bad practice.
Nevertheless isolated case reports, anecdotal experience and a few medico-legal
reports, together with patients innate dislike of needles, provide a background of
suspicion which is difficult to refute with a lack of data either for or against the

practice.
There are no prospective randomised controlled studies which compare the
relative risks of regional anaesthesia performed on anaesthetised or conscious
patients. The data that does exist comes from retrospective qualitative studies
(critical incident reporting, closed claim analysis and case reports) where there has
been a negative outcome. These studies have inherent weaknesses including
reporting bias, incomplete voluntary reporting and an increasing frequency of
medicolegal claims which means that the numerator is unknown. Similarly, the total
population at risk and the frequency with which different techniques are used
(which form the denominator) are also unknown so that the incidence with which
these rare but serious events occur cannot be calculated. Because of the time lag
of up to 10 years between the closure of a claim and the subsequent analysis,
original material may not be available for scrutiny and clinical practice can change
radically, reducing the value of the findings.
A number of recent studies on very large patient populations totalling nearly
900,000 patients show that serious morbidity related to regional anaesthesia is
extremely rare. Auroy [10] carried out one of the few prospective surveys available.
In 1994 103,000 patients received RA in France and whilst there is no data on the
combination with GA, there is a three - fold increase in the risk of complications
associated with spinals compared to epidural and peripheral blocks. If we assume
that spinals are rarely if ever performed on anaesthetised patients the conclusion
must be that neural damage can occur even in the awake patient and that factors
other than pain from intraneural injection can be responsible. Aromaa [11] surveyed
all the anaesthesia insurance claims made in Finland between 1987-1993, which
included 25 cases of serious morbidity from a total of 550,000 spinals and 170,000
epidurals. The coincident use of general anaesthesia was not noted but the relative
risk of complications was 8.6:1 for spinals compared to epidurals. Dahlgren [12]
examined the records of 18,000 central neural blocks again confirming their good
safety but all these studies highlight the importance of recognising the role of preexisting disease, technical difficulties and the need for high standards of patient
management perioperatively in reducing the risk of subsequent neurological
complications. There are no large studies in adults which specifically look at
peripheral blocks but an audit of 16,000 nerve blocks (9000 central and 7000
peripheral) performed in my department between 1991 and 1995 revealed that
85% of blocks were performed on anaesthetised patients with no serious
neurological sequelae.
Bromage recently published a closed claim case report which precisely highlights
the difficulties of determining the exact cause of neurological damage [13]. A 62
year old female with a history of previous lumbar laminectomy had multiple
unsuccessful attempts at a lumbar epidural under general anaesthesia, performed
by a trainee. After a successful catheter placement above the level of the
laminectomy scar by a more experienced colleague, several episodes of
inadequately treated perioperative hypotension occurred and the patient developed
permanent paraplegia. MRI scans subsequently showed a small air bubble at the
level of T10 and spinal cord infarction at T5. The pattern of injury suggested that
anterior spinal artery ischaemia was the most likely cause rather than spinal cord
damage so exactly which aspect of her management was responsible for the
outcome? Technical difficulty, inexperience and serious hypotension are all major
risk factors in adverse outcome from regional anaesthesia whether general
anaesthesia is employed or not. A detailed and damning response to this case
report was not long in coming [14]. Sixty paediatric anaesthetists published an
editorial in Regional Anesthesia and Pain management which is a telling indication
of the strong feelings case reports like this generate when conclusions are drawn

which cannot be justified by the events described.

In a frequently quoted review [15] of the American Society of Anesthesiologists
closed claims analysis of complications following anaesthesia, 15% of all claims
were for nerve damage - 227 patients in all of whom 61% received a general
anaesthetic and 36% a regional technique. The ulnar nerve was damaged in 34%
of cases, the brachial plexus in 23% and lumbosacral nerve damage in 16%. Ulnar
nerve damage was predominantly related to general anaesthesia, lumbosacral
damage was related to regional anaesthesia and brachial plexus damage was
distributed between both techniques but it was not possible to assess the
mechanisms of damage in the majority of cases. The frequency with which nerve
damage occurs under general anaesthesia tend to be forgotten; poor patient
positioning, inadequate padding, tourniquet compression, ischaemia, retractors
and surgical technique have all been reported to cause peripheral nerve damage.
Anaesthetic factors can be directly or indirectly associated with nerve damage and
many of the causes are equally likely to occur whether or not the patient is awake.
Paediatric regional anaesthesia poses a particular problem for the critics of those
who perform regional anaesthesia on anaesthetised or heavily sedated patients. In
common with adult practice, there has been a sustained growth in the use of
perioperative regional anaesthesia in children and general anaesthesia is usually
administered prior to the block. A prospective 12 month survey of paediatric
anaesthesia in France and Belgium, looked at data from over 85,000 anaesthetics
which included 15,000 central neural blocks and 9,300 peripheral blocks [16] .
General anaesthesia preceded the regional block in 89% of patients, 6% were
"sedated" with intravenous induction agents or inhaled halogenated drugs - only
5% were fully conscious. There were 25 reports of complications with no deaths
and no neurological damage. All the complications occurred in the central block
group, with an incidence of 1.5 per 1000 and a zero incidence in the peripheral
group.
So from a database of 881,000 patients - adult and paediatric what conclusions
can be drawn regarding the risks of central and peripheral nerve blocks under
anaesthesia? Frankly we are little the wiser.
We know that serious morbidity from regional anaesthetic techniques is vanishingly
rare - thankfully.
We also know that paediatric anaesthetists have no qualms about anaesthetising
their patients prior to performing both central and peripheral blocks. The
consequences of permanent neurological damage might reasonably be expected
to be greater and last for longer in children, especially neonates whose nervous
systems are still immature. It would appear then that we are expected to apply
different rules to adults even though nerve damage is an extremely rare risk and
there is no scientifically rigorous evidence that general anaesthesia per se
increases that risk.
The major factors in preventing neurological sequelae are the experience and
dexterity of the anaesthetist, proper training and supervision of trainees, detailed
assessment of pre-existing vascular and neurological disease, avoidance of
repeated attempts due to technical difficulties and prompt recognition and
treatment of complications to prevent permanent damage. The issue of whether to
administer a general anaesthetic prior to regional anaesthesia becomes less
contentious if the correct systems are in place to ensure high standards of practice.
Which blocks can be safely performed under general anaesthesia and which
should only be performed on fully conscious patients? Infiltration techniques, field
blocks and the discrete blockade of small peripheral nerves do not appear to cause
problems and in the absence firm data to the contrary, the weight of clinical

practice suggests that the majority of larger peripheral nerve and plexus blocks,
with the possible exception of the interscalene approach to the brachial plexus [17]
can be safely performed under sedation or light general anaesthetic in
spontaneously breathing patients. Caudal and lumbar epidurals performed below
the conus medullaris cannot directly cause spinal cord damage and even thoracic
epidurals are safe when carried out by experienced anaesthetists where the
benefits to the patient justify the practice[18]. This assumes that the anaesthetist is
painstaking in the execution of the technique, pays great attention to the feedback
from the needle and has a high index of suspicion in the event of any difficulties.
Although pain on injection cannot be verbalised by an anaesthetised patient, other
cardinal signs do warn of neural contact; reflex muscle movement, increasing
resistance to needle movement and, most importantly, any resistance to injection.
Most peripheral nerves are surrounded by loose connective tissue and correctly
placed needles should offer no appreciable resistance to flow. Some of these
practical nuances are subtle and may escape the novice unless properly
supervised but they can be safely taught by skilled practitioners. Peripheral nerve
stimulators are valuable teaching tools; they aid nerve location and improve
success rates but there is no evidence that they reduce the potential for nerve
damage in either anaesthetised or conscious patients.
The key to safe regional anaesthesia is not whether the patient is asleep or awake
- it rests entirely on the skills and experience of the anaesthetist who must have an
awareness of the risks, take all reasonable steps to avoid them and manage the
patient with a high standard of care throughout the perioperative period.
References:
1. Bromage PR Masked Mischief. Regional Anesthesia 1996; 21(6S); 62-63
2. Bromage P R. Epidural Analgesia. Philadelphia; W B Saunders 1978: 667
3. Bromage P R. The control of post thoracotomy pain. Anaesthesia 1989; 44: 445
4. Gough J D, Williams A B, Vaughan R S, Khalil J F, Butchart E G. The control
of post thoracotomy pain. A comparative evaluation of thoracic epidural fentanyl
infusions and cryo-analgesia. Anaesthesia 1988; 43: 780-783
5. Vaughan R S, Gough J D. The control of post thoracotomy pain. Anaesthesia
1989; 44: 445
6. Horlocker T T. Regional Anesthesia Survey. ASRA News, August 1997; 1-3
7. Romer HC, Russell GN. A survey of the practice of thoracic epidural analgesia
in the United Kingdom. Anaesthesia 1998; 53: 1016-22
8. Aitkenhead A R. The pattern of litigation against anaesthetists. British Journal
of Anaesthesia 1994; 73: 10-21
9. Fischer HBJ Regional Anaesthesia - before or after general anaesthesia?
Anaesthesia 1998; August
10. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications
related to regional anesthesia. Anesthesiology 1997; 87: 479-486
11. Aromaa V, Lahdensuu M, Cozanitis DA. Severe complications associated with
epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient
insurance claims. Acta Anaesthesiol Scand. 1997; 41: 445-452
12. Dahlgren N, Tornebrandt K Neurological complications after anaesthesia. A
follow-up of 18,000 spinal and epidural anaesthetics performed over three years.
Acta Anaesthesiol Scand 1995; 39:872-880
13. Bromage PR Benumof JL. Paraplegia following intracord injection during
attempted
epidural anesthesia under general anesthesia. Regional Anesthesia and Pain
Medicine 1998; 23: 104-107
14. Krane EJ et al. The safety of epidurals placed during general anesthesia. Reg
Anes and Pain Man 1998; 23; 433-438
15. Kroll D A, Caplan R A, Posner K, Ward R J, Cheney F W. Nerve injury
associated
with anesthesia. Anesthesiology 1990; 73: 202-207
16. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional

anesthesia in children: a one year prospective survey of the French language

Society of Paediatric Anesthesiologists. Anesth Analg 1996; 83: 904-912
17. Passannante A N. Spinal anesthesia and permanent neurological deficit after
interscalene block. Anesth Analg 1996; 82: 873-874
18. Bromage P R. Neurological complications of subarachnoid and epidural
anaesthesia. Acta Anaesthesiol Scand 1997; 41: 439-444

Peripheral nerve blocks in children

Bernard Dalens
Pavillon Gosselin
Htel-Dieu BP 69
F-63003 Clermont-Ferrand Cedex 1
France
Peripheral nerve blocks have long been underused in pediatric patients, both for
theoretical and practical reasons. During the last decade, many conditions have
changed: the importance of adequate pain management has been universally
accepted, the limitations and adverse effect of central block procedures have been
put in light and new devices allowing both easy and safe location of mixed nerve
and/or fascial planes have become available at reasonable cost. Currently, a
growing number of anesthesiologists are considering peripheral blocks for providing
intra- and post-operative pain relief in a localized area either as single shot
procedures (short duration pain relief, especially in the context of ambulatory
surgery) or continuous procedure with the placement of reinjection catheters (thus
allowing long lasting pain relief on a limited area of the body) (1,2).
SELECTION OF APPROPRIATE DEVICES AND ANESTHETIC SOLUTIONS
Location of mixed nerves
Mixed nerves trunks and plexuses are best localized by using electrical stimulation
to elicit twitches in supplied muscles. Whether unsheathed (cheap) needles have
been successfully used pediatric patients (3), sheathed needles of appropriate
length are the best devices for achieving the goal of safe and precise location of
mixed nerves. More sophisticated devices are now available which permit inserting
a reinjection catheter either through a cannulas mounted over a metallic blunt
needle, or directly through the insulated needle connected to a nerve stimulator.
Still more recently, the catheter itself, with a built-in spiraled metallic wire, can be
connected to the nerve stimulator, thus allowing its precise placement in close
contact to the relevant nerve path.
Location of fascial planes during compartment blocks

Precise identification of fascial planes is the essential step of

compartment blocks such as the fascia iliaca compartment
block or the ilioinguinal nerve block. To achieve this goal, it is
necessary to use a short bevel needle to allow good
identification of the relevant fascial plane. Using this kind of
needle also improves considerably the safety of the
procedure. In most cases, the fascial plane to be identified is
the external fascia. Since the internal fascia has the same
structure (and resistance), it is as difficult to cross it as it is
to cross the external fascia; therefore, using a short-beveled

needle virtually eliminates the risk of piercing

simultaneously the two fascias and threatening underlying
structures (organs or vessels). Several commercially
available short bevel needles allows safe placement of a
reinjection catheter along the inner surface of the relevant
fascial plane, thus allowing continuous or intermittent
injection of anesthetic solutions for both passive and active
(reeducation and joint mobilization) post-operative pain
relief.
Selection of local anesthetics
The same solutions as those used in adults are commonly used in children, at
doses and volumes adapted to patients' age and size.
LOCAL ANESTHETIC Usual
Usual
concentration doses
(%)
(mg/kg)
(plain)
AMINOESTERS
Procaine
1-2
7
Chloroprocaine
2-3
7
AMINOAMIDE
Lidocaine
Mepivacaine
Bupivacaine
Etidocaine(c)
Ropivacaine

Maximum(a) Maximum(b)
dose (mg/kg) dose with
(mg/kg)
epinephrine

10
10

10
10

0.5-2

7.5

10

0.5-1.5

5-7

10

0.25-0.5

2.5

3-5

0.2 - 1

2-3

3.5

Not used

(a): Maximum doses are controversial; the doses mentioned above are safe when
given as single injections.
(b): Danger of severe methemoglobinemia in infants (even with low therapeutic
doses).
(c): Etidocaine should not be administered alone because sensory blockade can be
insufficient.
Use of additives
Local anesthetics have a limited duration of action which can be significantly
prolonged by a sound selection of additives mixed with the injected solution.
Alpha2-adrenergic agonists have long been added to local anesthetics.
Epinephrine is the most commonly used of such agents, usually in concentrations
ranging from 1:200,000 to 1:400,000; when not contraindicated, this addition offers
two main advantages: 1) vascular absorption (thus systemic toxicity) is decreased;
2) inadvertent intravascular injection can be detected (within 20 seconds) by
checking the electrocardiographic tracings (ST segment elevation, T wave change
(4) and, occasionally, heart rate changes) provided the injected dose of epinephrine
is, at least, 0.5 g/kg (5).
Clonidine, another 2-adrenergic agonist, is now commonly added to local
anesthetics for central and peripheral(6,7) blocks. Administered at doses ranging
from 1 to 1.5 g/kg, clonidine consistently increases the duration of nerve blockade

with no perceptible hemodynamic effects in children; a slight sedation for 1 to 3

hours, more beneficial than detrimental is produced and usually allows a quiet
emergence from anesthesia.
Sodium bicarbonate has been added to various solutions of local anesthetics with
the aim of increasing the non-ionized form of the drug, allowing more molecules to
cross cell membranes with the expected benefit of shortening the latency and
increasing the potency of the solution. However, the clinical relevance of this
addition remains controversial (8).
Ketamine has recently been used as an additive to epidural and spinal local
anesthetics due to its local effects on spinal NMDA receptors (9,10,11). Its
addition to solutions injected nerve paths seems to have a similar considerable
prolongation effect of sensory blockade and this light play a consistent role in the
very next future.
Placement of a re-injection catheter

Due to greater attention being paid to pain relief and

availability of adequate devices, placement of re-injection
catheters is increasingly used in adult and, more recently,
pediatric patients (1,12,13). This technique allows provision
of excellent analgesia for a limited (iterative injections) or
extended (continuous infusion) period of time over a limited
body area with virtually no systemic side effects and
impairment of major functions.
SAFETY PRECAUTION
Peripheral nerve blocks are anesthetic techniques. They should only be performed
by experienced anesthesiologists in an operating theater environment with
monitoring procedures and safety procedures recommended for any general
anesthetic. Prior establishment of an intravenous line is essential (14) and
(automated) control of electrocardiographic tracings, blood pressure, respiratory
rate and central temperature are the minimal monitoring required. Vital parameters
as well as the agents, doses and techniques used should be recorded on a
complete anesthesia chart.
In adults, most peripheral nerve blocks are performed in conscious or lightly
sedated patients. The same management is applicable to cooperative children who
are willing to remain conscious throughout the procedures and are able to dominate
theirs fears and anxiety. More frequently, children do not want to be conscious and
fear needle punctures at most, thus requesting being given a general anesthetic. If
not contraindicated for medical reasons (poor physical status, full stomach etc.),
light general anesthesia can be safely used and is both very commonly practiced
and widely accepted in pediatrics (15).
The technique of injection is a key factor of safety and early diagnosis of
complications. All block procedures require that an aspiration test and evaluation of
a test dose (with 0.5 to 1 g/kg of epinephrine if not contra-indicated) be performed
before large amounts of local anesthetic are injected. The injection must be
performed slowly and any unusual resistance requires immediate cessation of the
technique.
UPPER EXTREMITY CONDUCTION NERVE BLOCKS
Indications, contraindications and complications

Whether all techniques are suitable, axillary first, then

supraclavicular approaches to the brachial plexus are the

main techniques used in children. Axillary blocks are

recommended for elective as well as emergency surgery on
the forearm and the hand, both for providing intra- and
postoperative analgesia, especially for outpatient surgery.
Contraindications are scarce, mainly represented by
lymphadenopathy (infectious or malignant) and the
morbidity of the technique is very low.
Supraclavicular brachial plexus blocks are recommended for
emergency surgery of the upper limb in a patient with a full
stomach when the lesions involve the proximal part of the
limb (shoulder, arm and elbow) or when the limb cannot be
moved, either due to pain or due to the lesion.
Supraclavicular approaches are preferred to axillary
approaches unless a tourniquet is used during surgery or in
case of anomalies in the axillary region (infectious or
malignant adenopathies especially). Occasionally, a
supraclavicular block is performed not only for analgesic
purposes but for its vasodilatory properties when blood
supply to the limb is compromised or to produce full motor
blockade of the limb in case of fragile tendon repair, nerve
reconstruction, skin graft, especially in boisterous children.
Classical contraindications to (most) supraclavicular
approaches include bilateral blockade and marked
respiratory insufficiency (acute or chronic) due to the
potential danger of pneumothorax and (bilateral) phrenic
nerve palsy. The parascalene approach, however, does not
have the same limitations as the technique does not
threaten any vital organs, especially the apical pleura.
Nonetheless, an axillary approach has to be envisaged first,
and is preferable for suitable surgery of the forearm and
hand), each time a brachial plexus block seems to be
mandatory.
Auxiliary block procedures
All the techniques initially described in adults series of patient can be directly
transposed to pediatric patients except for transaxillary approaches which should
not be used. The main limitation of the axillary approach is the inconstant blockade
of the musculocutaneous nerve. As this nerve runs within the coracobrachialis
muscle, which is easily identifiable by palpation, a trans-coracobrachialis approach
considerably improves the success rate of the technique. While the arm is
abducted by 90 as in classical approaches, the needle is inserted vertically at the
crossing of the coracobrachialis muscle with the lower edge of the pectoralis major
muscle, pointing to the lower border of the humerus, just above the axillary artery
which is firmly held by finger compression, until a "click" is felt and twitches are
elicited. A reinjection catheter can be introduced and securely taped. Long-lasting
postoperative pain relief can be achieved either by repeated injections of 0.3 to 0.5
ml/kg (up to 20 ml) of 1% lidocaine or mepivacaine, not exceeding 4 injections per
day or continuous infusion of 0.1 or 0.125% plain bupivacaine (or 0.2%
ropivacaine) at a rate of 0.5 ml per hour and per year of age.
The parascalene approach (16)

The technique is performed with the child in the supine position, arms
extended along the chest wall, head turned to opposite side, and a rolled
sheet slipped under the shoulders aiming at extending the neck and
stretching the brachial plexus components. The puncture site lies on the
line uniting the transverse process of C6 to the midpoint of the clavicle,
at the union of the lower third with the upper two thirds. The needle is
inserted vertically, toward the back plane until twitches are elicited in
the upper limb and 0.5 to 0.75 ml/kg (not exceeding 25 ml) of local
anesthetic is then injected. The overall success rate of the technique is
high (16,17,18) and the morbidity is extremely low (even Horner
syndrome is infrequent). A reinjection catheter can be inserted and the
same anesthetic regimen as for axillary blocks is suitable.
LOWER EXTREMITY NERVE BLOCKS
Lumbar plexus nerve blocks
Indications, contraindications and complications
The lumbar plexus can be percutaneously approached from posteriorly but the
technique is not as commonly used in children as are femoral nerve blocks and,
furthermore, multi-effective techniques both for elective and emergency procedure
(fractured shaft of the femur). The latter two techniques may represent a good, and
safer, alternative to epidural anesthesia, the more so as placement of a catheter
would allow long-lasting pain relief (19,20). Conscious and slightly sedated children
tolerate quite well the performance of a muscle biopsy under femoral and lateral
cutaneous nerve block (21). The saphenous nerve block is an excellent
complement of a sciatic nerve block for providing complete analgesia of the lower
with low or reasonable amounts of local anesthetics. These blocks are virtually free
of complications.
Specific femoral nerve block
Specific femoral nerve block is performed by inserting the needle at right angles to
the thigh, 0.5-1 cm both distal to the inguinal ligament and lateral to the femoral
artery until paresthesia or twitches are elicited in the thigh. High quality block is
obtained with the injection of 0.5 to 0.75 ml/kg of a local anesthetic (as for
parascalene blocks). A reinjection catheter can be left in place for iterative of
continuous injections (same regimen as for axillary block), thus allowing long
lasting postoperative pain relief (including pain-free mobilization of joints).
Fascia iliaca compartment block (22)
A multi-effective lumbar plexus nerve block is easily obtained by
injecting a local anesthetic at the inner surface of the fascia iliaca under
which run all the nerves emerging from the lumbar plexus. The needle is
inserted vertically 0.5-1 cm caudal to the junction of the lateral with the
medial two thirds of the inguinal ligament. Two losses of resistance are
sought, the first corresponding to the fascia and the second one to the
fascia iliaca: the local anesthetic is then injected following the safety
rules. The volume injected (1 ml/kg up to a maximum of 30 ml) is critical
and massaging the swollen area favors upward and lateral spread of the
solution at the inner surface of the fascia iliaca. This technique allows
easy insertion of a reinjection catheter for long-lasting postoperative
relief.
Saphenous/Vastus medialis nerve block (23)
The saphenous nerve is the terminal branch of the femoral nerve which supplies
the medial part of the leg, ankle and foot. Its block completes to the whole limb
(below the knee) the distribution of anesthesia provided by a sciatic nerve block.
This sensory nerve runs just lateral to the motor branch supplying the vastus

medialis muscle, which can be easily located by nerve stimulation 0.5 cm lateral to
the femoral artery and 3 to 6 cm (depending on patient's age and size) below the
inguinal ligament. An insulated needle is inserted vertically until twitches are elicited
in the vastus medialis; then 0.1 to 0.2 ml/kg of local anesthetic is injected, which
results in a constant and complete saphenous nerve block (additionally, the vastus
medialis nerve is blocked, but this has no practical interest). The very small doses
of local anesthetic required to achieve complete blockade makes this block the
ideal complement to a sciatic nerve block to ensure complete nerve blockade of the
leg below the knee.
Sciatic nerve blocks
Indications, contraindications and complications
Sciatic nerve blocks are recommended for all surgery involving the lower extremity
below the knee, especially at ankle and foot levels; as the medial part of the leg
down to the medial malleole and, sometimes, the great toe, is supplied by the
saphenous nerve, a complementary block of this nerve is required to ensure full
anesthesia of the leg and foot. Sciatic nerve blocks have no specific
contraindications. Whether irreversible damage to the sciatic nerve following
intragluteal injections has been reported in the first quarter of this century, both
experimental data and clinical experience with the use of local anesthetics have
confirmed the safety of the procedure.
Proximal Lateral approach
This technique allows approaching the sciatic nerve with the patient lying supine.
The insulated needle is inserted horizontally 1 to 2 cm below the lateral skin
projection of the greater trochanter of the femur, pointing to the lower border of the
femur until twitches are elicited in the foot. A volume of 1 ml/kg (up to 35 ml) of a
local anesthetic is then injected to achieve blockade (which lasts longer than with
any other nerve block with the same local anesthetic agent). Recently, new devices
have been released which allow insertion of a catheter, thus permitting iterative as
well as continuous injection of local anesthetics for long lasting postoperative pain
relief. The lateral approach is the easiest and safest proximal approach to the
sciatic nerve, with a very high success, even in the hands of a beginner.
Sciatic block in the popliteal fossa
The sciatic nerve can be approached in the popliteal fossa with smaller doses of
local anesthetics than following a proximal approach. A simplified single-shot
technique was recently reported for use in children placed in the lateral decubitus
position with the affected extremity lying uppermost (24). An insulated needle is
inserted cephalad at a 45 angle to the skin both lateral to the midline and
proximal to the popliteal fold until twitches are elicited in the sciatic territory;
complete blockade of the sciatic nerve was obtained in all 50 reported patients and
no adverse effects were observed.
BLOCK OF NERVES SUPPLYING THE TRUNK
Trunk nerve blocks are being increasingly used in pediatric patients.
Many of them are known and used, often only occasionally, in children for decades.
These include intercostal nerve and interpleural (or intrapleural) block, both
techniques allowing placement of a reinjection catheter for long-lasting pain relief ;
however, the danger of systemic toxicity must not be underestimated. The thoracic
paravertebral block has gained in renewed interest in recent years and can
represent an effective alternative to intercostal nerve blocks, the more so as it does
not require that several punctures are performed at different levels. However, the
technique is not that simple and its indications are scarce. Several simple and safe
compartment block techniques are available and should be used more extensively

as their benefit/risk ratio is very high.

Para-umbilical or rectus sheath block (25,26)
This old technique that has recently regained considerable interest as it provides
excellent analgesia of the peri-umbilical area, which makes it an ideal block for
repair of umbilical hernia and hernias of the linea alba. The technique consists of
inserting a short bevel needle 2 cm lateral to the linea alba, on each side, at a 60
degree angle to the skin pointing to the upper border of the umbilicus until it pierces
(with difficulty), the rectus abdominis sheath with a characteristic and audible give.
The local anesthetic (0.5% bupivacaine, plain of with 1/200,000 epinephrine) is
then injected on a weight basis (0.2 ml/kg) in a fan shape manner. When the needle
is withdrawn, injection 0.5-1 ml of the solution subcutaneously would still improve
the quality of analgesia. The same technique is repeated on the other side.
Iliohypogastric and ilioinguinal nerve blocks

The iliohypogastric and ilioinguinal nerve block provides

adequate ipsilateral analgesia for intra and postoperative
pain relief of most operations in the inguinal region
(herniorrhaphy, orchidopexy, hydrocele) including
emergency procedures (strangulated hernia with intestinal
obstruction). The technique compares favorably with caudal
anesthesia; it has no specific contraindications, no true
complications but undesired femoral nerve block, which may
preclude discharge from hospital in patients scheduled for
outpatient surgery, is not unusual especially when large
volumes of local anesthetics (more than 0.4 ml/kg) have
been injected. Unexpectedly high plasma bupivacaine
concentrations (without clinical signs of toxicity) have been
reported in children weighing 10-15 kg (from a series of 30
patients) (27), but no further similar data have been
reported yet. Ropivacaine might improve the safety of the
block procedure but no data are currently available and this
agent has no approval for use in this indication.
Penile blocks via the subpubic space
Penile block via the subpubic space is the ideal block procedure for anesthetizing
the penis and its envelopes. The technique has no specific contraindications but, as
the penis is supplied by terminal arteries, epinephrine must not be added to the
anesthetic solution. While the penis is pulled down, a short-bevel needle is
inserted almost perpendicularly to the skin, with a slight caudal and medial slope,
0.5 cm below the symphysis pubis and lateral to the linea alba (on both sides) until
it pierces Scarpa's fascia which covers the subpubic space. A 0.1 ml/kg volume (not
exceeding 5 ml) of local anesthetic is then injected at both sites of puncture. Longlasting pain relief is obtained with use of 0.5% plain bupivacaine.
Pudendal/perineal nerve block
This block procedure was once very popular in obstetric patients and is regaining
interest in pediatrics to complement an ilioinguinal/iliohypogastric nerve block when
a surgical incision of the posterior part of the scrotum is necessary. The child is
placed in the supine position, thighs abducted, knee flexed and the plantar aspects
of his feet conjoined (as for girl's bladder catheterization). The ischial tuberosity is
identified just above and lateral to the anus. A short-beveled needle is then inserted
in the frontal plane, pointing to the medial aspect of the ischial tuberosity until a

give is felt as the obturator fascia is pierced. The epinephrine-free local anesthetic
is then injected on a weight basis (0.1 ml/kg up to 5 ml).
CONCLUSION
Peripheral nerve blocks are still underused in pediatric patients in spite of their
many advantages. They result in a limited distribution of anesthesia with virtually no
general or systemic effects. Due the considerable improvements in the design of
devices made by the manufacturers, virtually all peripheral nerve block procedures
can be safely performed at any age, with a very high success rate. Additionally,
several now available devices allow placement of a catheter which permits
accurate management of pain relief both in terms of duration and intensity. The
application of such continuous techniques should develop considerably in
forthcoming years due to its high benefit/risk ratio and compete considerably with
continuous epidurals the morbidity of which is considerably greater.
References
1. Taras JS, Behrman MJ. Continuous peripheral nerve block in replantation and
revascularization. J Reconstr Microsurg 1998;14:17-21.
2. Sutherland ID. Continuous sciatic nerve infusion: expanded case report
describing a
new approach. Reg Anesth Pain Med 1998;23:496-501.
3. Bosenberg AT. Lower limb nerve blocks in children using unsheathed needles
and a
nerve stimulator. Anaesthesia 1995; 50: 206-210.
4. Freid EB, Bailey AG, Valley RD. Electrocardiographic and hemodynamic
changes
associated with unintentional intravascular injection of bupivacaine with epinephrine
in infants. Anesthesiology 1993,79:394-398.
5. Felberg MA, Berkowitz RA, Chowdhury P, McDonald TB. Variable epinephrine
concentrations in local anesthetic test doses for caudal anesthesia in pediatric
patients.
Anesthesiology 85: A 1073, 1996.
6. Singelyn FJ, Dangoisse M, Bartholomee S, Gouverneur JM. Adding clonidine to
mepivacaine prolongs the duration of anesthesia and analgesia after axillary
brachial
plexus block. Reg Anesth 1992;17: 69-74.
7. Singelyn FJ, Gouverneur JM, Robert A. A minimum dose of clonidine added to
mepivacaine prolongs the duration of anesthesia and analgesia after axillary
brachial
plexus block. Anesth Analg 1996;83:1046-1050.
8. Chow MYH, Sia ATH, Koay CK, Chan YW. Alkalinization of lidocaine does not
hasten
the onset of axillary brachial plexus block. Anesth Analg 1998; 86: 566-568.
9. Naguib M, Sharif AMY, Seraj M, El Gammal M, Dawlatly AA. Ketamine for caudal
analgesia in children: comparison with caudal bupivacaine. Br J Anesth
67: 559-564, 1991.
10. Tverskoy M, Oren M, Vaskovich M, Dashkovsky I, Kissin I. Ketamine enhances
local
anesthetic and analgesic effects of bupivacaine by peripheral mechanism: a study
in
postoperative patients. Neurosci Lett 1996; 215:5-8.
11. Semple D, Findlow D, Aldridge LM, Doyle E. The optimal dose of ketamine for
caudal
epidural blockade in children. Anesthesia 1996;51:1170-1172.
12. Mezzatesta JP, Scott DA, Schweitzer SA, Selander DE. Continuous axillary
brachial
plexus block for postoperative pain relief. Intermittent bolus versus continuous

infusion.
Reg Anesth 1997;22:357-362.
13. Ebert B, Ganser J. [Axillary plexus catheter block in childhood and
adolescence].
Handchir Mikrochir Plast Chir 1997;29:303-306.
14. Eyres RL. Local anaesthetic agents in infancy. Paediatr Anaesth 1995; 5: 213218.
15. Krane E.J., Dalens B.J., Murat I., Murrell D., et al. The safety of epidurals
placed
during general anesthesia [editorial]. Regional Anesthesia and Pain Medicine
1998;23:433-438.
16. Dalens B, Vanneuville G, Tanguy A. A new parascalene approach to the
brachial plexus
in children: comparison with the supraclavicular approach. Anesth Analg
1987;66:1264-1271.
17. McNeely JK, Hoffman GM, Eckert JE. Postoperative pain relief in children from
the
parascalene injection technique. Reg Anesth 1991;16: 20-22.
18. Vongvises P, Beokhaimook N. Computed tomographic study of parascalene
block.
Anesth Analg 1997;84:379-382.
19. Johnson CM. Continuous femoral nerve blockade for analgesia in children with
femoral
fractures. Anesth Intensive Care 1994;22: 281-283.
20. Tobias JD. Continuous femoral nerve block to provide analgesia following femur
fracture
in a paediatric ICU population. Anesth Intensive Care 1994;22:616-618.
21. Maccani RM, Wedel DJ, Melton A, Gronert GA. Femoral and lateral cutaneous
nerve
block for muscle biopsy in children. Paediatr Anesth 1995;5:223-227.
22. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca
compartment block
with the 3-in-1 block in children. Anesth Analg 1989;69:705-713.
23. Bouaziz H, Benhamou D, Narchi P. A new approach for saphenous nerve block.
Reg
Anesth 1996;21:490.
24. Konrad C, Jhr M. Blockade of the sciatic nerve in the popliteal fossa: a system
for
standardization in children. Anesthe Analg 1998; 87: 1256-1258.
25. Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediatric
anesthesia: new
indications for an old technique ? Paediatr Anesth 1996;6:463-466.
26. Courrges P, Poddevin F, Lecoutre D. Para-umbilical block: a new concept for
regional
anesthesia in children. Paediatr Anesth 1997;7:211-214.
27. Smith T, Moratin P, Wulf H. Smaller children have greater bupivacaine plasma
concentrations after ilioinguinal block. Br J Anesth 1996;76:452-455.

Sympathetic blocks in pain management.

Hypogastric plexus block

Nagy A. Mekhail, M.D., Ph.D.

Director, Pain Management Center
The Cleveland Clinic Foundation
Cleveland, Ohio, U.S.A.

AUTONOMIC INNERVATION OF PELVIC VISCERA

Location
The superior hypogastric plexus, sometimes referred to as the presacral nerve, is
located in the retroperitoneum within loose connective tissue, anterior to the lower
portion of the body of the fifth lumbar vertebra, sacral promontory, and upper
portion of the first sacral vertebra. Its anterior relations include the bifurcation of the
aorta, both common iliac arteries, the left common iliac vein, and the median sacral
vessels.
Formation
The superior hypogastric plexus is formed by the confluence of the lumbar
sympathetic chains and branches of the aortic plexus that contains fibers that have
traversed the celiac and inferior mesenteric plexuses. In addition it contains
parasympathetic fibers that originate in the ventral roots of S2-S4 and travel as
slender nervi erigentes (pelvic splanchnic nerves).
Branches
The superior hypogastric plexus divides into the right and left hypogastric nerves,
which descent lateral to the sigmoid colon and rectosigmoid junction, to reach the
two inferior hypogastric plexuses. The superior plexus gives off branches to the
ureteric and testicular (or ovarian) plexuses, the sigmoid colon, and to the plexus
that surrounds the common and internal iliac arteries.
In addition to pathways that traverse the superior hypogastric plexus, sympathetic
fibers also reach the pelvis through perivascular pathways that include the inferior
mesenteric plexus (sigmoid colon and rectum), and renal plexus (ureteric and
ovarian or testicular plexuses). The lumbar and sacral parts of the sympathetic
trunks are directly contiguous at the level of the pelvic brim. The sacral sympathetic
trunks lie in the parietel pelvic fascia behind the parietal peritoneum and rectum,
and on the ventral surface of the sacrum, just medial to its anterior foramina and
the exiting sacral nerves. Below, they converge and unite to form a solitary, small
"ganglion impar", located anterior to the sacrococcygeal junction.
Presacral Neurectomy
Surgical interruption of the hypogastric plexus (presacral neurectomy) is a timehonored procedure that has been demonstrated to relieve a variety of painful pelvic
conditions, predominantly of nononcologic origin (i.e., dysmenorrhea) as shown by
Frier (1965). In one series, presacral neurectomy for chronic pelvic pain (Lee, et
al., 1986) showed a success rate of 73% in dysmenorrhea, 77% in dyspareunia,
and 63% in other pelvic pains.
Superior Hypogastric Plexus Block
Superior hypogastric plexus block, a percutaneous procedure that is analogous to
presacral neurectomy, has emerged recently as an important option in the
management of intractable pelvic pain.

Plancarte (1990) published the first report on using neurolytic superior

hypogastric plexus block to treat 28 patients with pelvic pain secondary to
cancer [20=cancer of cervix; 4=cancer of prostate; 1=testicular cancer;
3=radiation injury]. His results showed significant pain relief without
complications (70% mean reduction of pain scores). Residual pain seemed
to be of somatosensory origin and was treated with epidural steroid
injections or oral administration of non-narcotic analgesics. A global
reduction of pain scores of 90% resulted.
Kent (1992) looked at 26 patients with pelvic cancer who were treated with

superior hypogastric block for intractable pain:

69% achieved satisfactory, lasting pain relief (VAS decreased from 10/10
to 3/10).
31% achieved partial pain relief (VAS reduced from 10/10 to 4-7/10).
No complications encountered.

Waldman (1991) and Wechsler (1995) used a computed tomography scanguided neurolytic superior hypogastric plexus block for a variety of chronic,
painful pelvic conditions

From the previous reports it appears that the superior hypogastric plexus block is
an effective way to provide good palliation for visceral pelvic cancer pain.
Indications for Superior Hypogastric Plexus Block
1. Pelvic cancer pain arising from one or more of the following pelvic organs

Uterus and upper vagina

Bladder, prostate, seminal vesicles and urethra

Sigmoid colon and rectum

2. Pelvic pain secondary to radiation injury

3. Sympathetically-maintained pelvic pain, e.g., after rectal anastomosis, APR, etc.
Technique of Superior Hypogastric Plexus Block
1. Local anesthesia achieved by:

Local infiltration of skin, subcutaneous tissue and intervening muscles with

1% lidocaine
L4-5 single shot epidural block with 10ml of 1% lidocaine "reduces reflex
muscle spasm and ameliorates the discomfort associated with contact of
needles with periosteum"

2. Position:

Patient assumes the prone position with padding placed beneath the pelvis
to flatten the lumbar lordosis
Lumbosacral region is cleansed aseptically

3. Landmarks:

L4-5 interspace
Iliac crest

Skin wheals are raised 5-7 cm bilaterally at the L4-5 interspace level

4. Procedure:
A six inch, 22-gauge, short beveled needle is inserted through one of the skin
wheals. From a position perpendicular in all planes to the skin, the needle is
oriented about 30 degrees caudad and 45 degrees mesiad so that its tip is directed
toward the anterolateral aspect of the bottom of the L5 vertebral body. The iliac
crest and the transverse process of L5, which sometimes is enlarged are potential
barriers to needle passage. If the transverse process of L5 is encountered during
advancement of the needle, the needle is withdrawn to the subcutaneous tissue
and redirected slightly caudad or cephalad. The needle is readvanced until the

body of the L5 vertebrae is encountered or until its tip is observed fluoroscopically

to lie at its anterolateral aspect. If the vertebral body is encountered, the needle is
withdrawn, and without altering its cephalocaudal orientation, is redirected in a
slightly less mesiad plane so that its tip is "walked off" the vertebral body. The
needle tip is advanced using the loss of resistance technique. Loss of resistance
indicates that the needle tip has traversed the anterior fascial boundary of the
psoas major muscle and lies in the retroperitoneal space.
Biplanar fluoroscopy is used during needle passage. Correct needle placement in
an anteroposterior view should demonstrate the needle tip locations at the level of
the junction of the L5 and S1 vertebral bodies, and lateral views confirm placement
of the needle tip just beyond the vertebral bodys anterolateral margin. The
injection of a contrast medium is recommended to further verify accuracy of
placement and visualize the spread of medications. In the anteroposterior view, the
spread of the contrast media should be confined to the paramedian region at the
L5-S1 junction. In the lateral view, a smooth posterior contour corresponding to the
anterior psoas fascia indicates that the needle depth is appropriate. Alternatively,
computerized axial tomography may be used, permitting visualization of vascular
structures.
Complications
Vascular puncture with a risk of subsequent hemorrhage and hematoma formation
are possible due to the close proximity of the bifurcation of the common iliac
vessels. Intramuscular or intraperitoneal injection may result from an improper
estimate of needle depth. Subarachnoid and epidural injection, somatic nerve
injury (e.g., obturator, genitofemoral or lumbosacral trunk), and ureteral puncture
usually can be avoided by careful observation of technique.
Drugs

Diagnostic hypogastric plexus block: 6-8ml of 0.25% or 0.375%

bupivacaine through each needle
Neurolytic hypogastric plexus block: 6-8ml of 6% to 10% phenol dissolved
in contrast medium through each needle

Ganglion Impar Block [Ganglion of Walther]

The ganglion impar is a solitary retroperitoneal structure located at the level of the
sacrococcygeal junction and marks the termination of the paired paravertebral
sympathetic chains.
Pain arising from disorders of the viscera and somatic structures within the pelvis
and perineum is a frequent cause of discomfort and disability, especially among
women. The perineum refers to the anatomic area immediately below the pelvis,
and is comprised of diverse anatomic structures with mixed sympathetic and
somatic innervation. Although various intervention have been proposed for the
management of intractable perineal pain, their efficacy and applications are limited
by the same factors that complicate the management of pelvic pain. In addition, the
target of nerve blocks in this region historically has focused on somatic rather than
sympathetic components. Plancarte (1990) introduced the presacral blockade of
ganglion impar as an alternative means of managing intractable perineal pain
especially those with significant sympathetic component.
SMP of the perineal region is characterized by being:

Vague and poorly localized

Accompanied by sensations of burning and urgency

In this first report Plancarte (1990) treated sixteen patients with intractable perineal
pain by ganglion impar blockade:

All patients had advanced cancer: cervix=9, colon=2, bladder=2, rectum=1,

endometrium=2
All had localized intractable perineal pain in spite of surgery, chemotherapy
and/or radiation

Pain was burning in 8 patients and of mixed character in the rest

After neurolytic block:

8 patients had 100% pain relief

1 patient had 90% pain relief

2 patients had 80% pain relief

1 patient had 70% pain relief

4 patients had 60% pain relief

Block was repeated in two patients for further pain relief

Residual somatic pain was treated with epidural steroid injections or sacral
nerve blocks

Technique
The patient assumes the prone position with padding beneath the pelvis to flatten
the lumbar lordosis. The sacrococcygeal region including the greater intergluteal
crease is cleansed aseptically. A skin wheal is raised in the midline at the superior
aspect of the intergluteal crease, over the anococcygeal ligament and just above
the anus. A standard 22-gauge 3.5 inch spinal needle, which is manually bent to
acquire a "C" or "J" shape depending on the length of the coccyx is made. This
maneuver facilitates positioning of the needle tip anterior to the concavity of the
sacrocyccygeal junction. The needle is inserted through the skin wheal with its
concavity oriented posteriorly, and under fluoroscopic guidance is directed anterior
to the coccyx, until its tip is observed to have reached the sacrococcygeal junction.
Retroperitoneal location of the needle is verified by observation of the spread of 2
ml contrast medium which typically assumes a smooth-margined configuration
resembling an apostrophe. Anteroposterior view should demonstrate the tip of the
needle is exactly midline. 0.25% bupivacaine is injected for diagnostic purposes, or
alternatively 5-7ml 6% phenol is injected for the therapeutic neurolytic blockade.
Under most circumstances, needle placement is relatively straightforward. Local
tumor invasion, particularly from rectal cancer, may prohibit the spread of injected
solutions.
Unless care is taken to confirm the needles postero-anterior orientation,
perforation of the rectum or anal canal, or periosteal injection are possible. Also,
spread into the epidural space within the caudal canal can be avoided by observing

the spread of contrast medium in a lateral view projection.

References

De Leon-Casasola OA, Kent E, Lema MJ: Neurolytic superior hypogastric

plexus
block for chronic pelvic pain associated with cancer. Pain 54:145-151,
1993.
Frier A: Pelvic Neurectomy in gynecology. Obstet Gynecol 25:48-55, 1965.

Jain S, Kestenbaum A, Shah N, Khan Y: Hypogastric plexus block: a new

technique for treatment of perineal pain. Anesth Analg 70:S175, 1990.

Kent E, de Leon-Casasola OA, Lema M: Neurolytic superior hypogastric

plexus block for cancer related pelvic pain. Regional Anesthesia 17
(suppl):19, 1992.

Lee RB, Stone K, Magelsen D, Belts RP, Benson WL: Presacral

neurectomy for chronic pelvic pain. Obstet Gynecol 68(4):517-521, 1986.

Plancarte R, Amescua G, Patt RB, Aldrete JA: Superior hypogastric plexus

block for pelvic cancer pain. Anesthesiology 73:236-239, 1990.

Plancarte R, Amescua C, Patt RB: Presacral blockade of the ganglion

impar (ganglion of Walther). Anesthesiology 73:A751, 1990.

Plancarte R, et al.: Neurolytic superior hypogastric plexus block for chronic

pelvic pain associated with cancer. Reg Anesth 22(6):562-8, 1997.

Waldman SD, Wilson WL, Kreps RD: Superior hypogastric plexus block
using a single needle and computed tomography guidance: description of
modified technique. Reg Anes 16:286, 1991.

Wechsler RJ, et al.: Superior hypogastric plexus block for chronic pelvic
pain in the presence of endometriosis: CT technique and results.
Radiology 196(1):103-6, 1995.

Anesthesia for Ankle & Foot SurgerFOOT

SURGERYANESTHESIA FOR ANKLE AND FOO

Anatomy and Innervation of the Foot and Ankle

Choice of Anesthetic Technique According to the Surgical Procedure
Advantages and Limitations of Various Techniques
Postoperative Pain Management
Special Considerations
Choice of Anesthetic Agents
o Popliteal block - lateral approach
o Popliteal block - lithotomy approach
o Ankle block
Summary
References

Regional anesthesia has a lot to offer in lower extremity surgery. The peripheral
location of the surgical site in foot surgery and the possibility to block the pain
pathways at multiple levels present a clear advantage over general anesthesia
techniques. Judiciously and skillfully conducted regional anesthetic can largely
prevent hemodynamic disturbances and pulmonary complications of general
anesthesia, facilitate postoperative pain management and timely discharge. For
instance, anesthesia can be limited to the spinal cord level (spinal and/or epidural
anesthesia), major trunks of the sciatic and femoral nerves (sciatic, popliteal and
femoral nerve blocks), or to their terminal branches (ankle and metatarsal blocks).
This allows one use of regional anesthesia even in patients in whom some regional
anesthesia techniques could be contraindicated. For instance, while neuraxial
anesthesia may be contraindicated in patients with sepsis and anticoagulation, there
are no reports of complications when ankle or popliteal blocks are used in this setting.
Similarly, when infection and swelling at the foot and ankle prevents use of the ankle
block, surgical anesthesia can be achieved using the sciatic or popliteal blocks with or
without the femoral nerve block.
In order to deliver anesthesia in a safe, efficient and competent manner, the selection
of a regional anesthetic must be based on site, degree and duration of the operation
and the requirement for pain control in the postoperative period. In this review we
offer some anatomical considerations for proper selection of regional anesthesia
techniques for foot and ankle surgery, and discuss some important aspects, advantages
and limitations of the commonly used regional anesthesia techniques in this setting.

Anatomy and Innervation of the Foot and Ankle

The ankle includes the ankle joint and the surrounding structures. The ankle joint
consists of the articulation between the tibia and fibula superiorly, and the talus

inferiorly. (Figure 1). The joint is covered with the capsule, stabilizing ligamentous
structures and distal projections of the tibia and fibula, which form medial and lateral
malleoli respectively. The foot is divided into the hindfoot, midfoot and forefoot
(Table 1 and Figure 1). Innervation to the foot and ankle is provided by five separate
nerves: saphenous nerve, the longest branch of the femoral nerve and four branches of
the sciatic nerve, deep peroneal (anterior tibial), posterior tibial, superficial peroneal,
and sural
Figure 1. Anatomy of the foot and ankle. Legend:
1. Tibia
2. Fibula
3. Tallus
4. Calcanous
5. Navicular
6. Cuboid
7. Cuneiform bones
8. Metatarsal bones
9. Phalanges
Red and blue shaded areas depict hindfoot and midfoot,
respectively.

Table 1. Functional division of the anatomical regions of the foot and ankle.
Hindfoot

Achilles tendon, calcaneus and talus bones

Midfoot

Navicular, cuboid and three cuneiform bones

Forefoot

Five metatarsal bones and phalanges

The sciatic nerve gives sensory and motor branches to all structures below the knee
except the anteromedial part of the lower leg and foot, which are supplied by the
saphenous nerve (Figure 2). In the popliteal fossa the sciatic nerve divides into two
main branches: posterior tibial and common peroneal nerves. The common peroneal
(lateral popliteal) nerve arises from the posterior part of the sacral plexus(L4-5 and
S1-2). The nerve separates from the tibial nerve to descend along the tendon of the
biceps femoris muscle and around the neck of the fibula (the nerve is at this level
easily palpated and accessible for blockade). Just below the head of the fibula the
common peroneal nerve divides into its terminal branches: the deep peroneal and
superficial peroneal nerves, both covered by the peroneus longus muscle (Figure 3).

Figure 2. Saphenous nerve emerges just below the medial aspect of the knee and
branches into subpatellar branches (1) and long branch (2) to the anterio-medial aspect of
the foot. Saphenous vein (3) accompanies the saphenous nerve.

Figure 3. Common peroneal nerve and its terminal branches. Legend:

1. Common peroneal nerve
2. Superficial peroneal nerve
3. Deep peroneal nerve.
Peroneus longus muscle removed to exposure the nerves.

The deep peroneal nerve runs downwards below the layers of the peroneus longus,
extensor digitorum longus and extensor hallucis longus muscles to the front of the leg
(Figure 2). At the ankle level, the nerve lies anteriorly to the tibia and the interosseous
membrane and close to the anterior tibial artery. It is usually "sandwiched" between
the tendons of the anterior tibial and extensor digitorum longus muscles. Here the
nerve divides into two terminal branches for the foot, the medial and the lateral
branches. The medial branch passes over the dorsum of the foot, along the medial side
of the dorsalis pedis artery, to the first interosseous space, where it divides into two
dorsal digital branches for the supply of the first web space between the big toe and
the second toe. The lateral branch of the deep peroneal nerve is directed
anterolaterally, penetrates and innervates the extensor digitorum brevis muscle and
terminates as the second, third and fourth dorsal interosseous nerves. These branches
provide the nerve supply to the tarsometatarsal, metatarsophalangeal and

interphalageal joints of the lesser toes. The superficial peroneal nerve (also called
musculocutanous nerve of the leg) is a branch of the common peroneal nerve. The
superficial peroneal nerve gives muscular branches to the peroneus longus and brevis
muscles. After piercing the deep fascia covering the muscles, the nerve eventually
emerges from the anterolateral compartment of the lower part of the leg and surfaces
from beneath the fascia 5-10 cm above the lateral maleolus. Here the nerve divides
into terminal cutanous branches: the medial and lateral dorsal cutanous nerves (Figure
4). These branches carry sensory innervation to the dorsum of the foot and
communicate with saphenous nerve medially, with deep peroneal nerve (Figure 5) in
the first web space and sural nerve on the lateral aspect of the foot.

Figure 4. Superficial peroneal nerve (1) emerges on the lateral aspect of the lower leg and divides into
medial (2) and lateral (3) dorsal cutanous nerves.

Figure 5. Deep peroneal nerve (1) emerges on the anterior aspect of the foot between extensor
digitorum (2) and extensor hallucis longus (3) tendons. It is accompanied by dorsal pedal artery (4).

The tibial nerve (medial popliteal or posterior tibial nerve) arises from the anterior
aspect of L4-5 and S1-3. It separates from the common popliteal nerve at a various
distance from the popliteal fossa crease and joins the tibial artery behind the knee
joint. The nerve runs distally in the thick neuro-vascular fascia and emerges at the
inferior third of the leg, from beneath the soleus and gastrocnemei muscles on the
medial border of the Achilles tendon (Figure 6). At the level of the medial malleolus,
the tibial nerve is covered by the superficial and deep fasciae of the leg and it is
positioned lateral and posterior to the posterior tibial artery, and midway between the
posterior aspect of the medial malleolus and posterior aspect of the Achilles tendon.

Figure 6. Tibial nerve at the level of the ankle. Legend:

1. Tibial nerve
2. Achilles tendon
3. Medial malleolus

Figure 7. Plantar nerve (1) divides into medial (2) and lateral (3) plantar nerve.

Figure 8. Sural nerve (1) emerges on the lateral aspect of the achilles tendon 15 cm above the lateral
malleolus. The nerve divides into multiple branches (2,3) and innervates the lateral aspect of the foot.

Just beneath the malleolus, the nerve divides into lateral and medial plantar nerves
(Figure 7). The posterior tibial nerve provides cutanous, articular and vascular
branches to the ankle joint, medial malleolus, inner aspect of the heel and achilles
tendon. It also carries the branches to the skin, subcutanous tissue, muscles and bones
of the sole. The sural nerve is a sensory nerve formed by the union of the medial sural

nerve - a branch of the tibial nerve - and lateral sural nerve a branch of the common
peroneal nerve. The sural nerve courses between the heads of the gastrocnemius
muscle and after piercing the fascia covering the muscles, emerges on the lateral
aspect of the Achilles tendon, 10 to 15 cm above the lateral mallelus (Figure 8). After
giving lateral calcaneal branches to the heel, the sural nerve descends 1-1.5 cm behind
the lateral malleolus, anterolateral to the short saphenous vein and on the surface of the
fascia covering the muscles and tendons. At this level the nerve supplies the lateral
malleolus, Achilles tendon and the ankle joint. The sural nerve continues on the lateral
aspect of the foot supplying the skin, subcutanous tissue, fourth interosseous space and
sensory innervation of the fifth toe.

Choice of Anesthetic Technique

According to the Surgical Procedure
While limiting the anesthesia to the very periphery of the extremity has obvious
advantages over more proximal or general anesthesia techniques, occasionally local
factors (infection, swelling) may not permit use of ankle or mid-tarsal blocks.
Fortunately, the advantageous anatomy of the lower extremity allows use of neuronal
blockade at different levels, as one ascends in the neuronal axis (mid-tarsal level,
ankle level, knee level, groin and hip levels, and the spinal/epidural level). Some
common surgical procedures and considerations regarding the choice of regional
anesthesia techniques are discussed in Table 2.
Table 2. Anesthesia Techniques for Common Foot and Ankle Operations
Surgical procedure

Hindfoot*

Remarks

Hallux valgus

Metatarsal, Ankle,
Popliteal Block

Block of the surral nerve not

necessary for the operation

Amputations

Ankle, Popliteal
Block

Popliteal block is the

anesthetic of choice whenever
swelling or infection prevents
reliable ankle block

Transmetatarsal
amputations

Ankle, Popliteal
Block

Forefoot*

Midfoot*

Anesthesia
Technique

Usually performed
under spinal,
Ankle arthroscopy
epidural or general
anesthesia

Usually the operation requires

good muscle relaxation of the
leg for manipulation and
traction.

Achilles Tendon
Repair

Spinal or epidural anesthesia

preferred
whenever thigh tourniquet is
considered

Popliteal block,
spinal or epidural
anesthesia

Ankle fractures

Triple arthrodesis

Spinal, popliteal or
epidural

Epidural block requires low

lumbar blockade L5-S1.

Popliteal Block

Neuroaxial blockade preferred

for bone graft harvesting;
popliteal blockade for
postoperative pain
management

Legend: The anesthetic techniques are listed in the order of these authors preference.
* Femoral or saphenous nerve block required if the incision extends on the medial part of the foot or
ankle.

Advantages and Limitations of Various

Techniques
Limiting extent of anesthesia to the most distal neuronal tree has number of potential
advantages. First, the more distally the neuronal blockade is approached, the easier is
to access the nerves. Secondly, systemic absorption of local anesthetic is of a lesser
magnitude when injected peripherally than when the local anesthetics is injected
proximally (e.g. epidurally). , Finally, peripheral blocks avoid the cardiovascular,
respiratory and other side-effects of neuraxial anesthetics. For that reason, for
example, metatarsal block is an excellent choice for most distal operations, especially
when muscle relaxation of the calf muscles and tourniquet are not required. This
technique provides reliable anesthesia of fast onset for operations on the toes.
However, when surgery involves more proximal parts of the foot, ankle or popliteal
blocks are better choices. Popliteal block is especially useful when soft tissue swelling
and/or infection at the ankle joint are present. Neuroaxial anesthesia also results in
excellent surgical conditions for ankle and foot surgery, but attention should be paid
to the level of blockade. For instance, epidural anesthesia may fail to produce
blockade in the sacral segments unless the needle is inserted at the lower lumbar
segments (L5-S1) and larger volumes of local anesthetics are used.
The main disadvantage of peripheral nerve blocks (e.g. popliteal, saphenous, sciatic
and/or femoral) for foot and ankle surgery is that these techniques do require some
expertise for consistent success rate. For those practitioners with less exposure to
these techniques, intravenous regional anesthesia may be better suited. Its simplicity
and relatively high success rate make the intravenous regional anesthesia (including
the upper extremity) probably the single most common type of regional block
practiced in the US. The duration of surgery however, is limited by the tourniquet
pain. Therefore, we avoid using this technique for operations that may last longer than
1 hour.

Postoperative Pain Management

Regional anesthesia techniques are also well suited for management of postoperative
pain after foot and ankle surgery. Many of the previously discussed peripheral nerve
block techniques (with exemption of intravenous regional anesthesia) when used for
surgical anesthesia will also provide excellent pain relief for extended period. For
example, customary doses of 0.5% bupivacaine for ankle-foot block will give

extended pain control after the operation. Similarly, when 1.5% mepivacaine with
bicarbonate and epinephrine is used for popliteal block, analgesia up to 10 hours is
frequently observed. The popliteal block can then be repeated using bupivacaine with
epinephrine, which frequently results in analgesia for 12-24 hours. Additionally, ankle
or popliteal block can also be repeated using lower concentration of bupivacaine
(0.25-0.375%).
Prolonged postoperative analgesia can be achieved by using longer-acting local
anesthetics for peripheral nerve blocks or adding epinephrine or clonidine to solutions
of local anesthetics. For instance, when epinephrine-containing solutions of
bupivacaine are used for popliteal or femoral blocks, duration of sensory blockade can
easily exceed 12-24 hours. It should be remembered here that epinephrine should not
be used for ankle or metatarsal blocks, since there is a risk of foot ischemia. Similarly,
combining clonidine with lidocaine (10 mcg/ml) for ankle or metatarsal blocks for
foot surgery significantly increases duration and quality of postoperative analgesia.
Another option is to repeat neuronal blockade or employ a continuous infusion of
local anesthetics through a catheter placed in the epineural sheath of the sciatic
(popliteal) nerve.

Special Considerations
Majority of elective foot and ankle operations are performed on an outpatient basis.
Ideal anesthetic for ambulatory operations would be administered in a time-wise
fashion, without unnecessary delays, and it would provide good intraoperative
anesthesia, rapid emergence and uneventful recovery with effective postoperative
analgesia. Regional anesthesia with its selective local action offers an excellent
anesthetic choice for ambulatory patients. In our institution majority of these
operations are performed under popliteal, ankle or metatarsal block, with excellent
results. Others have also documented an excellent safety record for regional
anesthesia in this setting. Ability to perform the blocks in the holding area prior to
surgery allowing fast turnover time, and high patient satisfaction , also add to the
value of these techniques in this setting.
Elderly patients, with smaller physiological reserves, higher frequency of concomitant
medical problems are also among the greatest beneficiaries of regional anesthesia.
The smaller body temperature decrease during operation, smaller blood loss and lesser
incidence of ischemia are some examples of advantages of regional anesthesia in this
group of patients. However, it should be remembered that local anesthetics may have
a more profound effect in the elderly, secondary to slower metabolism, concomitant
diseases or intake of medications which interfere with local anesthetic metabolism.
Thus, it would be prudent to choose regional techniques which result in lower blood
levels of local anesthetics (e.g., peripheral nerve blocks or spinal anesthesia vs.
epidural anesthesia).
Another group of patients that is likely to benefit most from regional anesthesia are
patients with diabetes mellitus. Reduction of stress response associated with surgery
and anesthesia is clearly beneficial in this patient population. For instance, the glucose
metabolism in patients with diabetes mellitus remains unaffected after retrobulbar
block for eye surgery, whereas considerable disturbance is likely after general
anesthesia. Patients with diabetes may have a number of vascular and infectious

complications of long standing disturbances of glucose metabolism, frequently

requiring foot surgery (e.g., ulcers, infection, gangrene). At the time of surgery, these
patients are often in sub-optimal condition due to sepsis or gangrene, yet the surgery
is emergent in nature (toes or foot amputation or debridment). Metatarsal or ankle
blocks are frequently difficult to perform or contraindicated in these patients, due to
the swelling and tissue acidosis at the ankle area. On the other hand, dehydration and
commonly present significant coexistent diseases (coronary artery disease,
anticoagulation) may present disadvantage to, or contraindicate neuroaxial anesthesia.
In this group of patients the popliteal block with or without saphenous nerve block is
an extremely valuable anesthetic option. The newer technique (e.g., lateral approach
to popliteal block) makes this approach suitable even in patients that can not assume
the prone position, which had traditionally been a prerequisite. It should be noted that
when performing a peripheral nerve stimulator-assisted neuronal blockade, diabetes
mellitus, sepsis, hypotherma, hypothyroidism and old age all may increase
requirements for stimulating current during nerve localization. While duration of
neuronal blockade in these patients may also be substantially prolonged, there is no
evidence that they are at increased risk of neurologic injury.

Choice of Anesthetic Agents

Choice of local anesthetics and various additives is based on the type of the planned
peripheral nerve block or neuraxial anesthesia, duration of the surgical procedure,
requirement for continuous postoperative analgesia, and need for ambulation.
With spinal anesthesia, in general, outpatient procedures are best performed using
short or intermediate acting local anesthetics. However, because of disturbing reports
of transient neurologic irritation after spinal anesthesia with lidocaine regardless of its
baricity, lidocaine is nowadays less commonly used. While it remains uncertain
whether mepivacaine has any advantages over lidocaine in this respect, hyperbaric
bupivacaine, has been shown to have a favorable recovery profile in the outpatient
setting, and provides reliable anesthesia of predictable duration. Addition of small
doses of fentanyl intrathecally can further augment anesthesia without prolonging the
recovery time.
Many local anesthetics can be employed for epidural anesthesia. Nevertheless, we
prefer using pH-adjusted 2% lidocaine (1mEq of bicarbonate added per 10 ml of
lidocaine) with 1:300,000 epinephrine as an initial bolus. Injection of local anesthetic
through the needle as a bolus may shorten the time to onset of the block and enhance
the quality of the block. If the surgery extends beyond the duration of the local
anesthetic, additional doses of lidocaine or 0.5% bupivacaine may be injected.
For peripheral nerve blocks (except ankle or midtarsal blocks), we prefer using pHadjusted solutions of 1.5% mepivacaine with bicarbonate and epinephrine 1:200,000.
Alternatively, 2% lidocaine can also be used. While short duration and fast onset of
action of chloroprocaine is theoretically advantageous for minor procedures in the
outpatient setting, , our experience is that this agent does not give adequate dense
anesthesia for bone surgery. In patients who are planned for admission, bupivacaine
and/or ropivacaine can be added if prolonged postoperative analgesia is desired.
Personal bias of these authors is however, that mepivacaine and lidocaine provide the

most consistent surgical anesthesia and that longer-acting agents are best reserved for
postoperative pain management.
Ankle block for foot surgery is usually performed using a mixture of 0.5%
bupivacaine with 1% lidocaine. This combination of local anesthetic gives fast onset
of surgical anesthesia and prolong postoperative analgesia. At the level of the ankle
there is no motor nerve supply to the foot other than the intrinsic muscles which
stabilize the foot but do not participate significantly during patient ambulation. Thus,
one of the advantages of the ankle block is the prolonged sensory block without
significant motor blockade. One should remember that with all techniques which are
likely to result in a prolong sensory block, it is important to instruct the patients
regarding the foot care until the sensation returns.
While major texts of regional anesthesia, as well as many previous issues of this
journal are replete with various nerve block techniques, we would like to turn our
focus to several newer techniques of lower extremity blocks which are particularly
well suited for foot and ankle surgery.

Popliteal block - lateral approach

While the posterior approach to popliteal block has traditionally mandated that
patients assume prone position during placement of the block, the lateral technique is
performed with a patient in supine position. Leg is extended at the knee joint and the
long axis of the foot is positioned at a 90 angle relative to the table. A 100 mm, long
insulated short bevel needle, attached to a low-output nerve stimulator is inserted in a
horizontal plane 7 cm cephalad to the most prominent point of the lateral femoral
epicondyle. The needle is inserted in the groove between the biceps femoris and the
vastus lateralis muscles until the shaft of the femoral bone is intentionally contacted
(Figure 9).

Figure 9. Popliteal block - lateral approach.

The needle is inserted horizontally in the groove between the biceps femoris and the vastus lateralis
muscles, 7 cm proximal to the lateral femoral epicondyle. The depth at which the tip of the needle
encounters the femur is noted.

Once the femoral bone is contacted, the needle is withdrawn to the skin, and
redirected posteriorly at a 30 angle to the horizontal plane (Figure 10). If the sciatic
nerve is not stimulated, the needle is withdrawn to the skin and reinserted through the

same skin puncture, first 5 to 10 anterior and then 5 to 10 posterior relative to the
initial insertion (30) plane. If these redirections do not result in nerve localization,
the same technique is repeated through new skin punctures in 5mm increments
posterior to the initial insertion plane.

Figure 10. Popliteal block - lateral approach.

After the femoral shaft is intentionally contacted, the needle is withdrawn to the skin and redirected
posteriorly at a 30 degree angle to the initial insertion plane. The popliteal nerve is contacted at a depth
1-1.5 cm beyond the measured skin-femur distance.

After obtaining plantar flexion (tibial nerve), or dorsal flexion (common peroneal
nerve) of the foot or toes 40 mL or more of 1.5% alkalinized mepivacaine (1 mEq of
NaHCO3 per 30 mL of mepivacaine) with 1:200,000 epinephrine is used. This dose
and volume of local anesthetic results in 4 to 6 hours of surgical anesthesia.
Bupivacaine 0.25-0.375 % with epinephrine is superior to mepivacaine for
postoperative analgesia. Ideally, stimulation of the nerve is achieved using a current of
0.4 mAmp or less. When this is not possible (e.g., diabetic, elderly or septic patients),
stimulation of the division of the sciatic nerve that predominantly innervates the
surgical area should be obtained. Block of the saphenous (or femoral) nerve is
required for surgery involving medial aspect of the leg.

Popliteal block - lithotomy approach

This approach is also performed with a patient in the supine position, but it allows use
of the identical landmarks as those used in the posterior approach. The leg is flexed at
both hip and knee joints, and supported by an assistant. Anatomical landmarks
include: popliteal fossa crease, the semimembranosus and semitendinosus muscles
tendons medially, and the long head of the biceps femoris muscle tendon laterally are
readily identified in this position (Figure 11). The insulated needle, attached to a
peripheral nerve stimulator, is inserted 7 cm above the popliteal crease, at the midline
and directed 45 degrees cephalad. When the nerve is not localized on the first
insertion, the needle is slowly withdrawn and reinserted laterally 5 to 10 degrees, until
the desired response is obtained. If these redirections do not result in nerve
localization, the needle is removed and reinserted 5 mm laterally to the initial
insertion site

Figure 11. Popliteal block - lithotomy approach.

The surface anatomy of the popliteal fossa is accentuated in the in the lithotomy position. Legend:
1. Popliteal fossa crease
2. Tendons of the semitendinosus and semimembranosus muscles
3. Tendon of the biceps femoris muscle
4. Midpoint between the biceps femoris and semitendinosus muscle tendons
5. The needle is inserted 7 cm above the popliteal fossa crease at the midpoint between the
semitendinosus and biceps femoris muscles.

The principles of nerve stimulation, motor response and type and volumes of local
anesthetics are otherwise identical to the ones in the lateral approach.
Saphenous or femoral nerve
Saphenous nerve block required for foot and ankle surgery can be performed at
multiple levels. Femoral nerve block at the inguinal area invariably results in
anesthesia of all branches of the saphenous nerve. If femoral nerve block, however, is
not sought, saphenous nerve block can also be accomplished more distally. These
approaches include the trans-sartorial approach, or saphenous nerve block at the knee
or ankle level (reference). Finally, the terminal branch of the nerve can also be
blocked using the midtarsal approach.

Ankle block
Ankle block can be performed at the midtarsal level for operations of the forefoot or
at the level of malleoli when surgery involves the midfoot or the heel. It is important
to remember that at the foot and ankle level, saphenous, sural and superficial peroneal
nerves are superficially located just above the fascia covering the muscles and
tendons. Thus, the needle should be inserted tangentially to the skin in order to
maintain the course of the needle above the level of the fascia. Additionally, these
superficial nerves have highly variable course and multiple branches. Therefore, for
their successful block, infiltration of local anesthetic must be done in a ring-type
fashion. In contrast, the anterior tibial (deep peroneal) and posterior tibial nerves are
located deeper, below the fascial level and usually at the level of tendons and arteries.
Therefore the needle should to be inserted perpendicularly to the skin for sub-fascial
placement of the needle tip. Contact with bone is frequently necessary to properly
identify position of these nerves.

Summary

Several highly efficacious regional anesthesia techniques can be used to provide

excellent surgical anesthesia and good postoperative analgesia for foot and ankle
surgery. Despite the absence of mounting scientific evidence that regional anesthesia
is safer than general anesthesia in lower extremity surgery, it is almost universally
accepted that regional anesthesia (peripheral nerve blocks in particular) offers
numerous advantages in this setting. By limiting the action of anesthetics to the site of
surgical interest, many highly undesirable side-effects of general anesthesia can be
avoided. This can especially be important among the ambulatory, diabetic and patients
with significant concomitant diseases, where nausea, vomiting, urinary obstruction,
orthostatic hypotension and intractable postoperative pain remain the main
postoperative challenges, frequently causing unplanned hospital admissions. For that
reason, regional anesthesia is undoubtedly the anesthetic of choice for majority of
patients undergoing foot and ankle surgery.

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