Lower Limbs Blocks

8/9/2019 Lower Limbs Blocks

1/10

Lower limb blocks

J. M. Murray,1

S. Derbyshire2

and M. O. Shields3

1 Consultant Anaesthetist, Department of Anaesthetics, Queens University, Belfast, UK

2 Research Nurse, Musgrave Park Hospital, Belfast, UK

3 Consultant Anaesthetist, Department of Anaesthetics, Royal Hospitals Trust, Belfast, UK

Summary

The advances in regional techniques for blocks of the lower limb have been driven primarily by the

need to produce effective analgesia in the postoperative period and beyond. These techniques are

commonly performed before or after central neuraxial blockade when this technique is used to

provide anaesthesia and analgesia for the surgical procedure. Increasingly, modern practice demands

a shorter hospital stay, improved patient expectations and early mobilisation. This article describes

the current methods and reasons for performing specific blocks to the lower limb and the man-

agement of these blocks particularly in the postoperative period.

........................................................................................................

Correspondence to: Dr James Murray

E-mail: [email protected]

Regional anaesthesia for major lower limb surgery such as

hip and knee arthroplasty is readily provided by central

neuraxial blockade, obviating the need for peripheral

blocks for the operative procedure itself. For this reason,

the advance of the popularity of peripheral nerve blocks

for lower limb surgery has been in the effective manage-

ment of pain and in accelerating postoperative mobility.

Pain management after lower limb surgery has a signif-

icant impact on overall postoperative outcome in terms of

faster mobilisation, less postoperative nausea and vomit-

ing, and decreased overall hospital stay. Both early

mobilisation and shorter hospital stay have been achieved

in large part by advances in anaesthesia, postoperative

rehabilitation and surgical technique [1]. Inadequate

control of pain prevents early mobilisation and militates

against these advances. Parenteral opioids still continue to

play a major role in postoperative pain control strategies

despite significant side effects such as nausea and vom-

iting, hypotension, confusion, constipation, urinaryretention, sedation, respiratory depression and pruritus

[26]. These side effects are undesirable for patients in

whom early mobilisation and hospital discharge are

planned. Capdevila et al. [7] highlighted the importance

of analgesia in optimising postoperative rehabilitation.

These authors insist on the need to develop techniques

that allow early functional recuperation, and they

emphasise the importance of integrating multimodal

analgesia into rehabilitation programmes.

Singelyn et al. [8] reported that regional analgesic

techniques (epidural analgesia or three-in-one blocks)

enhance early recovery after unilateral total knee replace-

ment. Nevertheless, there were no additional significant

differences between the groups at 6 weeks and 3 months

after surgery in term of knee flexion and mobility.

Capdevila et al. [7] also demonstrated a better early

quality of rehabilitation after major knee surgery by using

regional analgesia, but found no functional difference at

one or 3 months afterwards. More recently, Singelyn

et al. [9] also failed to demonstrate any advantage of

regional analgesia (epidural or femoral nerve block) over

morphine patient-controlled analgesia in terms of ambu-

lation, fatigue, patient activity, or hospital stay in a

classical program of rehabilitation after hip replacement.

However, even if there are no absolute, longer-term

advantages of regional analgesia, nerve blocks are still

important both for provision of good quality analgesia and

an excellent short-term side-effect profile. Progress inanaesthetic techniques and drugs has led to a decrease in

the incidence of mortality and major morbidity to the

point at which it may be difficult to compare these

outcomes without huge, randomised controlled trials or

patient databases. This also includes the methods of

delivery of the local anaesthetic (LA) such as the use of

infusion devices that provide patient-controlled regional

anaesthesia [10]. Therefore, patient-orientated outcomes

such as satisfaction, quality of life and quality of recovery

Anaesthesia, 2010, 65 (Suppl. 1), pages 5766 doi:10.1111/j.1365-2044.2010.06240.x.....................................................................................................................................................................................................................

2010 The Authors

Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland 57


2/10

have become more prominent [1113], reflecting

increased interest in patient-focussed assessments. All of

these new parameters are important to consider and are

valid outcomes.

One of the key drivers in modern practice is the need

to achieve a shorter length of hospital stay [14]. For this to

occur, changes to individual clinical practice are required,

including admissions on the day of surgery and better

patient preparation, leading to improved expectations of

patients and, most importantly, improved postoperative

pain management leading to earlier mobilisation. The

postoperative management of nerve blocks is one of the

key factors in successful outcome. It requires multidis-

ciplinary input from anaesthetists, physiotherapists and,

most importantly, the nurses who are looking after the

patient. Before introducing the technique, considerable

effort must be invested in educating the nursing and phys-

iotherapy staff about anatomy, complications, trouble-

shooting and pump delivery systems.The rest of this section will describe the important

aspects of some popular lower limb blocks.

Femoral nerve block

The femoral nerve arises from the lumbar plexus and has

the root value L2L4. The nerve travels through the

substance of the psoas muscle behind the fascia iliaca, and

then passes anterior to the iliopsoas muscle under the

inguinal ligament before becoming more superficial in the

anterior thigh. The nerve lies deep to the fascia lata and

fascia iliaca. As the femoral artery and vein pass behind the

inguinal ligament, they become surrounded in a fascial

sheath. The femoral nerve lies posterior and lateral to this

sheath and not within it. The femoral nerve divides into

numerous branches early in the proximal anterior thigh.

Blockade of the femoral nerve (Figs. 13) provides

sensory anaesthesia of the anterior thigh, knee and medial

aspect of the calf, ankle and foot. Femoral nerve block

should be distinguished from the three-in-one block and

the fascia iliaca block, techniques that hope to achieve

anaesthesia of the lateral femoral cutaneous and obturator

nerves as well as the femoral nerve.

Femoral nerve block can be used to provide peri-

operative analgesia for femoral neck fractures or total hip

Figure 1 In-plane approach for ultrasound-guided block of thefemoral nerve.

Figure 3 Ultrasound view of the anatomy of the left femoraltriangle after injection of local anaesthetic (LA). Note LAcontained below fascia iliaca.

Figure 2 Ultrasound view of the anatomy of the left femoraltriangle.

J. M. Murray et al. Lower limb blocks Anaesthesia, 2010, 65 (Suppl. 1), pages 5766......................................................................................................................................................................................................................

2010 The Authors

58 Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland


3/10

arthroplasty. When performed before surgery, it facilitates

patient positioning for placement of a neuraxial block.

Other indications for femoral nerve block include

providing pre-operative or postoperative analgesia for

femoral shaft fractures, surgical anaesthesia for day-case

saphenous vein stripping and knee arthroscopy, postoper-

ative analgesia for knee procedures or total knee arthro-

plasty, and surgical anaesthesia for femoropopliteal bypass

surgery [1517]. It is important to remember that failure

to obtain an opioid-sparing effect in certain knee

procedures may be related to lack of blockade of sensory

fibres from the sciatic and obturator nerves, which can

provide a significant proportion of the sensory innerva-

tion of the knee.

The presence of a prosthetic femoral artery graft is a

relative contraindication to femoral nerve block. The

procedure, particularly when combined with sciatic

block, is also relatively contraindicated in situations where

a dense sensory block could mask the onset of lowerextremity compartment syndrome, e.g. fresh fractures of

the tibia and fibula, or traumatic and extensive elective

orthopedic procedures of the tibia and fibula. This

contraindication is not specific for the femoral nerve

block but rather applies to regional anaesthesia of the

lower extremity in general. Best practice suggests that

consultation with surgical colleagues should be sought as

to the likelihood of the development of compartment

syndrome.

Postoperative analgesia can be continued for a number

of days with a LA infusion when a catheter is placed close

to the femoral nerve. This technique has been shown to

reduce systemic opioid requirements significantly with a

minimum of complications after total knee arthroplasty.

Both ultrasound-guided and nerve stimulator techniques

can be modified for the placement of an indwelling

catheter for continuous femoral nerve block [18, 19].

Continuous techniques have the advantage of providing

high quality postoperative analgesia and minimising

systemic opioid requirements, without the disadvantages

of epidural analgesia such as urinary retention, orthostatic

hypotension and impaired mobilisation. Much has been

written about continuous femoral nerve blocks and their

advantages regarding earlier mobilisation and duration of

hospital stay [2022]. Outpatient knee surgery has cometo involve increasingly complex procedures such as high

tibial osteotomy, multiple ligament reconstructions and

meniscal reconstruction. Many institutions, particularly in

the US, send patients home with a catheter and infusion

in place. This approach is particularly popular with

patients who have undergone total knee replacement.

Pain after knee replacement surgery can be intense,

especially during physiotherapy and rehabilitation, and

this is the one area in which good analgesia using a

continuous femoral nerve block really does make a

difference to postoperative outcome. This is not achieved

solely by the block itself but by input from a multidis-

ciplinary team comprising anaesthetists, nurses and phys-

iotherapists.

Continuous infusion was associated with significant

improvements in some functional outcomes in both

studies that compared continuous blockade with placebo

or no treatment. In their prospective study of 211

patients, Cuvillon et al. [23] found that continuous

femoral nerve catheters were effective for postoperative

analgesia but had a relatively high rate of bacterial

catheter colonisation. However, they found no serious

infections after short-term (2-day) infusion. Side effects

were few, but one nerve injury occurred. In a

retrospective study of patients having outpatient knee

surgery, Williams et al. [24] demonstrated that patients

undergoing complex surgery were significantly more

likely to be admitted to the hospital overnight than werepatients undergoing less invasive surgery, and that

patients undergoing complex surgery who were given

femoral or sciatic nerve blocks were significantly less

likely to require hospital admission than those patients

undergoing complex surgery and who were not given

nerve blocks.

Three-in-one block and fascia iliaca block

The three nerves referred to in this block are the femoral

nerve, the lateral cutaneous nerve of the thigh and the

obturator nerve. The three-in-one block is indicated

when anaesthesia in the distributions of the obturator and

lateral femoral cutaneous nerves as well as the femoral

nerve is desired. It is essentially a variation of the femoral

nerve block and was first described by Winnie et al. [25].

This technique relies on a single injection of large

volumes of LA within the neurovascular sheath with the

needle directed cranially, and the subsequent spread of

anaesthetic proximally, aided by pressure applied distal to

the sheath, to achieve anaesthesia in the desired location.

Dye injection studies in cadavers [26] have cast doubt on

whether LA spreads proximally to block the obturator

nerve, and there have been suggestions that when the

block is effective, it is because of lateral spread of LA.Clinical studies have also demonstrated that failure to

obtain anaesthesia in the distribution of lateral femoral

cutaneous and obturator nerves is common even with

large volumes (40 ml) of LA [27].

The fascia iliaca compartment block is a hybrid anterior

lumbar plexus approach with a puncture point relatively

distant from the neurovascular sheath. A nerve stimulator

is not necessary for this procedure. It was described in

children in 1989 [28]. It is widely used for postoperative

Anaesthesia, 2010, 65 (Suppl. 1), pages 5766 J. M. Murray et al. Lower limb blocks......................................................................................................................................................................................................................

2010 The Authors



4/10

analgesia after lower limb surgery in children and adults,

and provides effective postoperative analgesia after hip,

femoral shaft or knee surgery [29]. Compared with the

three-in-one block, it provides a faster and more

consistent simultaneous blockade of the lateral femoral

cutaneous nerve and femoral nerve [30].

As a result of the low incidence of obturator nerve

block, the three-in-one technique is best reserved for

surgical procedures in the distribution of the femoral and

lateral cutaneous nerves. It is thus not ideal for patients

undergoing femoral neck surgery and hip reduction or

replacement. The fascia iliaca compartment block pro-

vides a faster and more consistent simultaneous blockade

of the lateral cutaneous and femoral nerves than the

three-in-one block. Both blocks have value in the initial

management of patients with femoral neck fracture who

need to be moved and positioned for X-ray examination

or positioned for spinal anaesthesia. A sensory block of the

internal part of the thigh is an early predictive sign ofoptimal pain relief [30].

Posterior lumbar plexus block or psoas

compartment block

The lumbar plexus is formed from the anterior divisions

of the first three and the greater part of the fourth lumbar

nerves; the first lumbar often receives a branch from the

last thoracic nerve. It is situated in the posterior part of

the psoas muscle, in front of the transverse processes of

the lumbar vertebrae. From a practical point of view, the

main nerves to consider when performing a lumbar

plexus block are the femoral nerve, lateral cutaneous

nerve of the thigh and the obturator nerve. Using a

posterior approach, the plexus as a whole is blocked as the

nerves enter the psoas muscle. It is therefore a reliable

method for anaesthesia and analgesia of hip, and the

anterior aspects of the inner and outer thigh as far as the

knee.

The lumbar plexus is contained in an anatomical space

called the psoas compartment. Within the psoas muscle,

the branches of the plexus are close to each other at the

level of the transverse processes of the L4 and L5

vertebrae. Medially, the psoas compartment is continuous

with the intervertebral foramina of L4 and L5 [31]. Thisexplains why LA or a catheter inserted by the posterior

approach may reach the epidural space. The proximity of

the lumbar plexus to the retroperitoneum and peritoneal

cavity means that complications such as kidney and bowel

puncture may occur.

Lumbar plexus block is most commonly performed in

combination with either central neuraxial blockade or

general anaesthesia to provide analgesia for hip replace-

ment or as a sole procedure for femoral neck surgery [32

34]. When used in combination or as a sole technique, it

has the distinct advantage of delivering superior postop-

erative analgesia when compared to intravenous opioids

or femoral nerve block [35]. In addition, it may be used in

conjunction with a sciatic nerve block to provide

complete analgesia of the lower limb when central

neuraxial block is contraindicated. The combination of

general anaesthesia and lumbar plexus block is particularly

useful in revision joint replacement where the surgery is

likely to be prolonged.

Numerous posterior approaches have been described

and all tend to be variations on a theme [36]. Although

most anaesthetists currently use a nerve stimulator based

technique, Karmakar et al. [37] recently described the

sono-anatomy relevant to posterior lumbar plexus block

and recommended its routine use. In their paper, they

describe a technique of ultrasound-guided lumbar plexus

block that was successfully used in conjunction with

sciatic nerve block for anaesthesia in a series of patientsundergoing emergency lower limb surgery. In the

resultant longitudinal ultrasound image, the acoustic

shadow of the transverse processes produces the so-called

trident sign. The lumbar plexus is seen through the

acoustic window of the trident as multiple longitudinal

hyperechoic striations against a hypoechoic background

typical of muscle (Fig. 4).

Continuous lumbar plexus techniques have the advan-

tage of providing high quality postoperative analgesia and

minimising systemic opioid requirements, without the

disadvantages of epidural analgesia such as urinary reten-

tion, orthostatic hypotension and impaired ambulation

[15, 36, 38, 39].

Figure 4 Longitudinal ultrasound image of the lumbar spine,with the acoustic shadows of the lumbar transverse processesproducing the trident sign. TPL2, TPL3, TPL4: Transverseprocesses of second, third and fourth lumbar vertebrae.Reproduced with permission [37].


2010 The Authors



5/10


6/10

Proximal sciatic nerve block

The sciatic nerve is the largest peripheral nerve in the

human body. Its anatomy has been well described in

classical textbooks. However, as with much anatomy,

there are many variations from normal that may lead to

subsequent failure of a regional anaesthetic technique.

The sciatic nerve divides into two large terminal

branches. Although this typically happens approximately

6.6 cm proximal to the popliteal crease [50], the division

may occur at any level below the greater sciatic foramen,

and such high divisions may be a cause of incomplete or

failed blocks if unrecognised [51]. A sciatic nerve block

can be used to provide peri-operative analgesia for hip,

ankle and foot surgery, and is particularly useful in

providing postoperative analgesia for lower limb ampu-

tation, especially when a continuous catheter technique is

used.

There are at least four broad approaches to blockingthe sciatic nerve, including the classic posterior approach

of Labat [52], anterior approaches, lateral approaches,

and the supine lithotomy approach of Raj et al. [53].

The anterior, lateral, and lithotomy approaches have the

advantage of keeping the patient supine during the

performance of the block. The Labat approach requires

the placement of the patient in the lateral position,

which may be painful in the acutely injured patient and

may be contraindicated in the presence of spinal injury.

Another classification of the approaches to blocking the

sciatic nerve can be described as the transgluteal,

subgluteal mid-femoral and popliteal blocks. Of the

transgluteal blocks, the most proximal approach is the

parasacral technique that aims to block the sciatic nerve

at its exit from the greater sciatic foramen [54]. This

block has been shown to be quicker to perform than

other transgluteal approaches. However, it can have a

slow onset time [55].

Ultrasound-guided sciatic nerve block is rapidly

gaining popularity and has been described in both adults

and children [5658]. Kamarkar et al. [59] found the

subgluteal space to be an effective site for LA injection

or catheter insertion during ultrasound-guided sciatic

nerve block. Using ultrasound, the sciatic nerve can be

identified and followed using a posterior approach as itpasses distally from the subgluteal region. In lean

volunteers, the sciatic nerve is sufficiently thick and

close to the skin to make demonstration with ultrasound

optimal between 5.4 and 10.8 cm along its subgluteal

course [60]. Ultrasound can be used to identify the

sciatic nerve using an anterior approach. Ota et al. [61]

described the clinical use of an ultrasound-guided

anterior approach to sciatic nerve block and compared

the quality of the block and execution time of the

anterior approach with the posterior subgluteal approach

under ultrasound guidance in patients undergoing minor

knee surgery. They showed that there were no differ-

ences in the onset of sensory and motor blockade of the

sciatic nerve after the block between the two approaches

and argued that either the anterior or posterior approach

can be used interchangeably for minor knee surgery.

Sensory block of the posterior femoral cutaneous nerve,

which runs parallel to the sciatic nerve in the gluteal

region, is rarely achieved after the anterior approach.

However, this does not appear to constitute a disadvan-

tage for knee surgery in which a thigh tourniquet is

used.

Continuous sciatic nerve block using a perineural

catheter has been described for many of the approaches

described above [6266]. Few differences have been

reported between each of these techniques, with similar

rates of catheter dislodgement and occlusion. It may be

that fewer attempts are required for successful catheterplacement with a subgluteal approach [62]. Major neu-

rological complications related to catheter techniques are

few. However, minor complications may be more

common. These include local inflammation at the skin

site, infection and infection requiring surgical drainage

[67, 68]. In canine sciatic nerves, injections requiring high

pressures were associated with intrafascicular injections

and were predictive of nerve damage when compared

with injecting against low resistance [69]. Local bleeding

and extensive haematoma formation have been reported

in two patients with sciatic catheters in situ who were

given low molecular weight heparins on the first

postoperative day [70]. These resolved with conservative

management.

Various mechanisms for pain related to the use of a

tourniquet have been proposed. These include neuro-

pathic pain due to mechanical compression of Ad fibres

leaving C fibres functioning to conduct pain, direct pain

from compression of skin and muscle and finally pain due

to ischaemia [71]. For lower limb surgery under nerve

block, one controversy that remains is the role of the

posterior cutaneous nerve of the thigh in tourniquet pain.

Proximal posterior approaches to block the sciatic nerve,

especially the parasacral approach, were initially advo-

cated when use of a tourniquet was planned as these havea higher likelihood of blocking the posterior cutaneous

nerve of thigh [72]. However, more recent studies have

shown similar rates of tourniquet pain when comparing a

femoral and proximal sciatic nerve block with a femoral

and posterior popliteal sciatic nerve block, and also when

a posterior approach to the sciatic nerve was compared to

an anterior approach that consistently failed to provide

sensory block in the distribution of the posterior cutane-

ous nerve of thigh [61].


2010 The Authors



7/10

Popliteal sciatic nerve block

Various approaches to block the sciatic nerve in the

popliteal fossa have been described. These involve one or

two injections, and lateral or posterior approaches [73, 74].

Some controversy exists about the advantages of two

injections to block both the posterior tibial nerve and the

common peroneal nerve over a single injection to block

only the posterior tibial nerve with both posterior and

lateral approaches, similar rates of success being reported

with each when higher volumes of LA are used [75, 76].

Ultrasound has been shown to increase success rates at this

level when used alone or in combination with peripheral

nerve stimulation [77, 78]. This may in part be due to the

ability to demonstrate anatomical variation at this level [51,

58]. Effective LA volumes can also be decreased with the

use of ultrasound. This may make ultrasound a useful tool

when multiple lower limb blocks are being used in the same

patient. The success rate when using a lateral popliteal blockmay be lower compared to the transgluteal approaches,

with significantly longer onset times compared to both

transgluteal and mid-femoral approaches. However, pos-

terior popliteal blocks are associated with much less

procedure-related pain when compared to transgluteal

blocks, with no difference in the time taken to perform the

block, the onset time or the duration of action [75].

Summary

Simple decreases in postoperative pain scores do not

necessarily translate to clinically meaningful improved

pain relief or outcomes for the patient and, as such, use of

a regional anesthetic or analgesic technique by itself does

not automatically confer clinical advantage to the patient

if overall management is not optimal and is not adapted to

the individual patients needs. Having said this, there is

good evidence that lower limb regional anesthesia

provides superior postoperative analgesia that in itself

may contribute to an improvement in patient-related

outcomes. The benefits of a regional anesthesia technique

are increased when adapted to a particular patients

requirements. Obvious benefits such as the quality of

postoperative analgesia and a decrease in hospital stay or

in hospital costs are easy to demonstrate, but conclusiveproof that regional anesthesia improves the outcome from

surgery is still lacking. The ultimate goal will be to

demonstrate that regional analgesia can contribute to

improvements in long-term functional recovery and to a

decrease in the incidence of chronic pain.

Conflicts of interest

The authors declare no conflicts of interest.

References

1 Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY.

Health-related quality of life in total hip and total knee

arthroplasty. A qualitative and systematic review of the

literature. Journal of Bone and Joint Surgery American Volume

2004; 86: 96374.2 Viscusi ER. Emerging techniques in the treatment of post-

operative pain. American Journal of Health-System Pharmacy

2004; 61 (Suppl 1): S114.

3 Strassels SA, Chen C, Carr DB. Postoperative analgesia:

economics, resource use, and patient satisfaction in an urban

teaching hospital. Anesthesia & Analgesia 2002; 94: 1307.

4 Albert TJ, Cohn JC, Rothman JS, Springstead J, Rothman

RH, Booth RE Jr. Patient-controlled analgesia in a post-

operative total joint arthroplasty population. Journal of

Arthroplasty 1991; 6 (Suppl): S238.

5 Weinger M. Dangers of postoperative opioids. APSF

workshop and white paper address prevention of postoper-

ative respiratory complications. Anesthesia Patient Safety

Foundation Newsletter 2006; 21: 618.

6 Forst J, Wolff S, Thamm P, Forst R. Pain therapy following

joint replacement. A randomized study of patient-controlled

analgesia versus conventional pain therapy. Archives of

Orthopaedic and Trauma Surgery 1999; 119: 2677.

7 Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y,

Rubenovitch J, dAthis F. Effects of perioperative analgesic

technique on the surgical outcome and duration of rehabili-

tation after major knee surgery. Anesthesiology 1999; 91: 815.

8 Singelyn FJ, Deyaert M, Joris D, Pendevillet E, Gouverneur

JM. Effects of intravenous patient-controlled analgesia with

morphine, continuous epidural analgesia, and continuous

three-in-one block on postoperative pain and knee reha-

bilitation after unilateral total knee arthroplasty. Anesthesia &Analgesia 1998; 87: 8892.

9 Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of intra-

venous patient-controlled analgesia with morphine, contin-

uous epidural analgesia, and continuous femoral nerve sheath

block on rehabilitation after unilateral total hip arthroplasty.

Regional Anaesthesia and Pain Medicine2005; 30: 4527.

10 Rapp RP, Bivins BA, Littrell RA, et al. Patient-controlled

analgesia: a review of effectiveness of therapy and an

evaluation of currently available devices. Drug Intelligence &

Clinical Pharmacy 1989; 23: 899904.

11 Borgeat A. The role of regional anesthesia in patient

outcome: orthopedic surgery. Techniques in Regional

Anesthesia and Pain Management2008; 12: 17882.

12 Capdevila X, Ponrouch M, Morau D. The role of regional

anesthesia in patient outcome: ambulatory surgery. Tech-

niques in Regional Anesthesia and Pain Management 2008; 12:

1948.

13 Capdevila X, Choquet O. Does regional anaesthesia

improve outcome? Facts and dreams. Techniques in Regional

Anesthesia and Pain Management2008; 12: 1612.

14 Clarke A, Rosen R. Length of stay: how short should

hospital care be? European Journal of Public Health 2001; 11:

16670.


2010 The Authors



8/10

15 Dahl JB, Christiansen CL, Daugaard JJ, Schultz P, Carlsson

P. Continuous blockade of the lumbar plexus after knee

surgerypostoperative analgesia and bupivacaine plasma

concentrations. A controlled clinical trial. Anaesthesia 1988;

43: 10158.

16 Striebel HW, Wilker E. Postoperative pain therapy fol-

lowing total endoprosthetic surgery on the hip using acontinuous 3-in-1 blockade. Anasthesiologie, Intensivmedizin,

Notfallmedizin, Schmerztherapie 1993; 28: 16873.

17 Griffith JP, Whiteley S, Gough MJ. Prospective randomized

study of a new method of providing postoperative pain relief

following femoropopliteal bypass. British Journal of Surgery

1996; 83: 17358.

18 Postel J, Marz P. Continuous blockade of the lumbar plexus

(3-in-1 block) in perioperative pain therapy. [Article in

German]. Regional Anesthesia 1984; 7: 1403.

19 Pham-Dang C, Kick O, Collet T, Gouin F, Pinaud M.

Continuous peripheral nerve blocks with stimulating cath-

eters. Regional Anesthesia and Pain Medicine 2003; 28: 838.

20 Ilfeld BM, Enneking FK. Continuous peripheral nerve

blocks at home: a review. Anesthesia & Analgesia 2005; 100:182233.

21 Ilfeld BM, Gearen PF, Enneking FK, et al. Total knee

arthroplasty as an overnight-stay procedure using continuous

femoral nerve blocks at home: a prospective feasibility study.

Anesthesia & Analgesia 2006; 102: 8790.

22 Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous

femoral nerve blocks decrease time to discharge readiness

after tricompartment total knee arthroplasty: a randomized,

triple-masked, placebo-controlled study. Anesthesiology 2008;

108: 70313.

23 Cuvillon P, Ripart J, Lalourcey L, et al. The continuous

femoral nerve block catheter for postoperative analgesia:

bacterial colonization, infectious rate and adverse effects.Anesthesia & Analgesia 2001; 93: 10459.

24 Williams BA, Kentor ML, Vogt MT, et al. Femoral-sciatic

nerve blocks for complex outpatient knee surgery are asso-

ciated with less postoperative pain before same-day dis-

charge: a review of 1,200 consecutive cases from the period

19961999. Anesthesiology 2003; 98: 120613.

25 Winnie AP, Ramamurthy S, Durrani Z. The inguinal

paravascular technique of lumbar plexus anesthesia. The

3-in-1 block.. Anesthesia & Analgesia 1973; 52: 98996.

26 Cauhepe C, Oliver M, Colombani R, Railhac N. The

3-in-1 block: myth or reality? Annales Francaises

dAnesthesie et de Reanimation 1989; 8: 3768.

27 Seeberger MD, Urwyler A. Paravascular lumbar plexus

block: block extension after femoral nerve stimulation andinjection of 20 vs. 40 ml mepivacaine 10 mg ml. Acta

Anaesthesiologica Scandinavica 1995; 39: 76973.

28 Dalens B, Vanneuville G, Tanguy A. Comparison of the

fascia iliaca compartment block with the 3-in-1 block in

children. Anesthesia & Analgesia 1989; 69: 70513.

29 Hgh A, Dremstrup L, Jensen SS, Lindholt J. Fascia iliaca

compartment block performed by junior registrars as a

supplement to pre-operative analgesia for patients with hip

fracture. Strategies in Trauma and Limb Reconstruction. 2008; 3:

6570.

30 Capdevila X, Biboulet P, Bouregba M, Barthelet Y,

Rubenovitch J, DAthis F. Comparison of the three-in-one

and fascia iliaca compartment blocks in adults: clinical and

radiographic analysis. Anesthesia & Analgesia 1998; 86: 1039

41.31 Farny J, Drolet P, Girard M. Anatomy of the posterior

approach to the lumbar plexus block. Canadian Journal of

Anaesthesia 1994; 41: 4805.

32 Marino J, Russo J, Kenny M, Herenstein R, Livote E,

Chelly JE. Continuous lumbar plexus block for postopera-

tive pain control after total hip arthroplasty. A randomized

controlled trial. Journal of Bone and Joint Surgery American

Volume 2009; 91: 2937.

33 Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesia

for total hip and knee arthroplasty: a multimodal pathway

featuring peripheral nerve block. Journal of the American

Academy of Orthopedic Surgeons 2006; 14: 12635.

34 Pagnano MW, Hebl J, Horlocker T. Assuring a painless total

hip arthroplasty: a multimodal approach emphasizingperipheral nerve blocks. Journal of Arthroplasty 2006; 21 (4

Suppl 1): 804.

35 Biboulet P, Morau D, Aubas P, Bringuier-Branchereau S,

Capdevila X. Postoperative analgesia after total hip arthro-

plasty: comparison of intravenous patient-controlled anal-

gesia with morphine and single injection of femoral nerve

or psoas compartment block. A prospective, randomized,

double-blind study. Regional Anesthesia and Pain Medicine

2004; 29: 1029.

36 Capdevila X, Macaire P, Dadure C, et al. Continuous psoas

compartment blocks for postoperative analgesia after total

hip arthroplasty: new landmarks, technical guidelines, and

clinical evaluation. Anesthesia & Analgesia 2002;94

: 160613.

37 Karmakar MK, Ho AM-H, Li X, Kwok K, Tsang K, Ngan

WD. Ultrasound-guided lumbar plexus block through the

acoustic window of the lumbar ultrasound trident. British

Journal of Anaesthesia 2008; 100: 5337.

38 Siddiqui ZI, Cepeda S, Denman W, Schumann R, Carr DB.

Continuous lumbar plexus block provides improved anal-

gesia with fewer side effects compared with systemic opioids

after hip arthroplasty: a randomized controlled trial. Regional

Anesthesia and Pain Medicine2007; 32: 3938.

39 Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory

continuous posterior lumbar plexus nerve blocks after hip

arthroplasty: a dual-center, randomized, triple-masked,

placebo-controlled trial. Anesthesiology 2008; 109: 491501.40 Busch C, Shore BJ, Bhandri R, et al. Efficacy of periarticular

multimodal drug injection in total knee arthroplasty. A

randomized trial. Journal of Bone and Joint Surgery American

Volume 2006; 88: 95963.

41 Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M.

A multimodal analgesia protocol for total knee arthroplasty.

Journal of Bone and Joint Surgery American Volume 2006; 88:

282.


2010 The Authors



9/10

42 Ranawat AS, Ranawat CS. Pain management and acceler-

ated rehabilitation for total hip and total knee arthroplasty.

Journal of Arthroplasty 2007; 2: 125.

43 Millington J, Ayers J, Muirhead-Allwood S. Does intra-

capsular injection of local anaesthetic during primary total

hip arthroplasty improve postoperative pain management

and allow earlier mobilisation. Journal of Bone and Joint SurgeryBritish Volume 2004; 86B (Suppl 1): 1328.

44 Peters CL, Shirley B, Erickson J. The effect of a new mul-

timodal perioperative anaesthetic regimen on postoperative

pain, side effects, rehabilitation, and length of hospital stay

after total joint arthroplasty. Journal of Arthroplasty 2006; 21

(Suppl 2): 79.

45 Anderson LJ, Poulsen T, Krogh B, Neilsen T. Postoperative

analgesia in total hip arthroplasty: a randomized double-

blinded, placebo-controlled study on peroperative and

postoperative ropivacaine, ketorolac, and adrenaline wound

infiltration. Acta Orthopaedica 2007; 78: 18792.

46 Kerr DR, Kohan L. Local infiltration analgesia: a technique

for the control of acute postoperative pain following knee

and hip surgery: a case study of 235 patients. Acta Ortho-paedica 2008; 79: 17483.

47 Toftdahl K, Nikolajsen L, Harahdsted V, Madsen F, Ton-

nesen EK, Sobelle K. Comparison of periarticular and

intraarticular analgesia with femoral nerve block after total

knee arthroplasty: a randomised clinical trial. Acta Ortho-

paedica 2007; 78: 15961.

48 Rostlud T, Kehlet H. High-dose local infiltration analgesia

after hip and knee replacement what is it, why does it

work and what are the future challenges? Acta Orthopaedica

2007; 78: 15961.

49 Otte KS, Husted H, Andersen LO, Kristensen BB, Kehlet

H. Local infiltration analgesia in total knee arthroplasty and

hip resurfacing: a methodological study. Acute Pain 2008;10

:1116.

50 Vloka JD, Hadzic A, April E, Thys DM. The division of the

sciatic nerve in the popliteal fossa: anatomical implications

for popliteal nerve blockade. Anesthesia & Analgesia 2001; 92:

2157.

51 Clendenen SR, York JE, Wang RD, Greengrass RA.

Three-dimensional ultrasound-assisted popliteal catheter

placement revealing aberrant anatomy: implications for

block failure. Acta Anaesthesiologica Scandinavica 2008; 52:

142931.

52 Labat G. In: Regional Anaesthesia: Its technique and clinical

applications. Philadelphia: W.B. Saunders, 1924; 4555.

53 Raj PP, Parks RI, Watson TD, Jenkins MT. A new single-

position supine approach to sciatic-femoral nerve block.Anesthesia & Analgesia 1975; 54: 48993.

54 Mansour NY. Reevaluating the sciatic nerve block: another

landmark for consideration. Regional Anesthesia 1993; 18:

3223.

55 Cuvillon P, Ripart J, Jeannes P, et al. Comparison of the

parasacral approach and the posterior approach, with single-

and double-injection techniques, to block the sciatic nerve.

Anesthesiology 2003; 98: 143641.

56 Gray AT, Collins AB, Schafhalter-Zoppoth I. Sciatic nerve

block in a child: a sonographic approach. Anesthesia &

Analgesia 2003; 97: 13002.

57 McCartney CJ, Brauner I, Chan VW. Ultrasound guidance

for a lateral approach to the sciatic nerve in the popliteal

fossa. Anaesthesia 2004; 59: 10235.

58 Sinha A, Chan VW. Ultrasound imaging for popliteal sciaticnerve block. Regional Anesthesia and Pain Medicine 2004; 29:

1304.

59 Karmakar MK, Kwok WH, Ho AM, Tsang K, Chui PT,

Gin T. Ultrasound-guided sciatic nerve block: description of

a new approach at the subgluteal space. British Journal of

Anaesthesia 2007; 98: 3905.

60 Chan VW, Nova H, Abbas S, McCartney CJ, Perlas A,

Xu DQ. Ultrasound examination and localization of the

sciatic nerve: a volunteer study. Anesthesiology 2006; 104:

30914.

61 Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided

anterior approach to sciatic nerve block: a comparison with

the posterior approach. Anesthesia & Analgesia 2009; 108:

6605.62 Taboada M, Rodriguez J, Valino C, et al. A prospective,

randomized comparison between the popliteal and sub-

gluteal approaches for continuous sciatic nerve block with

stimulating catheters. Anesthesia & Analgesia 2006; 103: 244

7.

63 Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal

sciatic nerve block: an original technique to provide post-

operative analgesia after foot surgery. Anesthesia & Analgesia

1997; 84: 3836.

64 Ilfeld BM, Loland VJ, Gerancher JC, et al. The effects of

varying local anesthetic concentration and volume on con-

tinuous popliteal sciatic nerve blocks: a dual-center, ran-

domized, controlled study. Anesthesia & Analgesia 2008;107

:7017.

65 di Benedetto P, Casati A, Bertini L. Continuous subgluteus

sciatic nerve block after orthopaedic foor and ankle surgery:

comparison of two infusion techniques. Regional Anesthesia

and Pain Medicine 2002; 27: 16872.

66 Ilfeld BM, Thannikary LJ, Morey TE, Vander Griend

RA, Enneking FK. Popliteal sciatic perineural local

anesthetic infusion: a comparison of three dosing regimens

for postoperative analgesia. Anesthesiology 2004; 101: 970

7.

67 Neuburger M, Buttner J, Blumenthal S, Breitbarth J,

Borgeat A. Inflammation and infection complications of

2285 perineural catheters: a prospective study. Acta Anaes-

thesiologica Scandinavica 2007; 51: 10814.68 Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T,

Reske A. Complications and adverse effects associated with

continuous peripheral nerve blocks in orthopedic patients.


69 Kapur E, Vuckovic I, Dilberovic F, et al. Neurologic and

histologic outcome after intraneural injections of lidocaine in

canine sciatic nerves. Acta Anaesthesiologica Scandinavica 2007;

51: 1017.


2010 The Authors



10/10

70 Bickler P, Brandes J, Lee M, Bozic K, Chesbro B, Claassen J.

Bleeding complications from femoral and sciatic nerve

catheters in patients receiving low molecular weight heparin.


71 Estebe JP, Le NA, Chemaly L, Ecoffey C. Tourniquet pain

in a volunteer study: effect of changes in cuff width and

pressure. Anaesthesia 2000; 55: 216.72 Barbero C, Fuzier R, Samii K. Anterior approach to the

sciatic nerve block: adaptation to the patients height.


73 Singelyn FJ. Single-injection applications for foot and ankle

surgery. Best Practice and Research: Clinical Anaesthesiology

2002; 16: 24754.

74 Bailey SL, Parkinson SK, Little WL, Simmerman SR. Sciatic

nerve block. A comparison of single versus double injection

technique. Regional Anesthesia 1994; 19: 913.

75 Taboada M, Rodriguez J, Valino C, et al. What is the

minimum effective volume of local anesthetic required for

sciatic nerve blockade? A prospective, randomized com-

parison between a popliteal and a subgluteal approach.


76 Arcioni R, Palmisani S, Della RM, et al. Lateral popliteal

sciatic nerve block: a single injection targeting the tibial

branch of the sciatic nerve is as effective as a double-injec-

tion technique. Acta Anaesthesiologica Scandinavica 2007; 51:11521.

77 Prelas A, Brull R, Chan V, McCrtney C, Nuica A, Abbas S.

Ultrasound guidance improves the success of sciatic nerve

block at the popliteal fossa. Regional Anesthesia and Pain

Medicine 2008; 33: 25965.

78 Dufour E, Quennesson P, Van Robais AL, et al. Combined

ultrasound and neurostimulation guidance for popliteal sci-

atic nerve block: a prospective, randomized comparison with

neurostimulation alone. Anesthesia & Analgesia 2008; 106:

15538.


2010 The Authors


Documents

Lower Limbs Blocks