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A review of approaches and techniques for lower extremity nerve blocks

[Un bilan des approches et techniques pour les blocs nerveux du membre inférieur]

From the Department of Anesthesia, Montreal General Hospital, McGill University, Montreal, Quebec, Canada.

Address correspondence to: Dr. De QH Tran, Montreal General Hospital, Department of Anesthesia, 1650 Ave Cedar, D10-144, Montreal, Quebec H3G- 1A4, Canada. Phone: 514-934-1934, ext 43261; Fax: 514-934-4289; E-mail: de_tran{at}hotmail.com

Purpose: The purpose of this narrative review is to summarize the evidence derived from randomized controlled trials (RCTs) regarding approaches and techniques for lower extremity nerve blocks.

Source: Using the MEDLINE (January 1966 to April 2007) and EMBASE (January 1980 to April 2007) databases, medical subject heading (MeSH) terms "lumbosacral plexus", "femoral nerve", "obturator nerve", "saphenous nerve", "sciatic nerve", "peroneal nerve" and "tibial nerve" were searched and combined with the MESH term "nerve block" using the operator "and". Keywords "lumbar plexus", "psoas compartment", "psoas sheath", "sacral plexus", "fascia iliaca", "three-in-one", "3-in-1", "lateral femoral cutaneous", "posterior femoral cutaneous", "ankle" and "ankle block" were also queried and combined with the MESH term "nerve block". The search was limited to RCTs involving human subjects and published in the English language. Forty-six RCTs were identified.

Principal findings: Compared to its anterior counterpart (3-in- 1 block), the posterior approach to the lumbar plexus is more reliable when anesthesia of the obturator nerve is required. The fascia iliaca compartment block may also represent a better alternative than the 3-in-1 block because of improved efficacy and efficiency (quicker performance time, lower cost). For blockade of the sciatic nerve, the classic transgluteal approach constitutes a reliable method. Due to a potentially shorter time for sciatic nerve electrolocation and catheter placement than for the transgluteal approach, the subgluteal approach should also be considered. Compared to electrolocation of the peroneal nerve, electrostimulation of the tibial nerve may offer a higher success rate especially with the transgluteal and lateral popliteal approaches. Furthermore, when performing sciatic and femoral blocks with low volumes of local anesthetics, a multiple-injection technique should be used.

Conclusions: Published reports of RCTs provide evidence to formulate limited recommendations regarding optimal approaches and techniques for lower limb anesthesia. Further well-designed and meticulously executed RCTs are warranted, particularly in light of new techniques involving ultrasonographic guidance.