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Nerve stimulator guided pudendal nerve blocks

Hôtel Dieu, CHU de Clermont-Ferrand, France, E-mail : jebazin{at}chu-clermontferrand.fr

To the Editor:

We read with great interest Naja et al.’s recent article¹ regarding pudendal block with nerve stimulator guidance, and offer the following comments. This is the first randomized study demonstrating the efficacy of such blocks in providing postoperative analgesia following hemorroidectomy.

However, we are surprised by the landmarks proposed by the authors. Why did they use two injection points side by side?

We usually use this block for gynecological surgery (bartholin cyst removal and perineal surgery) and we use only one injection point at the intersection of a horizontal line running with the medial edge of the ischial tuberosity from the superior aspect of the anus.² In our experience, the mean depth of stimulation is 45.1 ± 11.6 mm (25–80) and the mean stimulation intensity is 0.6 ± 0.1 mA (0.5–1).

Motor responses are :

• contraction of the external anal sphincter (lower rectal response) and contraction of the vulva constrictor muscle (perineal response) in 52%;
  
• contraction of the external anal sphincter alone in 27%;
  
• contraction of the vulva constrictor muscle alone in 11%;
  
• contraction of the external anal sphincter, contraction of the vulva constrictor muscle and movement of the clitoris in 8%;
  
• No motor response in 2%.
  

In our opinion, the risk of the posterior injection points is an extension of the block to the sciatic nerve. This risk must be considered with a bilateral injection in ambulatory patients.

References

1 Naja Z, Ziade MF, Lönnqvist PA. Nerve stimulator guided pudendal nerve block decreases posthemorrhoidectomy pain. Can J Anesth 2005; 52: 62–8.[Abstract/Free Full Text]

2 Bolandard F. Pudendal nerve block with nerve stimulation. In: Gaertner E, Al Nasser B, Choquet O, et al. (Eds). Regional Anaesthesia: Truncular and Plexus Anaesthesia in Adults. Arnette; 2004: 213–7.

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Zoher Naja
CJA 2005 52: 773-774. [Full Text]  

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