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Correspondence |
Hôpitaux Universitaires de Genève, Geneva, Switzerland, E-mail: Anne.Weber{at}hcuge.ch
We thank the editor for giving us the opportunity to reply to the comments of Jutzi et al. Firstly, our results cannot be compared with those of Parkinson who injected local anesthetic via a needle and not via a catheter.1 Secondly, we threaded the catheters up to 12 cm in order to inject local anesthetic more cephalad to obtain a better block of the obturator nerve. Again, our results are difficult to compare with those of Capdevila2 who threaded the catheters up to 16–20 cm. Furthermore, Ritter studied the spread of solution injected via a needle and not via a catheter.3 However, there is a question that remains; are the study’s conditions similar in cadavers and in patients undergoing surgery. Concerning radiological control of the catheters, the aim of our study was to explore, in clinical conditions, the effect of different doses of local anesthetic injected via a catheter regardless of the exact position of its tip. However, lack of radiological verification of catheters is well mentioned in the discussion.
We agree that testing of the obturator nerve blockade is a complex problem. As have many others authors,2,4–6 we tested sensory obturator block at the medial aspect of the knee. In one of these studies, sensory and motor obturator blocks were tested and the results show that the sensory block is more consistent than the motor one. Recently, Bouaziz reported the lack of cutaneous innervation of the obturator nerve at the knee level in 57% of the subjects.7 If these data are confirmed by other investigations, motor rather than the sensory block of the obturator nerve should be tested. Nevertheless, even in the absence of skin fibres, the obturator nerve contributes to sensory inervation of the knee joint. Very low pain scores documented four hours after the block support the finding of a high percentage of obturator block in our patients. Finally, there is perhaps some doubt about the existence of three-in-one block, but this term is currently used in the anesthetic literature.
References
1 Parkinson SK, Mueller IB, Little WL, Bailey SL. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 1989; 68: 243–8.
2 Capdevila X, Biboulet P, Morau D, et al. Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: where do the catheters go? Anesth Analg 2002; 94: 1001–6.
3 Ritter JW. Femoral nerve "sheath" for inguinal paravascular lumbar plexus block is not found in human cadavers. J Clin Anesth 1995; 7: 470–3.[Medline]
4 Edwards ND, Wright EM. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg 1992; 75: 265–7.
5 Singelyn FJ, Gouverneur JM. Extended "three-in-one" block after total knee arthroplasty: continuous versus patient-controlled techniques. Anesth Analg 2000; 91: 176–80.
6 Capdevila X, Macaire P, Dadure C, et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: news landmarks, technical guidelines, and clinical evaluation. Anesth Analg 2002; 94: 1606–13.
7 Bouaziz H, Vial F, Jochum D, et al. An evaluation of the cutaneous distribution after obturator nerve block. Anesth Analg 2002; 94: 445–9.
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