Combined Lumbar Plexus-Sciatic Nerve Block for Urgent Lower Limb Surgery: A Good Alternative in Patients With High Anesthetic Risk.

The use of peripheral nerve blocks has grown significantly in recent years not only because of the progress and availability of the materials necessary for its realization but also for enhancing patient safety. Anesthesia in the elderly or individuals with high anesthetic risk is always a challenge for the practitioner. Hence, the importance of peripheral nerve blocks in avoiding the side effects associated with general or spinal anesthesia. In this report, we present a case series of five patients with high anesthetic risk (classified American Society of Anesthesiologists (ASA) III or IV) who underwent different lower limb surgeries under a combined lumbar plexus-sciatic nerve block. The goal of this case series was to evaluate the effectiveness of this technique as an anesthetic alternative for these different types of surgical procedures.

A Case Report of an Ultrasound-Guided Popliteal Sciatic Nerve Block: An Asset for Emergency Lower Limb Debridement in a High-Risk Patient.

Severe sepsis, a syndrome characterized by systemic inflammation and acute organ dysfunction in response to infection, is a major healthcare problem affecting all age groups throughout the world. Sepsis-associated encephalopathy (SAE) is a common but poorly understood neurological complication of sepsis. It is characterized by diffuse brain dysfunction secondary to infection elsewhere in the body without overt central nervous system (CNS) infection. Such cases commonly present for emergency surgical management with inadequate fasting hours, limited time for preparation, and preoperative optimization. Regional blocks become the savior in such cases where both general and central neuraxial anesthesia become perilous. Here, we present a 70-year-old male, with a case of necrotizing fascitis of the left lower limb with septic encephalopathy, with compromised cardiac or respiratory function and deranged laboratory investigations. The patient was admitted for emergency lower limb debridement, and ultrasound-guided left lower limb popliteal sciatic nerve block along with an adductor canal block was chosen as the plan of anesthesia management.

[Comparison of the effects of sciatic nerve block combined with continuted femoral nerve block or continuted adductor canal block on pain and motor function after total knee arthroplasty].

Objective: To compare the effect of sciatic nerve block (SNB) combined with continuted femoral nerve block (FNB) or continuted adductor canal block (ACB) on pain and motor function after total knee arthroplasty (TKA). Methods: A total of 60 patients with TKA-treated osteoarthritis of the knee who met the selection criteria were enrolled between November 2020 and February 2021 and randomised allocated into the study group (SNB combined with continuted ACB) and the control group (SNB combined with continuted FNB), with 30 cases in each group. There was no significant difference in gender, age, body mass, height, body mass index, preoperative Hospital for Special Surgery (HSS) score, femoral tibial angle, and medial proximal tibial angle between the two groups ( P>0.05). The operation time, the initial time to the ground, the initial walking distance, and the postoperative hospital stay were recorded. At 2, 4, 6, 12, 24, and 48 hours after operation, the numerical rating scale (NRS) score was used to evaluate the rest pain around the knee joint, the quadriceps femoris muscle strength was evaluated by the freehand muscle strength method, and the knee flexion and extension angles were measured. Results: There was no significant difference in the operation time and initial walking distance between the two groups ( P>0.05); the initial time to the ground and postoperative hospital stay of the study group were significantly shorter than those of the control group ( P<0.05). Except for the 48-hour postoperative NRS score of the study group, which was significantly lower than that of the control group ( P<0.05), there was no significant difference in the NRS scores between the two groups at the remaining time points ( P>0.05). The quadriceps femoris muscle strength from 4 to 24 hours postoperatively and the knee extension angle from 2 to 6 hours postoperatively of the study group were significantly better than those of the control group ( P<0.05); the differences in the quadriceps femoris muscle strength and knee extension and flexion angles between the two groups at the remaining time points were not significant ( P>0.05). Conclusion: SNB combined with either continuted ACB or continuted FNB can effectively relieve pain in patients after TKA, and compared with combined continuted FNB, combined continuted ACB has less effect on quadriceps femoris muscle strength, and patients have better recovery of knee flexion and extension mobility.

Construction of bupivacaine-loaded gelatin-based hydrogel delivery system for sciatic nerve block in mice.

Peripheral nerve blockade (PNB) is a common treatment to relieve postoperative pain. However, local anesthetics alone have a short duration of action and severe side effects during postoperative analgesia. In order to overcome these limitations, the present study reported an injectable hydrogel with a drug slow-release profile for regional nerve blockade. The injectable hydrogel was prepared by crosslinking with gelatin and NHS-PEG-NHS, which was degradable in the physiological environment and displayed sustainable release of anesthetics locally, thus improving the disadvantage of the high toxicity of local anesthetics. In this regard, we conducted a series of in vitro characterizations and proved that the hydrogel has a porous three-dimensional mesh structure with high drug loading capability, and sustainable drug release profile. And cytotoxicity experiments confirmed the good biocompatibility of the hydrogel. It was shown that using the animal sciatic nerve block model, the analgesic effect was greatly improved in vivo, and there was no obvious evidence of permanent inflammation or nerve damage in the block site's sections. This locally slow-release platform, combined with local anesthetics, is therefore a promising contender for long-acting analgesia.

The Gluteus Deep Investing Fascia Compartment Block: A Novel Technique for Posterior Femoral Cutaneous Nerve Block.

Purpose: The posterior femoral cutaneous nerve (PFCN) block is used in regional anesthesia for lower extremity surgery. This study introduces a new ultrasound-guided technique called the "Gluteus-Deep Investing Fascia compartment Block (GDIF block)" for blocking the PFCN. This approach involves injecting local anesthetic into the potential space between the gluteus maximus muscle and the deep investing fascia, named the 'Gluteus Deep Investing Fascia Compartment'. The study discusses the anatomical and sonographic features crucial for identifying this compartment and explores the potential benefits of this approach for achieving effective PFCN block. Additionally, it examines the clinical application of the GDIF block for PFCN block as part of the Complete Lower Extremity Fascia Tri-compartment Block technique, named "CLEFT Block." This technique combines the suprainguinal fascia iliaca block with GDIF compartment block for PFCN and a sciatic nerve block as exclusive anesthesia technique. Patients and Methods: Nine patients with weapon-related lower limb injuries underwent surgery at district hospitals supported by the International Committee of the Red Cross. Between October and December 2023, seventeen above-knee procedures were performed for the nine patients using the GDIF block as part of a CLEFT block technique. Anesthesia was performed with a CLEFT block technique using a volume ratio of 1:1 of 1% lidocaine and 0.5% levobupivacaine. Results: The GDIF block technique for PFCN blockade was performed successfully in all patients without complications, achieving complete PFCN blockade. The CLEFT block technique proved effective as the sole anesthetic technique for seventeen above-knee procedures. All surgeries were completed successfully without additional pain medication or conversion to general anesthesia. Conclusion: The GDIF block appears to be a promising technique for anesthetic management, alone or as part of the CLEFT block. Further research with a larger patient population is necessary to validate these findings.

The Successful Use of an Ultrasound-Guided Mid-Femur Sciatic Nerve Block in a Juvenile Emu (Dromaius novaehollandiae) under General Anaesthesia.

The current case report describes a successful ultrasound-guided mid-femur sciatic nerve block in an emu. A 2-month-old emu suffering from acute-onset lameness was referred to the University Clinic of Liège, where he was diagnosed with a lateral luxation of the Achilles tendon on both hind limbs. Two surgical procedures were performed for treatment. Both surgical procedures were performed under general anaesthesia with butorphanol, ketamine, midazolam and isoflurane in oxygen. The anaesthesia was continuously monitored. An ultrasound-guided sciatic nerve block was performed to prevent and treat surgically induced nociception. The technique was adapted from what is already described in other species. Levobupivacaine was injected perineurally under ultrasound-guidance. Intraoperative nociception was assessed based on the heart rate and mean arterial pressure changes. The recovery was uneventful and with no clinical signs of postoperative pain.

Dexamethasone versus Dexmedetomidine as Adjuvants in Ultrasound Popliteal Sciatic Nerve Block for Hallux Valgus Surgery: A Mono-Centric Retrospective Comparative Study.

Background and Aim: Ultrasound popliteal sciatic nerve block (UPSNB) is commonly performed in foot and ankle surgery. This study aims to assess the use of dexmedetomidine and dexamethasone as adjuvants in UPSNB for hallux valgus (HV) surgery, comparing their efficacy in producing motor and sensory block and controlling postoperative pain. The adverse event rate was also evaluated. Methods: This mono-centric retrospective study included 62 adult patients undergoing HV surgery: 30 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg and dexamethasone 4 mg (Group 1), whereas 32 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg, and dexmedetomidine 1 mcg/Kg (Group 2). At first, the visual analogue scale (VAS) was evaluated after 48 hours. The other outcomes were time to motor block regression, evaluation of the first analgesic drug intake, analgesic effect, adverse effects (hemodynamic disorders, postoperative nausea and vomiting (PONV)) and patient satisfaction. The continuous data were analyzed with student's t-test and the continuous one with χ2. Statistical significance was set at a p-value lower than 0.05. Results: No significant difference was found in VAS after 48 hours (4.5 ± 1.6 vs 4.7 ± 1.7, p = 0.621) to motor block regression (18.9 ± 6.0 vs 18.7 ± 6, p = 0.922). The number of patients that took their first analgesic drug in the first 48 h (p = 0.947 at 6 hours; p = 0.421 at 12 hours; p = 0.122 at 24 hours and p = 0.333 at 48 hours) were not significant. A low and similar incidence of intraoperative hemodynamic disorders was recorded in both groups (hypotension p = 0.593; bradycardia p = 0.881). Neither PONV nor other complication was found. Patients in Group 1 reported a lower degree of interference with sleep (p = 0.001), less interference with daily activities (P = 0.002) and with the affective sphere (P = 0.015) along with a more satisfactory postoperative pain management (p < 0.001) as compared to Group 2. Conclusion: No significant differences were observed in the duration of motor and sensory blockade between patients in both groups. Additionally, both groups showed good pain control with a low rate of adverse effects, even if there was no clinical difference between the groups. However, patients who received dexamethasone reported experiencing less interference with their sleep, daily activities and overall emotional well-being, and overall pain control.

Caudal Neuraxial Blocks for Pain Relief From Pelvic Neuropathy Caused by Extensive Diffuse Large B-cell Lymphoma.

Central neuraxial blocks can be a vital therapeutic tool for neuropathic pain, but they are infrequently implemented for pain management in cancer patients. Upon a literature review, further data on the role or efficacy of central nerve blocks for neuropathic cancer pain would be beneficial. Additionally, evidence-based guidelines and practices are lacking regarding additional interventions for neuropathic pain relief, a common manifestation of cancer burden. Here, we report the case of a 29-year-old male patient who presented in the ED with intractable neuropathic pain from extensive diffuse large B-cell lymphoma. The patient demonstrated left lower extremity pain, fevers, chills, and tenderness with erythema over the site of his port-a-catheter on his chest. The patient was also hypotensive, despite IV fluid resuscitation. Recent imaging showed a hypermetabolic soft tissue mass in the left upper quadrant of the abdomen. There was also extensive cancer spread in the peripheral pelvis, presacral region, and within multiple sacral foramina, with a secondary perineural spread of the tumor. The patient previously positively responded to a caudal nerve block at an outpatient pain clinic. The patient was admitted to the ICU for three days, and following the resolution of sepsis, the patient received caudal and sciatic nerve blocks on admission day 8. Upon further imaging showing metastasis to the brain, the patient was discharged to inpatient hospice on hospitalization day 10 following a palliative conversation with the patient and family.

Comparative Efficacy of iPACK vs Popliteal Sciatic Nerve Block for Pain Management Following Total Knee Arthroplasty: A Retrospective Analysis.

Introduction Total knee arthroplasty (TKA) is associated with severe acute postoperative pain. The use of tourniquets and drains (T/D) is common in TKA but may have an influence on postoperative pain and muscular strength. The infiltration of local anesthetic between the popliteal artery and capsule of the knee (iPACK block) is a motor-sparing block that provides analgesia to the posterior aspect of the knee. However, evidence regarding its efficacy is scarce. This study aims to assess the effectiveness of iPACK block and the impact of T/D use on pain and muscular strength after TKA. Material and methods A retrospective study was carried out including patients who underwent TKA from January 2020 to April 2023. Patients were allocated into groups according to the peripheral nerve block performed and T/D use. Results We included 415 patients in this study. No differences were found in pain at rest or the need for rescue analgesia between patients who received an iPACK block or sciatic nerve block (SNB) with T/D applied. Patients who received a SNB reported lower pain scores on movement (p = 0.019), but with a higher prevalence of motor block (p < 0.001). Patients who underwent surgery without using T/D reported lower pain scores on movement (p = 0.021) and reduced need for rescue analgesia (p = 0.041). Conclusion These findings indicate that iPACK block can facilitate early mobilization after TKA without significant impact on postoperative muscle strength. Furthermore, the use of a T/D may be a source of postoperative pain that could compromise early rehabilitation.

Endovascular revascularization of critical limb ischemia: the role of ultrasound-guided popliteal sciatic nerve block for the procedural pain management.

OBJECTIVES: To evaluate the impact of the ultrasound-guided popliteal sciatic nerve block (PSNB) for pain management during endovascular treatment of chronic limb-threatening ischemia (CLTI). MATERIAL AND METHODS: From November 2020 to January 2022, 111 CLTI patients that underwent endovascular procedures were prospectively enrolled in this prospective single-arm interventional study. Ultrasound-guided PSNB was used for procedural pain control. Pain intensity was evaluated throughout the procedure (baseline, 10 min after the block, pain peak, and at the end of the procedure) with the visual analog scale (VAS). RESULTS: Forty-six patients underwent above-the-knee revascularization (ATK), 20/111 below-the-knee (BTK) revascularization, 20/111 to both ATK and BTK revascularization. In 25 cases, no endovascular option was feasible at diagnostic angiography. The PSNB was effective in 96% of patients, with no need for further pain management with a statistically significant reduction (p < 0.0001) in the mean value of the VAS from 7.86 ± 1.81 (pre-procedural) to 2.04 ± 2.20 after 10 min from the block and up to 0.74 ± 1.43 at the end of the procedure (mean time 43 min). Only 1 complication related to the popliteal sciatic nerve block was registered (a temporary foot drop, completely resolved within 48 h). The time necessary to perform the block ranged between 4 and 10 min. CONCLUSION: Ultrasound-guided PSNB is a feasible and effective method to manage patients with rest pain and increase comfort and compliance during endovascular procedures. CLINICAL RELEVANCE STATEMENT: An ultrasound-guided popliteal sciatic nerve block is a safe, feasible, and effective technique to manage pain during endovascular treatment of chronic limb-threatening ischemia, especially in frail patients with multiple comorbidities who are poor candidates for deep sedoanalgesia or general anesthesia. KEY POINTS: Endovascular treatment of CTLI may require long revascularization sessions in patients with high levels of pain at rest, which could be exacerbated during the revascularization procedure. The PSNB is routinely used for anesthesia and analgesia during foot and ankle surgery, but the experience with lower limb revascularization procedures is very limited and not included in any international guideline. Ultrasound-guided PSNB is a feasible and effective regional anesthesia technique to relieve procedural and resting pain. Because of its safety and availability, every interventional radiologist should know how to perform this type of loco-regional anesthesia.

The use of granisetron on bupivacaine induced sciatic nerve block in rats.

PURPOSE: The effects of the 5-hydroxytryptamine (5-HT3) receptor antagonists on regional anaesthesia are complex and unclear. The present study was designed to test the hypothesis that granisetron, a selective 5-HT3 receptor antagonist, would decrease the duration of motor block, sensory block, and proprioception in a dose-dependent fashion in a rat model of bupivacaine-induced sciatic nerve blockade. MATERIALS AND METHODS: Thirty-eight male Wistar Albino rats that received unilateral sciatic nerve blocks were randomly divided into five experimental groups. Group B received a perineural of 0.3 ml of bupivacaine alone; Group BG800 received perineural 0.3 ml of bupivacaine and 800 µg of granisetron 10 min later; Group BG1200 received perineural 0.3 ml of bupivacaine and 1200 µg of granisetron 10 min later; Group BG1200IP received a perineural 0.3 ml of bupivacaine and an intraperitoneal injection of 1200 µg of granisetron 10 min later; and Group S was sham operated. A blinded investigator assessed motor, sensory and proprioception function every 10 min until the return of normal function. RESULTS: The medians for recovery times in Group B, Group BG800, Group BG1200, and Group BG1200IP were 105, 64, 85, and 120 min for motor function, respectively; 80, 64, 84, and 104 min for sensory function; 80, 63, 85, and 108 min were calculated for the proprioception function. The time to the return of normal motor, sensory, and proprioception function was not statistically significantly different between the groups (p > 0.05). Motor block did not develop in any of the rats in Group S. CONCLUSIONS: Local and systemic application of granisetron was not significantly decrease the duration of bupivacaine induced motor, sensory, and proprioception block of sciatic nerve in rat.

Evaluating the impact of ultrasound-guided subsheath versus extrasheath sciatic nerve block on postoperative wound pain in tibial and foot surgeries: A systematic review and meta-analysis.

This systematic review and meta-analysis evaluate the impact of ultrasound-guided subsheath versus extrasheath sciatic nerve blocks on postoperative wound pain in tibial and foot surgeries, crucial for effective pain management and patient recovery. Adhering to PRISMA guidelines, this study used a PICO framework, focusing on patients undergoing tibial and foot surgeries and comparing the efficacy and safety of subsheath and extrasheath sciatic nerve blocks. The literature search spanned four databases without time restrictions, assessing various outcomes like success rate, onset time, duration of analgesia and complication rates. Quality assessment employed the Cochrane Collaboration's risk of bias tool, and statistical analyses included heterogeneity assessment, fixed-effect and random-effects models, sensitivity analysis and publication bias evaluation using funnel plots and Egger's linear regression test. From an initial pool of 1213 articles, six met the inclusion criteria. The subsheath group showed a significantly higher success rate of complete sensory blockade within 30 min compared with the extrasheath group (OR = 5.39; 95% CI: 2.82-10.28; p < 0.01). No significant differences were found in procedure duration or incidence of nerve-related complications between the two techniques. The subsheath approach also demonstrated a quicker onset time of sensory blockade (MD = -8.57; 95% CI: -11.27 to -5.88; p < 0.01). Sensitivity analysis confirmed the stability of the results, and no significant publication bias was detected. Ultrasound-guided subsheath sciatic nerve blocks are more effective than extrasheath blocks in achieving rapid and complete sensory blockade for tibial and foot surgeries, with a quicker onset time and comparable safety profile. Subsheath injections are thus recommended as a preferred method for anaesthesia and postoperative pain management in these surgical procedures, enhancing overall patient outcomes.

The effect of warming ropivacaine on ultrasound-guided subgluteal sciatic nerve block: a randomized controlled trial.

BACKGROUND: There is a long latent period for the sciatic nerve block before a satisfactory block is attained. Changes in the temperature of local anesthetics may influence the characters of the peripheral nerve block. This study was designed to evaluate the effect of warming ropivacaine on the ultrasound-guided subgluteal sciatic nerve block. METHODS: Fifty-four patients for distal lower limbs surgery were randomly allocated into warming group (group W, n = 27) or room tempeture group (group R, n = 27) with the ultrasound-guided subgluteal sciatic nerve block. The group W received 30 ml of ropivacaine 0.5% at 30℃ and the group R received 30 ml of ropivacaine 0.5% at 23℃. The sensory and motor blockade were assessed every 2 min for 30 min after injection. The primary outcome was the onset time of limb sensory blockade. RESULTS: The onset time of sensory blockade was shorter in group W than in group R (16 (16,18) min vs 22 (20,23) min, p < 0.001), and the onset time of motor blockade was also shorter in group W than in group R (22 (20,24) min vs 26 (24,28) min, p < 0.001). The onset time of sensory blockade for each nerve was shorter in group W than in group R (p < 0.001). No obvious differences for the duration of sensory and motor blockade and the patient satisfaction were discovered between both groups. No complications associated with nerve block were observed 2 days after surgery. CONCLUSIONS: Warming ropivacaine 0.5% to 30℃ accelerates the onset time of sensory and motor blockade in the ultrasound-guided subgluteal sciatic nerve block and it has no influence on the duration of sensory and motor blockade. TRIAL REGISTRATION: The trial was registered on October 3, 2022 in the Chinese Clinical Trial Registry ( https://www.chictr.org.cn/bin/project/edit?pid=181104 ), registration number ChiCTR2200064350 (03/10/2022).

Quantitative assessment of ultrasound-guided sciatic nerve block - A comparison of a single-point versus two-point injection technique: A randomised controlled, double-blinded trial.

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Improvement in "Jumping Stump" Syndrome Following Diagnostic Sciatic Nerve Block and Home Exercise Program in a Transtibial Amputee.

"Jumping Stump" syndrome is a rare postoperative complication seen in the residual limb of amputees, with only a few cases documented in the literature. It has been defined as a peripherally induced movement disorder leading to either dystonia, myoclonus, tremors, or choreiform movements in the amputated residual limb. It is often associated with significant discomfort and an inability to ambulate with a prosthetic limb. Treatment options remain inconclusive at this time. We present a case of "Jumping Stump" syndrome in a young female transtibial amputee following revision transtibial amputation (TTA) with myodesis and targeted muscle reinnervation. About six weeks after revision surgery, the patient started experiencing significant myoclonus of the right residual limb when extending the knee. She was trialed on various oral pharmacologic agents over six months and had multiple prosthetic adjustments without any symptomatic relief. Moreover, the patient was also prescribed a daily knee range of motion (ROM) and stretching program. Six months after symptom onset, she underwent a diagnostic right sciatic nerve block and right biceps femoris point block with immediate and significant improvement in symptoms. She had a greater ROM in the affected limb without myoclonus and was able to ambulate once again with her prosthetic limb. Our patient's response to a diagnostic nerve and motor point block, as well as her marked improvement of symptoms with a consistent home exercise (stretching) program, suggests that desensitization of a muscle-tendon stretch response likely accounted for the improvement of symptoms. It is hypothesized that chemodenervation via botulinum toxin, in addition to the consistent home stretching program, would have accelerated the improvement of symptoms and should be further explored as a potential treatment modality for "Jumping Stump" syndrome.

Ultrasound-Guided Block of the Sciatic and the Femoral Nerves in Rabbits-A Descriptive Anatomical Study.

The rabbit is a popular animal model for human biomechanical research involving surgery on the hind limb. Mortality is higher in rabbits when undergoing general anesthesia compared to dogs and cats. Moreover, due to their nature as prey animals, rabbits have a tendency to hide signs of pain, making it challenging to detect discomfort at an early stage. Incorporating regional anesthesia into an anesthetic protocol can greatly reduce the requirements for systemic anesthetic and analgesic drugs, thereby minimizing associated side effects. In other species, a block of the sciatic (ScN) and the femoral nerves (FN) is usually applied in patients undergoing hind limb surgery. In phase 1 of this study, the ScN and the FN have been localized and an appropriate approach has been evaluated under sonographic guidance. In phase 2, a mixture of new methylene blue and lidocaine have been administered to the ScN and the FN in 10 cadavers (20 hind limbs). Staining of the nerves was evaluated by dissection. Ultrasonographically, the ScN appeared as a binocular structure surrounded by a hyperechoic rim. The FN appeared as a hypoechoic structure in the dorsal part of the iliopsoas muscle (IPM), becoming hyperechoic/honey-comb-like in the ventral part. Both nerves could be successfully stained in all animals over a median length of 2.3 cm which was considered effective. This technique allows feasible and accurate access to block the ScN and the FN and may lead to successful analgesia in rabbits undergoing hind limb surgery.

Tetra-block: ultrasound femoral, lateral femoral-cutaneous, obturator, and sciatic nerve blocks in lower limb anesthesia: a case series.

BACKGROUND: The gold standard anesthesiologic procedure for urgent femur fracture surgery is Spinal Anesthesia. It is not always feasible because of patients' severe comorbidities and difficulties in optimizing drug therapy in the appropriate time frame such as discontinuation of anticoagulant drugs. The use of four peripheral nerve blocks (tetra-block) can be a winning weapon when all seems lost. CASE PRESENTATION: We present, in this case series, three Caucasian adult femur fractures (an 83-year-old woman, a 73-year-old man, and a 68-year-old woman) with different and major comorbidities (cardiac or circulatory disorders on anticoagulants therapy that were not discontinued on time; breast cancer and others) underwent the same anesthesiologic approach in the urgent setting. Ultrasound peripheral nerve blocks, that is femoral, lateral femoral cutaneous, obturator, and sciatic with parasacral approach were successfully performed in all patients who underwent intramedullary nailing for intertrochanteric fracture. We evaluated the adequacy of the anesthesia plane, postoperative pain control with the VAS scale, and the incidence of postoperative side effects. CONCLUSIONS: Four peripheral nerve blocks (Tetra-block) can be alternative anesthesiologic management in urgent settings, in patients where drug therapy cannot be optimized, as in antiplatelet and anticoagulant therapy.

Evaluation of a New Method of Sciatic Nerve Block: A Prospective Pilot Study.

Purpose: The location of the sciatic nerve deep within the thigh tissue makes it challenging to locate while the patient is in a supine position. The posterior intermuscular septum of the thigh, which encircles the posterior surface of the adductor magnus muscle (AMM), is where the sciatic nerve is located. Our hypothesis was that administering local anesthetic injections into this area could block the sciatic nerve. Therefore, our aim was to evaluate the effectiveness of sciatic nerve block achieved by injecting local anesthetic into the posterior intermuscular septum of the thigh, named the AMM approach. Methods: Twenty-six patients undergoing total knee arthroplasty were included in the study. We performed an ultrasound-guided sciatic nerve block by injecting 20 mL of 0.25% ropivacaine into the posterior surface of the adductor magnus muscle, using the AMM approach. Additionally, we administered a femoral nerve block with 20 mL of 0.4% ropivacaine. We assessed the sensory and motor effects of the blockade in the operated lower limb and recorded postoperative pain scores at 0, 4, 8, 12, 24, and 48 hours after the operation. Results: The AMM approach successfully block the sciatic nerve in all 26 patients. The onset of the sensory and motor blockades was achieved within 5.4 ± 1.9 min and 8.7 ± 3.5 min, respectively. We achieved a satisfactory position with the first puncture in 19 of 26 patients (73.1%). The muscle strength of the tibialis anterior immediately after surgery was 4 (ranging from 2 to 5). Additional rescue analgesics were required in 5 of the 26 patients (19.2%) during the first 24 hours postoperatively. Conclusion: The AMM approach is an innovative and effective method for sciatic nerve block. When combined with simultaneous femoral nerve block in patients undergoing total knee arthroplasty, it provides a useful analgesic treatment option.

Sciatic Nerve Block Combined with Flurbiprofen Inhibits Spinal Cord Inflammation and Improves Postoperative Pain in Rats with Plantar Incision.

Background and Purpose: Peripheral nerve block is often used to relieve postoperative pain. But the effect of nerve block on inflammatory response is not fully understood. Spinal cord is the primary center of pain processing. This study is to investigate the effect of single sciatic nerve block on the inflammatory response of the spinal cord in rats with plantar incision and the combined effect with flurbiprofen. Methods: The plantar incision was used to establish a postoperative pain model. Single sciatic nerve block, intravenous flurbiprofen or the combination of both were used for intervention. The sensory and motor functions after nerve block and incision were evaluated. The changes of IL-1ß, IL-6, TNF-α, microglia and astrocytes in the spinal cord were examined by qPCR and immunofluorescence respectively. Results: Sciatic nerve block with 0.5% ropivacaine in rats induced sensory block for 2h and motor block for 1.5h. In the rats with plantar incision, the single sciatic nerve block did not alleviate postoperative pain or inhibit the activation of spinal microglia and astrocytes, but the levels of IL-1ß and IL-6 in spinal cord were decreased when the nerve block wore off. The combined effect of a single sciatic nerve block and intravenous flurbiprofen not only decreased the levels of IL-1ß, IL-6, and TNF-α, but also relieved the pain and alleviated the activation of microglia and astrocytes. Conclusion: The single sciatic nerve block cannot improve postoperative pain or inhibit the activation of spinal cord glial cells, but can reduce the expression of spinal inflammatory factors. Nerve block combined with flurbiprofen can inhibit spinal cord inflammation and improve postoperative pain. This study provides a reference for rational clinical application of nerve block.

Ultrasound-guided femoral and sciatic nerve block as an option for below-knee amputation in an elderly patient: A case report.

Peripheral nerve blocks can be a very safe option in elderlypatients with multiple comorbidities where spinal or general anesthesia may be associated with increased risks. We present a 67 years male taking antiplatelet drugs with deranged coagulation profile with bilateral pneumonia with diabetic foot with wet gangrene planned for emergency below knee amputation under ultrasound guided femoral and sciatic nerve block.