Popliteal sciatic nerve blocks after foot and ankle surgery: an adjunct to postoperative analgesia.

The use of sciatic popliteal nerve blocks in conjunction with common peroneal and saphenous nerve blocks can provide prolonged hours of analgesia after foot and ankle surgery. This adjunct to analgesia allows for reduced amounts of postoperative opioids and the undesirable and adverse effects associated with these drugs. The peripheral blocks are technically easy to perform and offer the surgical patient many hours of pain relief. Furthermore, when utilized preoperatively, a lighter depth of anesthesia can be maintained with little demand for opioids so that the postoperative recovery will be accelerated with fewer complications.     

Anesthesia and postoperative analgesia after percutaneous hallux valgus repair in ambulatory patients

Background

Postoperative pain is often severe after hallux valgus repair. Sciatic nerve blocks with long-acting local anesthetics have been recommended for surgical anesthesia and postoperative analgesia. However, a novel percutaneous approach may require less analgesia and make the procedure suitable for ambulatory care. We thus tested the hypothesis that mid-foot block and sciatic nerve blocks provide comparable surgical anesthesia and postoperative analgesia, but that patients ambulate independently sooner after mid-foot block.

Study design

Prospective, randomized study.

Methods

Forty patients scheduled for ambulatory percutaneous hallux valgus repair were randomly assigned to two anesthesia and analgesia blocks: foot infiltration achieved by a mild foot block, or sciatic nerve block (30 mL of 7.5% ropivacaine for each block). Surgery was performed without sedation or additional analgesia. Both groups were given oral paracetamol/codeine and ketoprofene systematically; tramadol was added if necessary. Walking ability and pain scores were assessed for 48 postoperative hours.

Results

Demographic and morphometric characteristics, and duration of surgery were similar in each group. Pain scores were comparable and low in each group at rest and while walking. The time to ambulation without assistance was significantly less for patients in the infiltration group (3.8 ± 1.4 hours) than patients in the sciatic group (19.2 ± 9.5 hours; P < 0.0001).

Conclusion

After percutaneous hallux valgus repair, mid-foot block and sciatic nerve block provided comparable postoperative analgesia. However, mid-foot block seems preferable since the time to ambulation without assistance is much reduced.     

Peripheral Foot Blockade Versus Popliteal Fossa Nerve Block: A Prospective Randomized Trial in 51 Patients

The majority of foot and ankle operations are performed on an outpatient basis and often under some form of regional anesthesia. In this prospective, randomized study of 51 patients undergoing elective unilateral forefoot procedures, we compared 2 different anesthetic techniques: the peripheral foot blockade and the popliteal sciatic nerve block. Variables assessed included the quality of surgical anesthesia, postoperative analgesia, and the incidence of postoperative complications. The anesthesia was classified as effective if it was the sole anesthetic technique for the forefoot surgery. We found successful results in both groups: 92% in the foot block group and 96% in the popliteal block group. Analysis of time required to perform the anesthetic procedure showed a significant difference between the 2 groups, with foot block being considerably faster (14.3 minutes vs 19.2 minutes for popliteal block) (P = .0078). Foot block patients demonstrated 10.96 hours of analgesia, whereas popliteal block patients exhibited 14.32 hours (P = .132). With a mean follow-up of 5.7 months, we did not find anesthesia-related complications in any of the patients. Both techniques showed a high level of safety and efficacy, with no significant difference detected between them. Our patients showed a high rate of satisfaction with both procedures (96% for foot block patients and 96.1% for popliteal block patients) and reported a good discharge disposition. These data show that both procedures are safe and effective anesthetic techniques and well suited to forefoot ambulatory surgery.     

Spinal Anesthesia With Peripheral Nerve Block Versus General Anesthesia With Peripheral Nerve Block for Elective Foot and Ankle Surgeries: A Retrospective Single-Center Study

Peripheral nerve blocks are the regional techniques in orthopedic surgeries to control postoperative pain and have early discharge from hospital. However, anesthesia protocols for foot and ankle surgeries of institutes do not include multimodal analgesics including peripheral nerve blocks. The objective of the study was to compare spinal anesthesia with peripheral nerve block against general anesthesia with peripheral nerve block for elective foot and ankle surgeries. Patients have treated for elective foot and ankle surgery under general anesthesia (using propofol, 0.05 mg/kg dezocine, and 1% sevoflurane; GA cohort, n = 112) or spinal anesthesia (using 0.5% bupivacaine, propofol, and 0.05 mg/kg dezocine; SA cohort, n = 132) or patients have treated for elective for foot and ankle surgery under general anesthesia (GL cohort, n = 115) or spinal anesthesia (SL cohort, n = 160) with the use of peripheral nerve block (the sciatic nerve blocks and adductor canal nerve blocks using 0.25% bupivacaine and 0.1 mg/kg dexamethasone). Propofol was administered in fewer amounts if anesthesia was used with the peripheral nerve block. Patients of the GL cohort were transferred to ward 36 minutes (mean) earlier than those of the SL cohort. None of the patients of the GL and the SL cohorts have received intraoperative opioid(s) for the management of pain. Patients of the GL and the SL cohorts have reported postoperative falls within 1 day after surgeries during movement. Patients of the SL cohort experienced more frequently difficulty with sleeping. Patients of the GL and the GA cohorts have reported nausea and vomiting. Only patients of the GL cohort were required usage of vasoactive drugs. The study provides information to anesthesiologists and surgeons regarding anesthesia techniques for elective foot and ankle surgeries for better surgical outcomes (Technical Efficacy Stage: 4).     

Continuous peripheral nerve blockade in lower extremity surgery

Peripheral nerve blocks afford numerous benefits for lower extremity surgery. There is growing interest in continuous peripheral nerve blocks, mainly for treatment of postoperative pain, a field that represents a challenge to the anaesthesiologist. This paper seeks to review the efficacy of continuous lower limb blocks for postoperative pain relief. Not only do continuous peripheral nerve blocks afford specificity of analgesic area but current research has shown that they enhance postoperative analgesia and patient satisfaction. New techniques and devices are increasingly appearing, and catheters are constantly being developed and improved; an example being the stimulating catheter, which represents one of the newest advances in this area. The above techniques show that continuous postoperative analgesia with catheters in the lower extremities is not only possible, but indeed provides sustained effective postoperative analgesia, reduces use of opioids, and improves rehabilitation and patient well-being with minimal side-effects. These techniques could prove an alternative to postoperative pain treatment following ambulatory surgery.     

Safety and efficacy of the popliteal fossa nerve block when utilized for foot and ankle surgery

The popliteal fossa nerve block (PFNB) offers numerous advantages that make it a suitable anesthetic technique for foot and ankle surgery. In this retrospective study, we investigated the acute and long-term safety and efficacy of this relatively underutilized anesthetic technique for foot and ankle surgery. A review of 834 patients who underwent foot and/or ankle surgery by the coauthor (NAA) was conducted. Four hundred sixty-seven patients received a PFNB with the aid of a peripheral nerve stimulator. Variables assessed included the quality of surgical anesthesia, postoperative analgesia and the acute and long-term incidence of postoperative neuralgia and neuropraxia. The PFNBs were performed by anesthesiologists with various levels of training at a tertiary care hospital and all were supplemented with a saphenous nerve block. The PFNB was successful as the sole anesthetic technique in 79% of the cases; 18% were converted to general anesthesia and 3% required augmentation with local anesthetic. There were no complications associated with the PFNB. There were no incidents of postoperative neuralgia or neuropraxia. Only 12% of patients with a successful block required analgesics in the PACU, while 60% of patients with a failed block required systemic analgesics for surgical site pain (p<0.01). These results suggest that the performance of the PFNB with the guidance of a peripheral nerve stimulator is a safe and effective anesthetic technique for foot and ankle surgery.     

Fast-track regional anaesthesia

Regional anaesthesia plays an important role in day case surgery because it combines reliable effects with low risk and the possibility of local postoperative analgesia without systemic side-effects. Fast-track regional anaesthesia allows short-term postoperative surveillance or even bypassing the post-anaesthesia care unit. Peripheral nerve blocks provide long-lasting pain relief, and can accelerate timely discharge if a persisting motor block is accepted. Multiple peripheral nerve stimulation and injection techniques may help to realize differential blockades with a pronounced analgesic rather than a motor blocking effect. Nerve blocks with local anaesthetics in combination with alpha2-adrenoceptor agonists or non-steroidal anti-inflammatory drugs and short-acting parenteral opioids represent an effective multimodal concept for ambulatory surgery.     

Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study

Background

Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours.

Methods

Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours.

Results

Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h.

Conclusion

One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.     

Upper extremity techniques for postoperative analgesia

There are several options available when utilizing regional anesthesia techniques for postoperative pain control after upper extremity surgery. Appropriate selection of the analgesia technique is determined by a thorough understanding of brachial plexus neuroanatomy as it relates to the surgical site. Development of dispensable continous infusion technology has allowed greater utilization of regional anesthesia techniques in the ambulatory population. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Ankle nerve block-perioperative pain relief in surgery of the forefoot

BackgroundSurgery of the foot induces intense pain in the postoperative periode. Peripheral nerve blocks provide reliable anesthesia for all foot surgery and is associated with an ability to ambulate immediately following surgery. The actual study was performed to evaluate the efficacy of nerve blocks in the postoperative phases of surgery of the forefoot.MethodOne hundred and sixteen patients were in this prospective study randomized to two groups; group 1 recieved an ankle nerve block with local anesthetics prior to surgery, group 2 recieved spinal or general anesthesia without a nerve block. Pain was evaluated with repeated VAS-scales, total consumption of analgesics were recorded. A record was kept on the requirement of the intraoperative intravenous anesthetic agents. Total hospital care time was recorded.ResultsThe ankle nerve block lowered the requirement of intraoperative intravenous anesthetic agents. The use of oral anelgesics was higher in the control group. The hospital care time was lower in the ankle nerve block group.ConclusionThe ankle nerve blocks reduces the consumption of analgesics. Good control of postoperative pain allows for early recovery of these patients. Use of nerve blocks should be encouraged when possible in surgery of the foot.     

Lateral popliteal sciatic nerve block compared with ankle block for analgesia following foot surgery

The purpose of this study was to compare postoperative analgesia after foot surgery in patients anaesthetised either with popliteal sciatic nerve block or ankle block. In a prospective study, 40 patients scheduled for foot surgery involving osteotomies were allocated randomly into one of two groups. Following induction of general anaesthesia, Group PS (n = 21) received a lateral popliteal sciatic nerve block and Group AB (n = 19) received an ankle block. Both groups received 20 ml bupivacaine 0.5% plain. In group PS 43% required morphine analgesia in the Post Anaesthetic Recovery Room (PAR) compared with 16% in group AB. Postoperative analgesia was assessed using VAS and a pain scale in the PAR and a questionnaire by telephone follow-up on the day after surgery. The ankle block appeared to be more reliable, providing more consistent analgesia in the PAR. Postoperative analgesia in Group PS lasted a median of 18.0 hr and in Group AB lasted 11.5 hr (P < 0.05). Both techniques provided effective analgesia after discharge home and high levels of patient satisfaction.     

Regional anesthesia for laparoscopy

A variety of laparoscopic procedures can be performed on patients under regional anesthesia. Diagnostic laparoscopy in elective and emergency patients, pain mapping, laparoscopy for infertility, and tubal sterilization are some examples. The key benefits of regional anesthesia include less emesis, less postoperative pain, shorter postoperative stay, improved patient satisfaction, and overall safety. Regional techniques, such as rectus sheath blocks, inguinal blocks, and caudal blocks, are useful adjuncts to general anesthesia and facilitate postoperative analgesia. Other techniques, such as spinal and epidural anesthesia, and combination of the two, are suitable as a sole anesthetic technique for laparoscopy. The physiologic changes during laparoscopy in the awake patient appear to be tolerated well under regional anesthesia. It is reasonable to assume that with advances in instrumentation and surgical techniques, the role of laparoscopy will increase in the future. The benefits conferred by regional anesthesia make it an attractive option to general anesthesia for many patients and procedures. Successful implementation of regional anesthesia is an important determinant of how anesthesiologists, surgeons, and surgical facilities cope with new challenges. In the future, it could be possible to provide "walk-in/walk-out" regional anesthesia with a real possibility of fast tracking patients through the recovery process after ambulatory surgery. For maximal patient safety, however, facilities offering regional anesthesia must have appropriately trained anesthesia personnel and the equipment necessary for monitoring and providing full resuscitation in the event of complications or a need to convert to general anesthesia.     

The use of central regional anesthesia techniques in Sweden: results of a nation-wide survey

Background: Epidural and subarachnoid anesthesia are well established central regional techniques for surgical anesthesia. TWO additional techniques, combined spinal epidural (CSE) block and continuous spinal anesthesia (CSA), have recently become popular. However, data on nation-wide use of central regional blocks are not available.
Method: With the aims to survey the use of central regional techniques, to evaluate the risk of complications to central regional blocks and to document the use of continuous epidural techniques for postoperative pain management in Sweden during 1993, a questionnaire was mailed to all 105 Swedish anesthesiology departments.
Results: Questionnaires were returned by 62 departments, representing all categories of Swedish hospitals. Central regional blocks were used for surgical anesthesia in 2040% of reported surgical procedures. Subarachnoid anesthesia was the main technique for orthopedic surgery on the lower limb, elective cesarean section and transurethral resection of the prostate. Epidural block was used for orthopedic and vascular surgery. CSE block was used by 42 departments and CSA by 21 departments. Postoperative epidural analgesia was used by 59 departments, most commonly with continuous infusion of local anesthestics and/or epidural bolusdoses of morphine. Nineteen neurological sequelae were reported after epidural (n=7) and subarachnoid (n=12) blocks. Routines for registration of complications varied greatly.
Conclusions: Subarachnoid block was preferred for shorter surgical procedures (<60 min), whereas epidural and CSE blocks were chosen when severe postoperative pain could be anticipated, as continuous epidural analgesia was well established for postoperative pain management. Improved routines for registration of complications to central regional blocks are needed.     

Caudal block in children: ropivacaine compared with bupivacaine.

BACKGROUND: Bupivacaine provides reliable, long-lasting anesthesia and analgesia when given via the caudal route. Ropivacaine is a newer, long-acting local anesthetic that (at a concentration providing similar pain relief) has less motor nerve blockade and may have less cardiotoxicity than bupivacaine. METHODS: In a double-blind trial, 81 healthy children, undergoing ambulatory surgical procedures, were randomly allocated to receive caudal analgesia with either bupivacaine or ropivacaine, 0.25%, 1 mVkg. All blocks were placed by an attending anesthesiologist or an anesthesia fellow after induction of general anesthesia. RESULTS: Data were available for 75 children. There were no significant differences between the two groups in baseline characteristics or in anesthesia, surgery, recovery room, or day surgery unit durations. The quality and duration of postoperative pain relief did not differ. Motor and sensory effects were similar. Time to first micturition did not differ. CONCLUSION: Ropivacaine (0.25%, 1 ml/kg) provided adequate postoperative analgesia with no difference from bupivacaine (0.25%, 1 ml/kg) in quality and duration of pain relief, motor and sensory effects, or time to first micturition in our study children.     

Caudal Block in Children: Ropivacaine Compared with Bupivacaine

Background: Bupivacaine provides reliable, long-lasting anesthesia and analgesia when given via the caudal route. Ropivacaine is a newer, long-acting local anesthetic that (at a concentration providing similar pain relief) has less motor nerve blockade and may have less cardiotoxicity than bupivacaine.

Methods: In a double-blind trial, 81 healthy children, undergoing ambulatory surgical procedures, were randomly allocated to receive caudal analgesia with either bupivacaine or ropivacaine, 0.25%, 1 ml/kg. All blocks were placed by an attending anesthesiologist or an anesthesia fellow after induction of general anesthesia.

Results: Data were available for 75 children. There were no significant differences between the two groups in baseline characteristics or in anesthesia, surgery, recovery room, or day surgery unit durations. The quality and duration of postoperative pain relief did not differ. Motor and sensory effects were similar. Time to first micturition did not differ.     

Regional anesthesia for ambulatory foot and ankle surgery

Regional anesthesia provides significant advantages for the patient and practitioner involved in ambulatory foot and ankle surgery. Reliable techniques for administering regional ankle blocks emphasizing their importance in the practice of ambulatory surgery are presented.     

Lower extremity blocks for analgesia

A large proportion of patients undergoing surgery do not receive adequate postoperative analgesia.[1] Postoperative pain is the leading cause of unplanned hospital admissions after ambulatory surgery and a major source of dissatisfaction with perioperative outcome. [2] The establishment of acute pain services in major institutions both in the United States and overseas has had a major effect on postoperative comfort and patient satisfaction. [3 and 4] Most acute pain services primarily use intravenous patient-controlled analgesia (PCA) or patient-controlled epidural infusion; however, advances in neuronal blockade offer an unprecedented range of effective and surgery site–specific analgesic options. Using long-acting local anesthetics, peripheral nerve blocks can be used to provide an excellent anesthesia and postoperative analgesia. Additionally, a catheter for continuous infusion of local anesthetics can be inserted perineurally to extend the analgesia beyond the duration of the single-shot blocks. This review will discuss the advantages and limitations of various nerve block techniques when used for postoperative pain management for several common surgical indications. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Lateral trans-biceps popliteal block for elective foot and ankle surgery performed after induction of general anesthesia

BACKGROUND: The purpose of this study was to determine safety and efficacy of lateral transtendinous popliteal blocks performed after induction of general anesthesia for intraoperative and postoperative pain control in elective foot and ankle surgery. METHODS: The charts of 475 consecutive patients were retrospectively reviewed. The technique was a lateral transtendinous popliteal block under nerve stimulator direction (described in the text). Patient records were retrospectively evaluated from the postanesthesia care unit, as well as at followup on postoperative day 1 and weeks 2, 6, and 12. RESULTS: The block was complete in 398 patients (83.7%). An incomplete block was found in 77 patients (16.2 %). In the incomplete category, 21 patients (4.4%) had no pain but some motor function, 32 patients (6.5%) reported mild to moderate pain, and 24 patients (5.3%) had severe pain. The average block duration was 16.5 hours. There were no adverse effects documented in any patient at followup. CONCLUSIONS: Lateral popliteal nerve block after induction of general anesthesia appears to be safe and effective for intraoperative and postoperative pain control in elective foot and ankle surgery.     

Single-Injection Femoral and Sciatic Nerve Blocks for Pain Control After Total Knee Arthroplasty

This study was designed to evaluate the addition of a single-injection sciatic nerve block to a femoral nerve block for analgesia after total knee arthroplasty. Fifty-seven patients undergoing primary total knee arthroplasty were randomized to receive femoral nerve blockade or a sham block. A subsequent 31 patients received both femoral and sciatic nerve blocks (FSNBs) before general anesthesia. Intravenous morphine use and visual analog pain scale scores were recorded at regular intervals. Femoral and sciatic nerve blocks were placed in less than five minutes, on average. Lower visual analog pain scale scores were noted in both femoral nerve blockade and FSNB groups compared to shams through 48 hours. Morphine use was significantly lower in the FSNB group. Femoral and sciatic nerve block can be placed quickly and consistently in the operating room with improved postoperative pain relief and reduced narcotic consumption.     

Perineural injection of morphine fails to relieve postoperative pain in humans

Ten patients scheduled for bilateral foot surgery were given general anesthesia plus ankle blocks. One side was blocked with 0.02% morphine and the other with 0.9% saline. A second group of 10 patients for bilateral foot surgery had one side blocked with 0.02% morphine and the other with 0.01% morphine. A within-patient blind comparison of postoperative analgesia between the two sides was performed by nurse observers, using categorical and visual analogue scales for both pain intensity and pain relief. Postoperative analgesia recorded by the nurse observer was not significantly different between morphine and saline. Similarly, there was no significant difference in postoperative analgesia between legs blocked with the higher or lower dose of morphine. Thus, perineural morphine does not relieve postoperative pain at doses equivalent to 2-4 mg in a 70-kg man.