Abstract
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-I 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.
Résumé
Objectif
L’objectif de cet examen narratif est de résumer les données probantes dérivées d’études randomisées contrôlées (ERC) concernant les approches et techniques pour les blocs nerveux du membre inférieur.
Source
A l’aide des bases de données MEDLINE (janvier 1966 à avril 2007) et EMBASE (janvier 1980 à avril 2007), les termes MeSH (vedette-matière médicale) « lumbosacral plexus », « femoral nerve », « obturator nerve », « saphenous nerve », « sciatic nerve », « peroneal nerve » et « tibial nerve » ont été recherchés et combinés au terme MeSH « nerve block » à l’aide de l’opérateur « and ». Les mots clés « lumbar plexus », « psoas compartment », « psoas sheath », « sacral plexus », « fascia iliaca », « three-in-one », «3-in-1», «lateral femoral cutaneous», «posterior femoral cutaneous », « ankle » et « ankle block » ont également été recherchés et combinés au terme MeSH « nerve block ». La recherche a été limitée aux ERC impliquant des sujets humains et publiées en langue anglaise. Quarante-six ERC ont été identifiées.
Constatations principales
Par rapport à son équivalent antérieur (bloc 3-en-1), l’approche postérieure du plexus lombaire est plus fiable quand une anesthésie du nerf obturateur est requise. Le bloc du compartiment de l’aponévrose iliaque pourrait également représenter une meilleure alternative que le bloc 3-en-1 à cause d’une efficacité et d’une efficience améliorées (temps de performance plus court, coût moindre). Pour un bloc du nerf sciatique, l’approche transglutéale constitue une méthode fiable. En raison d’un temps potentiellement plus court pour l’électrolocation du nerf sciatique et le positionnement du cathéter que par la voie transglutéale, l’approche subglutéale devrait également être prise en considération. Par rapport à l’électrolocation du nerf péronier, l’électrostimulation du nerftibial pourrait offrir un taux de réussite plus élevé, particulièrement avec les abords transglutéal et latéral poplité. De plus, lors de la mise en place de blocs sciatique ou fémoral avec de petits volumes d’anesthésiques locaux, une technique d’injection multiple devrait être utilisée.
Conclusion
Les comptes rendus publiés d’ERC fournissent des données probantes qui permettent de formuler des recommandations limitées en ce qui concerne les approches et techniques optimales pour l’anesthésie du membre inférieur. Des ERC bien conçues et exécutées avec soin sont requises, particulièrement à la lumière de nouvelles techniques d’écho-guidage.
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Tran, D., Clemente, A. & Finlayson, R.J. A review of approaches and techniques for lower extremity nerve blocks. Can J Anesth 54, 922–934 (2007). https://doi.org/10.1007/BF03026798
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DOI: https://doi.org/10.1007/BF03026798