Tran De Quang Hieu, Clemente Antonio, Finlayson Roderick J
Department of Anesthesia, Montreal General Hospital, McGill University, Montreal, Quebec, Canada.
Can J Anaesth. 2007 Nov;54(11):922-34. doi: 10.1007/BF03026798.
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.
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.
Compared to its anterior counterpart (3-in-1 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.
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.
本叙述性综述的目的是总结来自随机对照试验（RCT）的关于下肢神经阻滞方法和技术的证据。
利用MEDLINE（1966年1月至2007年4月）和EMBASE（1980年1月至2007年4月）数据库，检索医学主题词（MeSH）“腰骶丛”、“股神经”、“闭孔神经”、“隐神经”、“坐骨神经”、“腓总神经”和“胫神经”，并使用运算符“and”与MeSH词“神经阻滞”进行组合。还查询了关键词“腰丛”、“腰大肌间隙”、“腰大肌鞘”、“骶丛”、“髂筋膜”、“三合一”、“3合1”、“股外侧皮神经”、“股后皮神经”、“踝关节”和“踝关节阻滞”，并与MeSH词“神经阻滞”进行组合。检索仅限于涉及人类受试者且以英文发表的RCT。共识别出46项RCT。
与前路（三合一阻滞）相比，当需要对闭孔神经进行麻醉时，腰丛后路阻滞更可靠。由于疗效和效率提高（操作时间更快、成本更低），髂筋膜间隙阻滞也可能是比三合一阻滞更好的选择。对于坐骨神经阻滞，经典的经臀途径是一种可靠的方法。由于坐骨神经电定位和导管置入时间可能比经臀途径短，也应考虑臀下途径。与腓总神经电定位相比，胫神经电刺激可能成功率更高，尤其是经臀和腘外侧途径。此外，当使用少量局部麻醉药进行坐骨神经和股神经阻滞时，应采用多次注射技术。
已发表的RCT报告为制定关于下肢麻醉最佳方法和技术的有限建议提供了证据。有必要进行进一步精心设计和严格执行的RCT，特别是鉴于涉及超声引导的新技术。
