Choquet Olivier, Noble Guillaume Brault, Abbal Bertrand, Morau Didier, Bringuier Sophie, Capdevila Xavier
From the *Department of Anesthesiology and Critical Care, Montpellier University Hospital; †Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital; ‡Epidemiology and Clinical Research Department, Arnaud de Villeneuve University Hospital; and §Institut National de la Sante et de la Recherche Médicale U1046, UM1, Montpellier, France.
Reg Anesth Pain Med. 2014 Jul-Aug;39(4):306-11. doi: 10.1097/AAP.0000000000000095.
The ideal spread of local anesthetic for effective, rapid, and safe sciatic nerve block is debated. We hypothesized that subparaneural ultrasound-guided injection results in faster onset and has a better success rate than extraneural circumferential spread.
Patients undergoing elective tibial, foot, and ankle surgery with popliteal sciatic nerve blocks were prospectively enrolled. After randomization, the needle tip position was adjusted to ensure circumferential extraneural or subparaneural spread; 0.3 mL/kg of mepivacaine 10 mg/mL was injected. Post hoc video analysis was used to group the patients according to extraneural, subparaneural, and unintentional intraepineural spread.
There were 26 (43.3%) patients in the subparaneural group and 22 (36.7%) in the extraneural group. Block onset time was shorter in the subparaneural group than in the extraneural group (11 [3-21] minutes; mean [95% confidence interval], 11 [8.97-13.02] minutes and 17 [6-30] minutes; mean [95% confidence interval] 18.37 [14.17-22.57] minutes, respectively; P = 0.002). The duration of sensory blockade increased (397 [178-505] minutes vs 265 [113-525] minutes; P = 0.04). The success rate of the block also increased. Unintentional intraepineural injection occurred in 8% of patients (3 patients in the subparaneural group and 1 patient in the extraneural group; NS). Block onset time was shorter than for the subparaneural and extraneural groups (6 [3-12] minutes, 12 [3-21] minutes, and 18 [6-30] minutes; P = 0.01).
A subparaneural injection accelerated the onset time and increased the duration of tibial nerve sensory blockade compared with circumferential extraneural injection. With unintentional intraepineural spread, the onset time was significantly shorter than for the other groups.
关于局部麻醉药有效、快速且安全的坐骨神经阻滞理想扩散方式存在争议。我们假设神经旁超声引导注射比神经外周围扩散起效更快且成功率更高。
前瞻性纳入接受腘部坐骨神经阻滞的择期胫骨、足部和踝关节手术患者。随机分组后，调整针尖位置以确保周围神经外或神经旁扩散；注射0.3 mL/kg的10 mg/mL甲哌卡因。采用事后视频分析根据神经外、神经旁和意外的神经内扩散对患者进行分组。
神经旁组有26例（43.3%）患者，神经外组有22例（36.7%）患者。神经旁组的阻滞起效时间比神经外组短（分别为11[3 - 21]分钟；均值[95%置信区间]，11[8.97 - 13.02]分钟和17[6 - 30]分钟；均值[95%置信区间]18.37[14.17 - 22.57]分钟；P = 0.002）。感觉阻滞持续时间延长（397[178 - 505]分钟对265[113 - 525]分钟；P = 0.04）。阻滞成功率也有所提高。8%的患者发生意外神经内注射（神经旁组3例，神经外组1例；无显著差异）。其阻滞起效时间比神经旁组和神经外组短（分别为6[3 - 12]分钟、12[3 - 21]分钟和18[6 - 30]分钟；P = 0.01）。
与周围神经外注射相比，神经旁注射加速了胫神经感觉阻滞的起效时间并延长了其持续时间。意外神经内扩散时，起效时间显著短于其他组。
