British Journal of Anaesthesia 98 (3): 3905 (2007)

doi:10.1093/bja/ael364

REGIONAL ANAESTHESIA
Case Report

Ultrasound-guided sciatic nerve block: description of a new

approach at the subgluteal space
M. K. Karmakar*, W. H. Kwok, A. M. Ho, K. Tsang, P. T. Chui and T. Gin
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales
Hospital, Shatin, NT, Hong Kong, SAR, China
*Corresponding author: Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince
of Wales Hospital, Shatin, NT, Hong Kong, SAR China. E-mail: karmakar@cuhk.edu.hk

Br J Anaesth 2007; 98: 3905

Keywords: anaesthetic, techniques, regional, sciatic; nerve, nerve block, ultrasound guided,
subgluteal
Accepted for publication: November 15, 2006

Sciatic nerve block (SNB) is frequently used for anaesthesia

or analgesia during lower limb surgery. Depending on the
surgical indication, SNB can be used on its own or in
combination with an ipsilateral lumbar plexus block or
femoral nerve block for surgical anaesthesia. There are
several techniques or approaches for SNB. Most techniques
described to date rely on surface anatomical landmarks,
which can be complex. Although anatomical landmarks
provide valuable clues to the position of the sciatic nerve,
they are only surrogate markers, can vary in patients, and
may be difficult to locate in obese patients. Even nerve
stimulation that is considered the gold standard for peripheral nerve localization may not always elicit a motor
response and also does not guarantee success.
Recently, there has been an increase in interest in the use
of ultrasound for peripheral nerve block and ultrasoundguided SNB has been described.1 3 We have also used
ultrasound to perform SNB in both adults and children.
However, instead of performing SNB at the traditional sites
described previously (anterior, parasacral, transgluteal,
infragluteal, lateral, posterior subgluteal, infraglutealparabiceps, proximal thigh, or at the popliteal fossa), we have
found the subgluteal space to be an effective site for local
anesthetic injection or catheter insertion during

ultrasound-guided SNB. In this report, we describe a series

of five patients in whom SNB was successfully performed
under ultrasound guidance at the subgluteal space.
The anatomy, sonographic features, and technique of identifying the subgluteal space at the level of the greater trochanter and ischial tuberosity using ultrasound are also
discussed.

Case report
We performed ultrasound-guided SNB for anaesthesia in
five ASA physical status IIII patients (2764 yr old,
weight 5574 kg) who were scheduled for orthopaedic foot
surgery. No premedication was prescribed to any of these
patients. The patients were positioned laterally, with the side
to be anaesthetized uppermost and with the hip and knees
flexed (Fig. 1). The lateral prominence of the greater trochanter and the ischial tuberosity were then identified, and a
line was drawn between these two landmarks using a skin
marking pen (Fig. 1). The sciatic nerve was scanned at this
location using a low-frequency, 52 MHz, curved array
probe (C60e, 52 MHz) and a Micromaxx ultrasound
system (Sonosite Inc., Bothell, WA, USA) with tissue harmonic imaging (THI) and image capturing capabilities. A

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Sciatic nerve block is frequently used for anaesthesia or analgesia during orthopaedic foot
surgery and there are several different approaches to the sciatic nerve. This report describes a
new approach to the sciatic nerve using ultrasound. Local anesthetic was injected into the
subgluteal space under ultrasound guidance which was effective in producing sciatic nerve block
in a small series of five patients. The anatomy, sonographic features, technique of identifying the
subgluteal space, and potential advantages of this approach to the sciatic nerve are discussed.

US-guided subgluteal sciatic nerve block

liberal amount of ultrasound gel was applied to the skin

over the area to be scanned for acoustic coupling and the
ultrasound probe was positioned parallel to the line previously drawn with its orientation marker directed laterally
(i.e. directed towards the greater trochanter, so as to provide
a transverse scan of the subgluteal space and the sciatic
nerve). A scout-scan (pre-intervention scan) was performed to identify the sciatic nerve in the subgluteal space
and to optimize the ultrasound image before the intervention. The ultrasound image was optimized by making the
following adjustments on the ultrasound unit: (a) selecting a
scanning preset, (b) setting an appropriate scanning depth,
(c) selecting the General (mid range) frequency range as
the ultrasound probe used was a broadband probe, (d) selecting the THI option, and (e) finally, the gain was adjusted
manually to obtain the best possible image (Fig. 2). On a
sonogram, the subgluteal space was seen as a hypoechoic
area between the hyperechoic perimysium of the gluteus
maximus and the quadratus femoris muscles (Fig. 2). It
extended from the greater trochanter laterally to the ischial
tuberosity medially. The medial limit of the subgluteal
space was difficult to see. At this level, the sciatic nerve was
seen as an oval hyperechoic nodule approximately 1.5
2 cm in diameter within the subgluteal space (Fig. 2).

Under aseptic precautions, a 100-mm, 21-gauge insulated nerve block needle (Stimuplexw A, B. Braun
Melsungen AG, Germany) connected to a nerve stimulator
(Stimuplexw HNS11, B. Braun) delivering a current of
1 mA at a frequency of 1 Hz was inserted in the long axis
(in plane) of the ultrasound beam (Fig. 1) and advanced
slowly towards the sciatic nerve under real-time ultrasound
guidance. As the needle was advanced in the long axis of
the ultrasound beam, it was possible to see the advancing
needle in most cases. However, when the needle could not
be seen, the position of the needle tip could only be
inferred by jiggling the needle and looking for tissue
movement on the ultrasound scan. Once the block needle
was in contact with the sciatic nerve (identified by observing nerve movement) or in the subgluteal space close to
the sciatic nerve, a positive motor response (dorsiflexion
or plantar flexion) of the foot was observed in all except
one patient ( patient 5, aged 64 yr, motor response was
only obtained at a current of 2 mA). The final position of
the needle in the subgluteal space was confirmed in all
five patients by injecting 2 5 ml of saline through the
needle and observing a distention of the subgluteal space
[i.e. separation of the perimysium of the gluteus maximus
and quadratus femoris muscle on the ultrasound image

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Fig 1 Position of the patient and the ultrasound transducer during an ultrasound-guided SNB at the subgluteal space. Also seen is an insulated nerve
block needle (100 mm, 21 gauge insulated needle, Stimuplexw A, B. Braun Melsungen AG, Germany) being inserted in the long-axis (in plane) of the
ultrasound beam (reproduced with permission from www.aic.cuhk.edu.hk/usgraweb).

Karmakar et al.

(Fig. 3)]. In two patients, although the needle was seen to

be in contact with the sciatic nerve and there was a positive motor response in the foot-to-nerve stimulation, the
test injection of saline only spread posterior to the perimysium of the gluteus maximus muscle. This indicated that
the tip of the needle was not in the subgluteal space and
was easily rectified by advancing the needle a little further
after which the typical distention of the subgluteal space
to the saline test injection was seen on the ultrasound
image. Occasionally, a subtle pop was felt as the needle
tip traversed the perimysium of the gluteus maximus
muscle and entered the subgluteal space.
After negative aspiration through the needle, 25 30 ml
of lignocaine 1% and ropivacaine 0.25% with epinephrine
1:400 000 was injected incrementally over 2 3 min while
observing the distribution of the local anaesthetic in real
time on the ultrasound scan. Distention of the subgluteal
space (seen in all patients, Fig. 3) and circumferential
spread of the local anaesthetic around the sciatic nerve (in
four patients, Fig. 3) was noted (see video at www.aic.
cuhk.edu.hk/usgraweb). Longitudinal scan of the sciatic
nerve in between the greater trochanter and ischial tuberosity after the local anaesthetic injection also demonstrated
longitudinal spread of the local anaesthetic on either side
of the sciatic nerve. Complete anaesthesia, adequate for
surgery over the foot, developed in all patients within
15 20 min after the injection of local anaesthetic. There
were no complications directly related to the SNB or to
the local anaesthetic injection, and recovery from the
anaesthesia was uneventful.

Discussion
Sciatic nerve block is frequently used for anaesthesia or
analgesia during orthopaedic foot surgery, and several different approaches to the sciatic nerve have been described
in the literature. In this report, we have demonstrated that
the subgluteal space, where the sciatic nerve is located, is a
well-defined anatomical space and can be identified using
ultrasound at the level of the greater trochanter and ischial
tuberosity. We have also shown that local anaesthetic
injected into the subgluteal space under ultrasound guidance
is effective in producing SNB.
The technique of ultrasound-guided SNB at the subgluteal space, as described in this report, should be distinguished from, and not confused with, the technique of
posterior subgluteal SNB described by Di Benedetto and
colleagues.4 The two techniques are different: (a) ultrasound guided vs landmark technique and (b) local anaesthetic is also injected into two different locations along the
course of the sciatic nerve. While we inject the local
anaesthetic into the subgluteal space, defined as the space
between the gluteus maximus and quadratus femoris
muscle at the level of the greater trochanter and ischial
tuberosity, Di Benedetto and colleagues4 perform their
subgluteal SNB technique caudal to the inferior border of
the gluteus maximus muscle. Another approach to the
sciatic nerve that is comparable to the one that we
describe, as far as injecting the local anaesthetic into the
subgluteal space, is the lateral approach described by
Guardini and colleagues.5 However, this modified lateral
approach is performed with the patient in the supine

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Fig 2 Transverse sonogram between the greater trochanter and ischial tuberosity showing the hypoechoic subgluteal space between the hyperechoic
perimysium of the gluteus maximus and the quadratus femoris muscle. The sciatic nerve is seen as a hyperechoic nodule in the medial aspect of the
subgluteal space (reproduced with permission from www.aic.cuhk.edu.hk/usgraweb).

US-guided subgluteal sciatic nerve block

position, using nerve stimulation, and the landmarks

described introduce, the needle along the inferior border
of the quadratus femoris muscle.5
The sciatic nerve (L4,5, S1-3) arises from the sacral
plexus and exits the pelvis through the greater sciatic

foramen, between the piriformis and the superior

gemellus muscles (Fig. 4), to enter the subgluteal space
below the piriformis muscle.4 It then descends over the
dorsum of the ischium, lying on the dorsal surface of
the gemellus superior muscle, tendon of obturator

Fig 4 Relation of the sciatic nerve to the muscles of the buttock and upper thigh (reproduced with permission from www.aic.cuhk.edu.hk/usgraweb).

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Fig 3 Transverse sonogram of the sciatic nerve at the level of the greater trochanter and ischial tuberosity after 25 ml of local anaesthetic injection.
Note the distention of the subgluteal space and circumferential spread of local anaesthetic around the sciatic nerve (reproduced with permission from
www.aic.cuhk.edu.hk/usgraweb).

Karmakar et al.

internus, gemellus inferior muscle, and quadriceps

femoris muscle (in a cranial to caudal relation, Fig. 4)
before it enters the hollow between the greater trochanter and the ischial tuberosity and then on to the posterior compartment of the thigh. The anterior surface of
the gluteus maximus muscle covers the upper part of
the sciatic nerve and immediately distal to its lower
border (infragluteal position), the sciatic nerve is fairly
superficial. In between the greater trochanter and ischial
tuberosity, the subgluteal space is a well-defined anatomical space between the anterior surface of the gluteus
maximus and the posterior surface of the quadratus
femoris muscle.5 On a sonogram, the subgluteal space is
seen as a hypoechoic area between the hyperechoic perimysium of the gluteus maximus and quadratus femoris
muscles. It extends from the greater trochanter laterally
to the ischial tuberosity medially. The sciatic nerve is
seen as an oval hyperechoic nodule, approximately
1.52 cm in diameter in an average adult within the
subgluteal space (Fig. 2). The medial limit of the subgluteal space is often difficult to see using ultrasound.
This may be because of the attachment of the semimembranosus, semitendinosus, and biceps femoris
muscles to the ischial tuberosity (Fig. 5). Other structures that are present in the subgluteal space include the
posterior cutaneous nerve of the thigh, inferior gluteal
vessels and nerve, nerve to the short and long head of
biceps femoris, the comitans artery and vein of the
sciatic nerve, and the ascending branch of the medial
circumflex femoral artery.5 The anatomical relations of

the above structures are shown in Figure 5.

Occasionally, pulsations of the inferior gluteal artery can
be seen medial to the sciatic nerve in the subgluteal
space.
Although the subgluteal space covers a wide area
anterior to the gluteus maximus muscle, we have found
that it is best seen using ultrasound at the level of the
greater trochanter and ischial tuberosity and in relation to
the quadratus femoris muscle. The quadratus femoris
muscle is a quadrangular muscle, about 4 cm in height and
attached to the posterior surface of the greater trochanter
and ischial tuberosity.5 Two lines extended laterally along
the upper and lower border of the quadratus femoris
muscle will intersect the femur about 1 cm above and
3 cm below the point of maximum lateral prominence of
the greater trochanter.5 The plane of the subgluteal space
at this level is therefore parallel to and posterior to the
plane of the quadratus femoris muscle.5 Moreover, as the
ischial tuberosity is slightly caudal and dorsal in position
relative to the greater trochanter, the plane of the subgluteal space is also slightly oblique (15 208) to the coronal
plane at this level.5
The ability to identify a potential space along the proximal course of the sciatic nerve using ultrasound is unique
and may offer several advantages over existing methods
for SNB. We have found that it is relatively simple to
insert a block needle under ultrasound guidance into the
subgluteal space. This is confirmed by injecting 2 3 ml of
saline through the needle and observing a distention of the
subgluteal space (i.e. separation of the perimysium of the

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Fig 5 Transverse section through the gluteal region at the level of the quadratus femoris muscle showing the subgluteal space and its contents
(reproduced with permission from www.aic.cuhk.edu.hk/usgraweb).

US-guided subgluteal sciatic nerve block

the subgluteal space under ultrasound guidance is effective

in producing SNB. Considering the potential advantages
of performing SNB at the subgluteal space, future studies
should compare this technique with other proximal
approaches to the sciatic nerve.

Acknowledgement
The authors would like to thank Sonosite Inc., USA for providing equipment support.

References
1 Gray AT, Collins AB, Schafhalter-Zoppoth I. Sciatic nerve block in a
child: a sonographic approach. Anesth Analg 2003; 97: 1300 2
2 McCartney CJ, Brauner I, Chan VW. Ultrasound guidance for a
lateral approach to the sciatic nerve in the popliteal fossa.
Anaesthesia 2004; 59: 1023 5
3 Sinha A, Chan VW. Ultrasound imaging for popliteal sciatic nerve
block. Reg Anesth Pain Med 2004; 29: 130 4
4 Di Benedetto P, Bertini L, Casati A, Borghi B, Albertin A,
Fanelli G. A new posterior approach to the sciatic nerve block:
a prospective, randomized comparison with the classic
posterior approach. Anesth Analg 2001; 93: 1040 4
5 Guardini R, Waldron BA, Wallace WA. Sciatic nerve block: a new
lateral approach. Acta Anaesthesiol Scand 1985; 29: 515 9

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gluteus maximus and quadratus femoris muscle, on ultrasound imaging). Local anaesthetic injected into the subgluteal space readily spreads to and around the sciatic
nerve. It is also easy to pass a catheter into the subgluteal
space when a continuous SNB is planned (unpublished
data). In theory, the subgluteal injection should also block
the posterior cutaneous nerve of the thigh, which is an
advantage when anaesthesia over the posterior aspect of
the thigh is warranted. There are no major blood vessels in
the subgluteal space and thus vascular complications
related to the SNB may also be reduced. Currently, we use
nerve stimulation in conjunction with ultrasound imaging
for SNB at the subgluteal space, but we envisage that,
with experience, it may be possible to perform an
ultrasound-guided SNB at the subgluteal space without
using nerve stimulation. This will be particularly useful in
young children as the majority of SNB in this age group
is performed under general anaesthesia when the use of a
neuromuscular blocking agent makes nerve stimulation
impractical.
In conclusion, the subgluteal space, where the sciatic
nerve is located, is a well-defined anatomical space. It can
be identified using ultrasound at the level of the greater
trochanter and ischial tuberosity as a hypoechoic area
between the perimysium of the gluteus maximus and the
quadratus femoris muscles. Local anesthetic injected into