13652044, 2009, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.05915.x by INASP/HINARI - INDONESIA, Wiley Online Library on [01/12/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia, 2009, 64, pages 638–642 doi:10.1111/j.1365-2044.2009.05915.x
.....................................................................................................................................................................................................................

Ultrasound vs nerve stimulation multiple injection

technique for posterior popliteal sciatic nerve block
G. Danelli,1 A. Fanelli,1 D. Ghisi,1 E. Moschini,1 M. Rossi,1 A. Ortu,1 M. Baciarello1
and G. Fanelli2
1 Anaesthetist, 2 Professor of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Therapy,
University Hospital, Parma, Italy

Summary
In this prospective, randomised, observer-blinded study we evaluated whether ultrasound
guidance can shorten the onset time of popliteal sciatic nerve block as compared to nerve
stimulation with a multiple injection technique. Forty-four ASA I–III patients undergoing
posterior popliteal sciatic nerve block with 20 ml of 0.75% ropivacaine were randomly
allocated to nerve stimulation or ultrasound guided nerve block. A blinded observer recorded
onset of sensory and motor blocks, success rates, the need for fentanyl intra-operatively, the
requirement for general anaesthesia, procedure-related pain, patient satisfaction and side-effects.
Onset times for sensory and motor blocks were comparable. The success rate was 100% for
ultrasound guided vs 82% for nerve stimulation (p = 0.116). Ultrasound guidance reduced
needle redirections (p = 0.01), were associated with less procedural pain (p = 0.002) and
required less time to perform (p = 0.002). Ultrasound guidance reduced the time needed for
block performance and procedural pain.
. ......................................................................................................
Correspondence to: Dr Daniela Ghisi
E-mail: ghisidan@hotmail.com
Accepted: 22 January 2009

The multiple twitch technique is based on searching and of ultrasound guidance for sciatic block at the popliteal
identifying the targeted nerve by eliciting each nerve’s fossa [10, 11].
motor component with nerve stimulation [1–3]. It has We conducted a prospective, randomised, observer-
been associated with a reduction in sensory and motor blinded study to test the hypothesis that ultrasound
block onset and a greater efficacy than a single injection guidance can shorten the onset of posterior popliteal
technique [2]. Recently, ultrasound guidance has been sciatic nerve block as compared with nerve stimulation
introduced in order to improve the efficacy of peripheral guidance for nerve location when using the multiple
nerve blocks, to shorten procedural time, to reduce injection technique.
the minimum local anaesthetic volume required for a
successful block and to lower the incidence of compli-
Methods
cations and side-effects [4–6]. Ultrasound guidance may,
theoretically, offer an advantage over conventional tech- With Local Ethics Committee approval (University of
nique (anatomical landmarks and nerve stimulation) since Parma, Parma, Italy) and written informed consent, 44
it allows direct visualisation of nerve structures, needle American Society of Anesthesiologist physical status 1–3
pathway and local anaesthetic spread in real time [7, 8]. patients undergoing foot and ankle surgery were enrolled
Ultrasound guidance for upper limb nerve blocks has in the study in January–March, 2008. Patients with
been showed to have a greater success rate than nerve clinically significant coagulopathy, infection at injection
stimulation alone and it also allowed a reduction in local site, allergy to local anaesthetics, severe cardiopulmonary
anaesthetic dose for femoral nerve block [6]. While its disease, body mass index > 35 kg.m2, diabetes mellitus,
role for proximal sciatic nerve block has been widely or known neuropathies, as well as patients receiving
described [9], some authors still argue about the feasibility opioids for chronic analgesic therapy were excluded.

Ó 2009 The Authors

638 Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland
 13652044, 2009, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.05915.x by INASP/HINARI - INDONESIA, Wiley Online Library on [01/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia, 2009, 64, pages 638–642 G. Danelli et al. Æ Ultrasound vs multiple injection for popliteal sciatic block
. ....................................................................................................................................................................................................................

After arrival in the operating room, an 18-G intravenous or first ultrasound scan in the US group and needle
catheter was placed at the forearm opposite to the surgical removal at the end of the block in both groups. The
side and intravenous premedication was given (midazo- number of skin punctures and needle redirections
lam 0.03 mg.kg)1). Standard monitoring was applied required to obtain the correct needle placement were
throughout the procedure, including non-invasive arterial registered by an independent observer (a nurse). A needle
blood pressure with automated cuff, heart rate and pulse redirection was defined as any needle withdrawal of at
oximetry. Using a computer-generated random allocation least 10 mm with subsequent forward movement. Blood
list and sealed envelopes, patients were selected to receive aspiration and the incidence of paraesthesia were regis-
a posterior popliteal sciatic nerve block with nerve tered. Pain intensity related to the procedure was assessed
stimulation and multiple injection technique (group NS, at the end of the block using a verbal Numerical Rating
n = 22) or ultrasound guidance (group US, n = 22). All Scale (NRS) from 0 = no pain to 10 = worst imaginable
blocks were placed by an experienced anaesthetist (GD) pain. A blinded observer recorded the onset time of
skilled in both regional anaesthesia techniques. sensory and motor blocks in the distribution territories of
Each patient was placed in the prone position with a the tibial and common peroneal nerves. The starting time
pillow under the ankle in order to allow free movements point to evaluate sensory and motor block onsets was the
of the foot during nerve stimulation. All blocks were completion of the last local anaesthetic injection. Both
performed with 20 ml of 0.75% ropivacaine. In group sensory and motor blocks were evaluated for each sciatic
NS, a popliteal sciatic nerve block was performed branch by a blinded observer (tibial nerve and peroneal
following Singelyn’s landmarks [12, 13] and a nerve nerve) every 5 min until 30 min after the last local
stimulator was used for nerve location (PlexygonÒ; anaesthetic injection. Sensory block was defined as loss of
Vygon, Padova, Italy) using a stimulating, 100 mm long, pinprick sensation in the central sensory region of each
21G, short-beveled, Teflon-coated needle (LocoplexÒ; nerve with the same stimulus delivered to the contralat-
Vygon, Padova, Italy). The nerve stimulator was set to a eral side and scored as follows: normal sensation (touch
pulse duration of 0.1 ms, current intensity of 1.5 mA, and and pain) or touch sensation without pain = incomplete
frequency of 2 Hz. The two sciatic branches were located block, no sensation = complete block. Motor block was
according to the specific muscular twitches elicited by defined as follows: no loss of force or reduced force
their stimulation (tibial nerve: foot plantar flexion and compared with contralateral limb = incomplete motor
inversion; common peroneal nerve: foot dorsal flexion block; no movement = complete block.
and eversion). After the correct twitch was elicited, the If required a surgical tourniquet was positioned below
stimulating intensity was progressively reduced to 0.4 mA, the knee. In case of pain or discomfort during surgery we
while maintaining the twitch. For each sciatic branch administered intravenous boluses of fentanyl (50 lg) and
10 ml of 0.75% ropivacaine were injected. In the group the number of patients who required fentanyl was
US, a 5-cm long, 5–13 MHz linear probe (LOGIQ eÒ; recorded. If the patient was unable to complete surgery
GE Healthcare, Milan, Italy) was used to localise the without discomfort, had pain on pinprick testing 30 min
sciatic nerve. With a ‘trace back’ technique [14] the probe after block completion or required > 100 lg fentanyl
was first applied at the popliteal crease to identify the during surgery general anaesthesia (GA) was administered
popliteal artery and, laterally, the tibial nerve. After that, with laryngeal mask airway and the block was recorded as
the transducer was moved more cranially until 10 cm ‘failed’.
from the popliteal fossa, and following the tibial nerve Patients were interviewed the day after surgery to
pathway, the confluence of the tibial branch with the assess their satisfaction with the anaesthesia technique.
peroneal nerve was identified. Maintaining the sciatic We registered it as ‘satisfactory’ when patients stated
nerve in the centre of the image, a 21-G, 10-cm long, that, if needed, they would have the same anaesthetic
short-beveled, Teflon-coated needle (LocoplexÒ) was procedure again and ‘unsatisfactory’ if they stated that
inserted with using ‘in plane’ approach, (with the shaft of they would rather have different anaesthesia in the
the needle lying in the path of the ultrasound beam). future. The patient was also assessed for complete
Nerve stimulation was not used. Using real time imaging recovery of neurological function as well as the occur-
of local anaesthetic spread around the nerve, 20 ml of rence of untoward events including paraesthesia, dysaes-
0.75% ropivacaine were injected. After the nerve block, thesia or motor deficits.
patients in both groups were positioned in the supine The primary endpoint was the onset time for sensory
position for a saphenous or femoral block, depending on and motor blocks. Secondary endpoints were duration of
the surgical indication. the anaesthetic procedure, the number of needle punc-
Block onset time was defined as the time interval tures and redirections, the incidence of paraesthesia and
between muscular landmarks palpation in the NS group blood aspiration, the completeness of sensory and motor

Ó 2009 The Authors

Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland 639
 13652044, 2009, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.05915.x by INASP/HINARI - INDONESIA, Wiley Online Library on [01/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. Danelli et al. Æ Ultrasound vs multiple injection for popliteal sciatic block Anaesthesia, 2009, 64, pages 638–642
. ....................................................................................................................................................................................................................

blocks for each sciatic branch, the need for fentanyl

Tibial motor block
during surgery, the need for general anaesthesia, the
intensity of pain during the anaesthetic procedure as
scored by the verbal NRS, the patients’ satisfaction with Peroneal motor block
the anaesthesia technique and the number of neuro- *
logical complications. Power calculations were based on
the results of a previous investigation using a multiple Tibial sensory block
injection technique [15]. We considered as clinically NS
relevant a 5-min difference in the main outcome variable, US
Peroneal sensory block
with an effect size to standard deviation (SD) ratio of 1.
We determined that a total of 22 patients per group were
required to detect a difference in the onset of nerve block, 0 5 10 15 20 25 30
accepting a two-tailed a error of 5% and b error of 15% Time (min)
and considering a drop-out rate of 10–20%. Statistical
Figure 1 Onset times of sensory and motor blocks in both
analysis was performed using the SYSTAT 7.0 statistical sciatic nerve branches (tibial and peroneal nerves) *p = 0.028.
software package (SPSS Inc., Chicago, IL, USA). Normal
distribution of the collected data was first evaluated using
the Kolmogorov–Smirnov test. Continuous variables in group NS (p = 0.003). Block performance in group
were analyzed using the Student t test or the Mann– US required less needle redirections than in group NS,
Whitney U-test according to data distribution. Categor- four [1–7] vs six [1–20] needle redirections, respectively
ical variables were analysed using the contingency tables (p < 0.001).
analysis and the Fisher exact test. Continuous variables are Sixty-eight per cent of patients in group US vs 36% in
presented as mean (SD) or median [range]. Categorical group NS had complete sensory and motor blocks
data are presented as number (%). A p value < 0.05 was (p = 0.070). The number of incomplete sensory and
considered significant. motor blocks of each sciatic branch are shown in Table 2.
The number of patients with a failed block requiring
GA, the number requiring fentanyl < 100 lg to complete
Results
surgery under regional anaesthesia (that is, patients
Demographic characteristics and type of surgery are who required fentanyl but needing < 100 lg so GA
reported in Table 1. No patient was withdrawn from not required according to the protocol), and the
the study. The anaesthetic procedure duration was 2 (2–8) incidence of blood aspiration and paraesthesia in the
min in group US group and 5 (2–15) min in group NS two groups are reported in Table 3. Patient satisfaction
(p = 0.002). Figure 1 shows the onset times of sensory was comparable between the two groups although
and motor blocks in the sciatic branches (tibial and ultrasound guidance nerve block was reported as less
peroneal nerves). The peroneal motor block onset time painful than nerve stimulation: NRS 2 [0–6] and 4
was shorter in group US than in group NS 12.2 (4.8) min [0–10], respectively (p = 0.002). No neurological com-
vs 17.9 (8.5) min, respectively (p = 0.028). There was no plications were reported during the 24 h follow-up and
difference between the other onset times. The number of complete recovery of sensory and motor functions was
skin punctures was two [1–4] in group US and two [2–4] observed in all patients.

Table 1 Demographic data and surgical details of patients.

Values are presented as number (proportion) or mean (SD). Table 2 Proportion of patients with complete sensory and
motor block.
Group US Group NS
Group Group
Sex; M:F 9:3 10 : 2 US (%) NS (%)
Age; years 48 (17) 55 (12)
Weight; kg 69 (14) 72 (15) Sensory block
Height; cm 168 (8) 168 (9) Tibial 100 91
Type of surgery (%) Peroneal 95 86
Foot 14 (64) 13 (59) Motor block
Ankle 6 (27) 6 (27) Tibial 73 40
Leg 2 (9) 3 (14) Peroneal 73 64

US, ultrasound; NS, nerve stimulation. US, ultrasound; NS, nerve stimulation.

Ó 2009 The Authors

640 Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2009, 64, pages 638–642
. ....................................................................................................................................................................................................................
Table 3 Proportion of patients requiring general anaesthesia
(GA) or intra-operative fentanyl to complete surgery without
GA; patient satisfaction; and the incidence of blood aspiration
and paraesthesia on injection.
GA required to complete surgery
Fentanyl (<100 lg) required to
complete surgery
Patient satisfied with regional
anaesthesia technique
Blood aspiration
Paraesthesia
US, ultrasound; NS, nerve stimulation.
Discussion
In this prospective, randomised, observer-blinded study,
we compared ultrasound guidance with electrical nerve
stimulation guided multiple injection technique for
posterior popliteal sciatic nerve block. We demonstrated
that these two techniques provide comparable onset times
for posterior popliteal sciatic sensory and motor blocks
with as little as 20 ml of 0.75% ropivacaine; only the onset
of motor peroneal nerve block was faster in ultrasound
guided group. In ultrasound guided group we found a
reduction in the time needed to perform the block and
less procedural pain. There was no difference in side-
effects and there were no neurological complications in
either group. Success rates were high with both tech-
niques: in group US – no patient required GA (success
rate 100%), vs four patients in group NS (success rate
82%).
In contrast with previous studies (success rate in US
group = 89% vs 61% in NS group [16]) the difference in
our success rate is not significant (p = 0.116), although
clinically notable. Our success rate for either technique is
better than that reported in previous studies where nerve
stimulation was used with a single injection [17]. It is
difficult to predict whether double injection could have
an impact on success rate at this anatomical site as the
needle entry point (at 10 cm from the popliteal crease) is
very close to the sciatic nerve bifurcation.
We would like to differentiate between those blocks
that were adequate for the entire surgical procedure and
those blocks that allowed no sensation to pinprick and
complete absence of movement in both either sciatic
branches. The large majority of the blocks defined as
‘incomplete’ according to the protocol were still satis-
factory and permitted the surgical procedure to be
completed.
An advantage of ultrasound guidance is that peripheral
nerves can be identified [7], and we found that the
Ó 2009 The Authors
Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland
13652044, 2009, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.05915.x by INASP/HINARI - INDONESIA, Wiley Online Library on [01/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
G. Danelli et al. Æ Ultrasound vs multiple injection for popliteal sciatic block
median number of needle skin punctures was less than
with nerve stimulation. Ultrasound guidance allowed us
to reduce both needle punctures and redirections, low-
ering Numerical Rating Scores (NRS) for procedure-
Group Group
related pain during block performance. It is interesting to
US (%) NS (%) note that, even if ultrasound guidance leads to a longer
needle pathway, reducing needle movements and the
0 18 absence of muscular twitches reduces procedure related
27 18
pain. There was no difference in the incidence of vascular
72 68 puncture and paraesthesia. However, 22% of patients in
group NS experienced paraesthesia and we aspirated
0 22
0 22
blood during the block procedure in 22% of patients in
the same group (Table 3). As previously reported the
multiple injection technique is the most effective nerve
stimulation technique, improving success rates, reducing
onset time and local anaesthetic volumes, although
increasing the time required to perform the block
[17].We found that ultrasound guidance reduces block
time. Dufour et al. [18] reported that combined ultra-
sound and neurostimulation guidance does not reduce
block time of posterior popliteal sciatic block vs neuro-
stimulation alone. Perlas et al. [16] demonstrated that
block procedure time was similar between ultrasound and
nerve stimulator-guided blocks when using a single-
injection technique. Nevertheless, to our knowledge, the
present study is the first to compare, as separately applied
techniques, ultrasound guidance with nerve stimulation
for a multiple-injection technique for popliteal sciatic
nerve block.
In conclusion, we have shown that ultrasound and
nerve stimulation used with a multiple injection tech-
nique are associated with similar onset times for sensory
and motor blocks. However, ultrasound guidance
resulted in shorter procedure times and less needle
punctures and redirections, resulting in less procedure-
related pain.
References
1 Handoll HH, Koscielniak-Nielsen ZJ. Single, double or
multiple injection techniques for axillary brachial plexus
block for hand, wrist or forearm surgery. Cochrane Database
Systematic Review 2006; 25: CD003842.
2 Paqueron X, Bouaziz H, Macalou D, et al. The lateral
approach to the sciatic nerve at the popliteal fossa: one or
two injections? Anesthesia & Analgesia 1999; 89: 1221–5.
3 March X, Pineda O, Garcia M, Caramès D, Villalonga A.
The posterior approach to the sciatic nerve in the popliteal
fossa: a comparison of single-versus double-injection tech-
nique. Anesthesia & Analgesia 2006; 103: 1571–3.
4 Orebaugh SL, Williams BA, Kentor ML. Ultrasound guid-
ance with nerve stimulation reduces the time necessary for
resident peripheral nerve blockade. Regional Anesthesia and
Pain Medicine 2007; 32: 448–54.
641

G. Danelli et al. Æ Ultrasound vs multiple injection for popliteal sciatic block
. ....................................................................................................................................................................................................................
5 Koinig H, Mayer N, Kapral S. Ultrasonographic guidance
reduces the amount of local anesthetic for 3-in-1 blocks.
Regional Anesthesia and Pain Medicine 1998; 23: 584–8.
6 Casati A, Baciarello M, Di Cianni S, et al. Effects of ultra-
sound guidance on the minimum effective anaesthetic vol-
ume required to block the femoral nerve. British Journal of
Anaesthesia 2007; 98: 823–7.
7 Casati A, Danelli G, Baciarello M, et al. A prospective,
randomized comparison between ultrasound and nerve
stimulation guidance for multiple injection axillary brachial
plexus block. Anesthesiology 2007; 106: 992–6.
8 Marhofer P, Greher M, Kapral S. Ultrasound guidance in
regional anaesthesia. British Journal of Anaesthesia 2005; 94:
7–17.
9 Chan VW, Nova H, Abbas S, et al. Ultrasound examination
and localization of the sciatic nerve: a volunteer study.
Anesthesiology 2006; 104: 309–14.
10 Saranteas T, Chantzi C, Iatrou C, Kostopanagiotou G,
Dimitriou V. Ultrasound and regional anesthesia techniques-
is there any limitation? Regional Anesthesia and Pain Medicine
2007; 32: 546–7.
11 Danelli G, Ghisi D, Ortu A. Ultrasound and regional
anesthesia technique: are there really ultrasound guidance
technical limits in sciatic nerve blocks? Regional Anesthesia
2008; 33: 281–2.
12 Singelyn FJ, Gouverneur JM, Gribomont BF. Popliteal
sciatic nerve block aided by a nerve stimulator: a reliable
642
13652044, 2009, 6, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2009.05915.x by INASP/HINARI - INDONESIA, Wiley Online Library on [01/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia, 2009, 64, pages 638–642
technique for foot and ankle surgery. Regional Anesthesia and
Pain Medicine 1991; 16: 278–81.
13 Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal
sciatic nerve block: an original technique to provide post-
operative analgesia after foot surgery. Anesthesia & Analgesia
1997; 84: 383–6.
14 Tsui BCH, Finucane BT, Chan B. The importance of
ultrasound landmarks: a traceback approach using popliteal
blood vessels for identification of sciatic nerve. Regional
Anesthesia and Pain Medicine 2006; 31: 481–2.
15 Taboada M, Alvarez J, Cortes J, et al. The effects of three
different approaches on the onset time of sciatic nerve blocks
with 0.75% ropivacaine. Anesthesia & Analgesia 2004; 98:
242–7.
16 Perlas A, Brull R, Chan VWS, Nuica A, Abbas S. Ultra-
sound guidance improves the success of sciatic nerve block at
the popliteal fossa. Regional Anesthesia and Pain Medicine
2008; 33: 259–65.
17 Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator
and multiple-injection technique for upper and lower limb
blockade: failure rate, patient acceptance, and neurologic
complications. Anesthesia & Analgesia 1999; 88: 847–52.
18 Dufour E, Quennesson P, Van Robais AL, et al. Combined
ultrasound and neurostimulation guidance for popliteal
sciatic nerve block: a prospective, randomized comparison
with neurostimulation alone. Regional Anesthesia 2008; 106:
1553–8.
Ó 2009 The Authors
Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland