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Level of blockadeCoverage distribution (Figure 147-1 and chapter 140)
  • Sciatic nerve in the popliteal fossa
  • Alternatively, the tibial or peroneal nerve can be blocked independently
Tibial nerve:
  • Motor: gastrocnemius and soleus (plantar flexion and inversion)
  • Sensory: posterior aspect of lower leg
  • Peroneal nerve:
  • Motor: anteromedial muscles of the lower leg (dorsiflexion and eversion)
  • Sensory: lateral aspect of lower leg
  • Sciatic nerve: combination of both
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Figure 147-1. Coverage Distribution of the Popliteal Block
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Reproduced from Hadzic A. The New York School of Regional Anesthesia Textbook of Regional Anesthesia and Acute Pain Management. Figure 38-2. Available at: http://www.accessanesthesiology.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

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Anatomy (Figure 147-2):

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Figure 147-3. Landmarks for Posterior Approach Using NS
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The needle insertion point is 7 cm cephalad to the flexion crease, about 1 cm lateral to the center of the flexion crease line.

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The sciatic nerve divides into tibial and peroneal nerves at a variable level, typically 7–10 cm above the flexion crease, but occasionally as high as the buttock, or below the knee joint.

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It emerges in the popliteal fossa between the biceps femoris laterally, and the semitendinosus/semimembranosus medially.

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Indications:

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  • Surgery of the lower leg, ankle, and foot (in combination with a saphenous block if the skin of the anteromedial aspect of the lower leg or the medial aspect of the ankle or foot is involved)
  • Isolated tibial nerve block for postoperative analgesia after knee surgery (in combination with a continuous femoral block, and GA/spinal for anesthesia, especially if a thigh tourniquet is to be used)

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Contraindications:

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None specific.

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Technique using NS:

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  • Posterior approach:
    • Patient prone or in lateral decubitus, lying on the nonoperative side
    • Mark the flexion crease and the muscles on each side (biceps femoris laterally, semitendinosus and semimembranosus medially)
    • Draw a perpendicular extending cephalad, about 1 cm lateral to the center of the flexion crease line. The needle insertion point is 7 cm cephalad to the flexion crease
    • Insert a 50 mm needle aiming 45° cephalad, setting the PNS at 1.2 mA, 2 Hz, 0.1 millisecond, and elicit a response in the tibial or peroneal innervation territory
    • If a tibial response is obtained, adjust needle position while decreasing current. If a response is still present at 0.4 mA, aspirate and then inject one half of the local anesthetic (typically 10–15 mL) in a fractionated fashion, and redirect needle laterally to obtain a peroneal ...

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