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Proximal sciatic nerve blocks

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Proximal sciatic nerve blocks target the nerve where it emerges from the lower pelvis. Here, various means of access are possible. In most patients, the two branches of the sciatic nerve – the tibial nerve and the common peroneal nerve – are still united in the gluteal region or, at least, are located very close together. It is also of clinical relevance that proximal sciatic nerve blocks reach the posterior femoral cutaneous nerve. For that reason, to achieve full analgesia of the leg, it is sensible to combine the proximal sciatic nerve block with a lumbar plexus block (psoas or femoral).

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Parasacral approach (according to Mansour)

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Anatomical landmarks

Posterior superior iliac spine, ischial tuberosity, (greater trochanter)

parasacral

Transgluteal approach (according to Labat)

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Anatomical landmarks

Posterior superior iliac spine, greater trochanter, sacral hiatus, ischial tuberosity

transgluteal

Indications / Contraindications / Side effects

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Indications

Surgical interventions on the dorsal thigh, lower leg (not in the supply area of the saphenous nerve), whole foot, pain management. In combination with psoas compartment block/femoral nerve block for operations on the whole leg below the hip.

 

Contraindications

No specific

 

Side effects/complications

Vessel puncture (inferior gluteal artery)

Subtrochanteric approach (according to Guardini)

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subtrochantaer2As with the anterior approach to the sciatic nerve, the subtrochanteric approach offers the advantage that it does not require painful repositioning of the patient, for example secondary to trauma or fractures. Another even greater advantage over the anterior approach, we believe, is the low puncture depth into the nerves and the fact that no vulnerable structures are located in or along the puncture channel.

Ultrasound-guided proximal sciatic block

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One form of proximal sciatic nerve block which is relatively easy to perform involves a subgluteal, lateral approach to the nerve. This technique is reminiscent of the „classical“ subtrochanteric access (see the respective section). For a good display of the nerve along its course on the dorsal side of the thigh, it is appropriate to elevate the lower leg of the patient with a positioning aid (e.g. an arm rest). In most cases it is easy to track the sciatic nerve from the popliteal space in a proximal direction. The primary anatomic landmark here is the long head of the femoral biceps muscle, below which the nerve passes on its mediolateral path.

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Anterior approach (according to Meier)

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anterior ischiadicus detailThe anterior approach to the sciatic nerve is advantageous in patients who cannot be reasonably placed in the lateral recumbent position due to pain or their condition.

Indications / Contraindications / Side effects

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Indications

Surgical interventions on the dorsal thigh, lower leg (not in the supply area of the saphenous nerve), whole foot, pain management. In combination with psoas block/femoral nerve block for operations on the whole leg below the hip.

 

Contraindications

No specific

 

Side effects/complications

Vessel puncture (femoral artery, profunda femoris artery), Neural injury (femoral nerve or its branches)

Anterior access (based on Wiegel et al.)

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anterior ischiadicus wiegel detailAnother option which has proven useful for anterior sciatic nerve block in practice is the ‚Wiegel‘ technique. Accidental puncture of blood vessels is relatively rare with the anterior access variant described below.

Ultrasound-guided anterior sciatic approach

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anterior ischiadicus sono detailThe patient lies supine; the leg to be blocked is slightly to the side and is rotated at the hip towards the outside.

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