Techniques in Regional Anesthesia & Pain Management
Volume 7, Issue 1 , Pages 1-2, January 2003

Introduction☆

Article Outline

 

A large proportion of patients undergoing surgery do not receive adequate postoperative analgesia.1 Postoperative pain is the leading cause of unplanned hospital admissions after ambulatory surgery and a major source of dissatisfaction with perioperative outcome.2 The establishment of acute pain services in many institutions both in the United States and overseas has had a major impact on postoperative comfort and patient satisfaction.3, 4 Most acute pain services primarily use patient-controlled intravenous analgesia and/or epidural infusion, however, advances in neuronal blockade offer an unprecedented range of effective and surgery-site specific analgesic options. By using long-acting local anesthetics, peripheral nerve blocks can be used to provide excellent anesthesia and postoperative analgesia. The advent of techniques and equipment for continuous infusion of local anesthetics using catheters inserted perineurally have allowed for extension of the analgesia beyond the duration of the single-shot blocks.

Although relatively infrequently used as sole anesthetic techniques, cutaneous blocks of the lower extremity are useful and an often essential ingredient to success with major conduction blocks. In their article, Drs. Visan and Bartoc discuss the techniques and applications of blocks of the lateral femoral cutaneous, posterior femoral cutaneous, saphenous, sural, and superficial peroneal nerves. These blocks are simple to learn and perform, they essentially are devoid of complications, and they nicely complement the other major conduction blocks of the lower extremity. The combination of their applicability and simplicity should mandate that these blocks be in the armamentarium of every anesthesia practitioner.

The femoral nerve block is an easy to master and highly efficacious regional anesthesia technique, yet remains underused in wider clinical practice.5 Drs. Neilsen, Klein, and Steele in their article summarize anatomy, techniques, equipment and local anesthetic selection, indications, complications, and future developments and clinical outcome studies.6 Although femoral nerve block provides an easy and convenient method to achieve anesthesia and analgesia in the femoral nerve distribution, the lumbar plexus block offers much wider coverage that extends to the entire lumbar plexus.7 In his contribution, Dr. Greengrass outlines methods and tips on how to accomplish lumbar plexus blockade.

When lumbar plexus, femoral, or saphenous blocks are combined with sciatic nerve blocks, a complete anesthesia and postoperative analgesia of the lower extremity can be accomplished. Contrary to common belief, sciatic nerve blocks are relatively simple to master and perform. However, the deep location of the sciatic nerve mandates proper training and thorough knowledge of anatomy. Dr. Chelly in his article shares with us some recent more reliable techniques, as well as an overview of the relevant anatomy of the sciatic nerve.8, 9

There is an increasing trend of using continuous nerve block techniques in patients undergoing same-day surgery. Although this form of analgesia offers significant improvements in pain control after many procedures, multiple factors must be accounted for to provide safe and effective continuous nerve blocks at home. The article by Drs. Ilfeld and Enneking reviews important issues related to ambulatory perineural local anesthetic infusion. In their article they discuss indications for ambulatory continuous nerve block techniques, exclusion criteria, patient education, discharge criteria, patient follow-up, potential complications, documentation, catheter removal, and infusion pump selection.

Applications of plexus and conduction nerve blocks in pediatric patients have increased considerably in recent years as they large scope of indications in virtually all aspects of surgical and procedural pain, including outpatient surgery. Dr. Dalens reviews lower-extremity nerve block techniques in pediatric patients and discusses some recent discoveries supporting the use of neuronal blockade, such as the role of sensitization of the peripheral nervous system in sustaining postoperative and pronociceptive effects of opiods.10-13

It is clear that there is a renewed, growing interest in lower-extremity nerve blocks. This issue of Techniques in Regional Anesthesia & Pain Management discusses some recent developments, advantages, and limitations of various peripheral nerve block techniques both in surgical anesthesia and postoperative pain management applications and takes a look at what the future may look like in this highly specialized subspecialty of anesthesiology.

Back to Article Outline

References 

  1. Rawal N. 10 years of acute pain services—achievements and challenges. Reg Anesth Pain Med. 1999;24:68–73
  2. Gold BS, Kitz DS, Lecky JH, et al.  Unanticipated admission to the hospital following ambulatory surgery. JAMA. 1989;262:3008–3010
  3. Maier C, Kibbel K, Mercker S, et al.  Postoperative pain therapy at general nursing stations. An analysis of eight years experience at an anesthesiological acute pain service. Anaesthetist. 1994;43:385–397
  4. Ready LB. How many acute pain services are there in the US and who is managing patient-controlled analgesia?. Anesthesiology. 1995;82:322; (letter)
  5. Hadzic A, Vloka JD, Kuroda MM, et al.  The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med. 1998;23:241–246
  6. Vloka JD, Hadzic A, Drobnik L. Anatomical landmarks for femoral nerve block: A comparison of four needle insertion sites. Anesth Analg. 1999;89:1467–1470
  7. Capdevila X, Barthelet Y, Biboulet P, et al.  Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91:8–15
  8. Chelly JE, Delaunay L. A new anterior approach to the sciatic nerve block. Anesthesiology. 1999;91:1655–1660
  9. di Benedetto P, Bertini L, Casati A, et al.  A new posterior approach to the sciatic nerve block: A prospective, randomized comparison with the classic posterior approach. Anesth Analg. 2001;93:1040–1044
  10. Dalens BJ. Regional anesthetic techniques. In:  Bissonnette B,  Dalens B editor. Pediatric Anesthesia: Principles and Practice. New York: , McGraw Hill; 2002;p. 528–575
  11. Laulin JP, Celerier E, Larcher A, et al.  Opiate tolerance to daily heroin administration: An apparent phenomenon associated with enhanced pain sensitivity. Neuroscience. 1999;89:631–636
  12. Celerier E, Rivat C, Jun Y, et al.  Long-lasting hyperalgesia induced by fentanyl in rats: Preventive effect of ketamine. Anesthesiology. 2000;92:465–472

☆ Guest Editors

PII: S1084-208X(03)00002-8

doi:10.1053/trap.2003.123523

Techniques in Regional Anesthesia & Pain Management
Volume 7, Issue 1 , Pages 1-2, January 2003

Article Tools