Ultrasound Guided Regional Anaesthesia-

Case series on ‘Dual-View’ technique for sciatic nerve

block via the anterior approach
Azrin Mohd Azidin, Amiruddin Nik Mohamed Kamil,
Department of Anaesthesiology and Intensive Care,
Hospital Kuala Lumpur

Abstract

Background; Identifying sciatic nerve from anterior thigh is difficult due to its depth, inconsistent
surface anatomy and its location posterior to the femur. In this study we evaluated the use of ‘dual
view’ technique in identifiying the sciatic nerve.
Objective; To evaluate the use of ‘dual view’ technique in identifying the sciatic nerve for
ultrasound guided regional block using the anterior approach.
Methods; After obtaining consent from patients, seventeen (17) cases of orthopaedic lower limb
procedures were done under sciatic nerve block via anterior approach. ‘Dual View’ technique
was used, as post operative analgesia or surgical anaesthesia. Data collected include
demographics, use of peripheral nerve stimulator and its electrical responses, types and location
of surgery, and Visual Analogue Scores (VAS) of patients before discharge from recovery.
Results; In all seventeen (17) patients, the sciatic nerve were successfully located using the ‘Dual
View’ technique. The sciatic nerves of seven (7) patients were located without neurostimulation,
while in ten (10) cases, peripheral nerve stimulation were used, with plantar response being the
highest observed. Seven (7) cases were done under purely regional anaesthesia, while ten (10)
cases were combined general anaesthesia with sciatic nerve block. In patients whom sciatic
nerve block were given as post-operative analgesia, all but one (1) yielded good Visual Analogue
Score (VAS) of less than 4 with minimal supplementary short acting opioids. All cases were
orthopaedic below knee procedures.
Conclusion; Based on this small case series, we recommend the use of ‘dual view’ technique to
visualize the sciatic nerve for regional block via the anterior approach.

Introduction
performed with the patient in
Anterior approach to the supine position, particularly
sciatic has several advantages beneficial in patients who have
over the posterior or lithotomy compromised mobility1. However,
techniques. With the anterior identifying sciatic nerve from
approach the block can be anterior thigh is difficult due to its
depth, inconsistent surface in the transverse view. The probe
anatomy and its location is placed antero-medially to the
posterior to the femur, which has femur, and the nerve will appear
made this block one of the least as a distinctly continuous hyper-
popular compared to the other echoic structure with a
approaches2. characteristic fascicular pattern.
When the structure is followed
Ultrasound guided distally, it will be seen to diverge
technique to block the sciatic via to its two branches. This 'diverging
the anterior approach has been highway' appearance will help
previously described as the indicate the point where the
proximal thigh, and the mid-thigh sciatic nerve gives its common
short-axis view approaches3,4. peroneal and tibial branches. The
We have recently observed in our probe can be brought back
sonographic survey of 52 anterior proximally before the point of
thighs, higher success rates in divergence, and the nerve can
identifying the sciatic nerve with be blocked at any point
the anterior approach using ‘Dual proximally throughout its course in
View’ technique compared to the thigh, in its transverse view.
the two conventional transverse
view scans. This technique We have seen that with this
involves using both transverse ‘dual view’ technique, the sciatic
and longitudinal axis views to nerve is easier to identify, and
pinpoint the sciatic nerve. can act as a confirmatory
maneuver in cases which the
Sciatic nerve scans in its sciatic is not well defined.
long-axis view5, help to correctly
identify the location of the nerve,
especially if it is difficult to confirm
Objective Society of Anaesthesiologist (ASA)
Classification I - 3, without any
To evaluate the use of relative or absolute
‘dual view’ technique in contraindication to block
identifying the sciatic nerve for technique or local anaesthetics,
ultrasound guided regional block who consented for this
using the anterior approach. procedure.

Methodology Exclusion criteria

Ultrasound guided regional All patients without consent for

block of the sciatic nerve using regional block, and those with
‘dual view’ technique were relative and absolute
performed on seventeen patients contraindication for block
for orthopaedic procedures of procedure and local
the lower limb, in General anaesthetics.
Operation Theatre of Hospital
Kuala Lumpur. All blocks were After preparation of
done after explanation and anaesthetic equipments and
consent as per clinical indication resuscitative drugs, the patients
for either post operative were put supine under standard
analgesia or as the sole monitoring. Intravenous
anaesthetic technique. Midazolam 1-2 milligrams were
given as sedation before the
block procedure. Patients were
Inclusion criteria placed with the thigh to be
imaged exposed up to the
Patients for orthopaedic lower inguinal region. After sterile
limb procedures with American preparation of the block field and
placement of sterile cover for the the aid of a peripheral nerve
transducer and cable, a curvi- stimulator (Stimuplex DIG BBraun,
linear low-frequency ultrasound Germany). In cases whereby the
probe was placed in its long axis nerve stimulator technique was
view on the antero-medial used, a starting current of 1.2 milli
aspect of the thigh. Confirmation Amperes and a frequency of 2
was by the appearance of Hertz were used initially. Block
continuous longitudinal hyper- needle was advanced and
echoic structure with a visualized under real time, close
characteristic fascicular pattern, to the sciatic nerve, until muscle
which diverges as the probe was twitches in its motor distribution
moved distally. (Diverging was seen. The block needle will
highway sign) Once this was then be maneuvered to maintain
seen, the probe was moved back the same twitch response while
to the point before this stimulating current was reduced
divergence, traced until the most gradually to 0.5 milliAmperes.
proximal point where the image Ropivacaine at a concentration
can be identified clearly, and of 0.375% (for analgesia)or 0.5%
was then rotated back to (for surgical anaesthesia) were
visualize the sciatic nerve in its then deposited around the sciatic
transverse axis (Dual View nerve, Confirmation of successful
Technique). block were done clinically under
real time ultrasound visualization
Blocks were then of local anaesthetic spread, and
performed with 100mm Stimuplex subsequent testing of
insulated stimulating peripheral dermatomal distribution of
nerve block needle (BBraun, sensory loss before the surgical
Germany) using In-Plane procedure was allowed to
approach either with or without proceed. In the event of clinical
suggestion of unsuccessful block, were given at anaesthetic
the surgery was then converted induction with or without muscle
to general anaesthesia at the relaxant, as determined by
discretion of the attending individual case requirement at
anaesthetist. Unsuccessful block is the discretion of the attending
defined as, no reduction in anaesthesiologist. Airway was
sensation in dermatomal secured either by using Laryngeal
distribution of the sciatic nerve to Mask Airway or through
ice pack after 20 minutes of endotracheal tube. Ultrasound
block, or conditions in which the image of the sciatic nerve, and
procedure was not able to be the block procedure was
done under regional block alone performed using the same
after 20 minutes of block technique as described earlier. In
completion. Post-operatively, all patients whom muscle relaxant
patients were then observed in were not administered,
the recovery area as per confirmation of the sciatic nerve
standard block protocol and required the use of peripheral
were allowed to be discharged nerve stimulation before
to the wards once a Post deposition of local anaesthetic. In
Operative Recovery Score of 6 patients whom muscle relaxant
were achieved. were given, perineural spread of
local anaesthetics were guided
In patients whom the by real time visualization alone.
purpose of the regional block was Intraoperative rescue analgesic
for postoperative analgesia, were given at the discretion of
standard monitoring was put in the attending anaesthesiologist
place prior to induction of as required. Postoperative
anaesthesia. Intravenous Fentanyl patients were then observed in
(2ug/kg) and Propofol (2 mg/kg) the recovery area as per
standard block protocol and classification, use of nerve
Postoperative Visual Analogue stimulation with distribution of
Scores were recorded at 10 response and post operative pain
minutes after arrival in the scores at recovery area before
recovery area. All patients were discharge.
allowed discharge to the wards
once achieving Post Operative Results
Recovery Score of 6. Block was
considered successful if the VAS 12 were sonograms of male
score in the recovery area is less thighs and 5 were female. 12
than 4. If VAS score was more patients were Malay, while 2, 2 and
than 4, intravenous rescue 1 were Chinese, Indian and other
analgesia (fentanyl 2ug/kg) was races respectively (chart 1). Mean
given and a proper age, weight and ASA classification
postoperative analgesia plan was are as illustrated in Table 1.
formulated.

Other data recorded were

demographics, weight, ASA
Table 1: Table showing age, weight and ASA classification of patients

Age (years) 37.0

Weight (kg) 63.23

ASA Classification :
ASA 1 12
ASA 2 5
ASA 3 0

As shown in Table 2, All 17 appearances of the sciatic nerve

sciatic nerves were identified were validated with the use of
based on ultrasonic appearance neurostimulation. As for the other 7
using ‘Dual View’ technique. Out of cases, confirmation of successful
those 17 cases, 10 were done in block were done under real time
combination of general ultrasound visualization of local
anaesthesia, and 7 cases were anaesthetic spread, and further
done under pure regional block. In testing of dermatomal distribution
10 patients, sonographic of sensory loss.
Table 2: Number of identified sciatic nerve with block done with and
without validation with nerve stimulator

Number of cases

Sciatic nerve identified based on ultrasound 17

appearance

Block done without neurostimulation 7

Block done with neurostimulation 10

Hamstring stimulation 2
Foot dorsiflexion 3
plantar flexion 5

Table 3: Post Operative Visual Analogue Scores (VAS) for patients

undergoing orthopaedic procedures under combined General
Anaesthesia with Sciatic block

Visual Analogue Scores (VAS) Number of patients

1-2 6

3-4 3

>5 1

Surgical anaesthesia 7
Table 4: Number of patients and the type of surgery done under sciatic
nerve block (performed using ultrasound guided anterior approach with
the ‘Dual View’ technique )

Surgical Procedure Number of cases

Patella Knee arthrotomy 1

Tibia Interlocking 2

Removal of Inplant 4

Plating 2

Below knee amputation 1

Ankle Open reduction Internal fixation 6

Foot Disarticulation of toes 1

Total 17

Discussion have led to this approach being

the least popular technique
Our small series have
among the other approaches2.
demonstrated a high success rate
With the advent of ultrasound,
in identifying and producing
the sciatic nerve can now be
successful blocks of the sciatic
visualized from the anterior thigh
nerve using 'Dual View'
making this approach feasible in
technique. Problems in identifying
certain situations3,4,6,7. High block
the nerve from the anterior thigh
success rates comparable to the
more commonly used posterior Time to onset of block for
approach has also been sciatic nerve varies from 20
documented8 . minutes to an hour depending on
the volume, concentration and
Our previous survey of 52 the type of local anaesthetic
sonograms of the anterior thigh, used. We used 20 minutes as our
showed that 'dual view' cut off point for onset of block for
technique yielded the highest practical purposes. In cases
percentage of identification of wherby there was still no surgical
the sciatic nerve, compared to anaesthesia beyond this point,
the short axis views at the mid- we proceeded with conversion to
thigh and the proximal thigh. general anaesthesia, and
Comparing short axis views at analgesia was assessed
both locations, mid-thigh postoperatively. A successful
approach appears to have block was defined by a VAS
higher success rates of score of less than 4, with minimal
identification. However, blocking opioids usage intraoperatively
the sciatic nerve at this point may (defined as intravenous morphine
be inadequate for certain less than 0.05 mg/kg or last
number of procedures because intravenous fentanyl of more than
of missed proximal branches. With 45 minutes). All patients had
this approach, the depth of the successful blocks of the sciatic
nerve can be identified along its nerve based on those criteria in
course, and injectate can be this series. All patients with
deposited as proximal as possible combined general anaesthesia
covering a larger sensory block and sciatic block had used
distribution. minimal intravenous fentanyl. All
(10) had 100-150 micrograms of
intravenous fentanyl only at
induction. Another 2 (two) During this survey, 10
patients had a total of 200 (58.82%) of the sciatic nerve
microgram of intravenous identified based on ultrasound
fentanyl for a procedure of two appearance, were actually
hours duration. One patient had validated with the use of a nerve
only 2 mg of intravenous stimulator. All target images that
morphine for a procedure of 2.5 appeared to be the sciatic, was
hours duration. All patients electrically identified as responses
except for 1, had a VAS of less in the distribution of sciatic nerve
than 4. The patient that had a supply. This suggests that the
VAS of 5, was clinically relatively structure targeted was the sciatic
comfortable. One patient for nerve, with highest response
screw fixation of lateral malleolus being twitches of the hamstring
done under pure femoral and muscles. When the stimulating
sciatic nerve block had needle was brought to an area
tourniquet pain over the back of close to the inferior surface of the
the thigh but not any other nerve, responses in the foot was
region. This corresponds to the seen. In another 7 (seven) cases,
area supplied by the posterior block was done with local
cutaneous nerve of the thigh anaesthetic deposition and
which comes directly from the spread visualized in real time
lumbar plexus. If the sciatic nerve without neurostimulation.
can be traced more proximally to Successful block was ensured
an area which corresponds to the before start of procedure.
subgluteal region posteriorly, with
adequate volume, the block of
posterior cutaneous nerve of the
thigh may be achieved.
 Anterior

Proximal Distal

Posterior

Figure 1. A longitudinal view of the sciatic nerve with the transducer over
the antero-medial aspect of the thigh. Distally, the sciatic nerve can be
seen to diverge to its branches (‘Diverging highway’ sign)
 Femur

Lateral Medial

Figure 2. A transverse view of the sciatic nerve in the anterior thigh scans
at the proximal thigh using ‘dual view’ technique. The sciatic nerve was
viewed in a longitudinal axis first before having the transducer rotated to
view the sciatic nerve in its transverse axis

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