Surg Radiol Anat (2011) 33:9195 DOI 10.

1007/s00276-010-0709-2

O R I G I N A L A R T I CL E

A new lateral approach to the parasacral sciatic nerve block: an anatomical study
Thomas Le Corroller Rodolphe Wittenberg Vanessa Pauly Nicolas Pirro Pierre Champsaur Olivier Choquet

Received: 27 May 2010 / Accepted: 24 July 2010 / Published online: 5 August 2010 Springer-Verlag 2010

Abstract Background Sciatic nerve block is a commonly used technique for providing anesthesia and analgesia to the lower extremity. At the parasacral level, the nerve block is classically performed via a posterior approach in lateral decubitus position causing patients discomfort. Therefore, we aimed to conduct an anatomical study describing a new lateral approach to the parasacral sciatic nerve in supine position. Methods The skin entry point was located on the vertical line through the greater trochanter (GT) at the midpoint between the anterior superior iliac spine (ASIS) level and the GT. The angle to the skin was 10 dorsally oriented. According to these palpable anatomical landmarks, the parasacral lateral approach was simulated bilaterally in four cadavers in supine position. Anatomical dissection allowed assessment of the needle tip position with regard to the sciatic nerve. Then, to reWne the anatomical description of this new lateral approach, 40 pelvic computer tomography (CT) examinations were retrospectively selected and

post-processed to bilaterally simulate the needle route to the sciatic nerve. The skinnerve distance, the optimal angle to the skin, and the sciatic nerve anteroposterior diameter at parasacral and ischial tuberosity levels, respectively were recorded by two independent readers. Results Cadaver dissection showed that the needle tip was placed in the vicinity of the sciatic nerve in 8/8 cases. Then, CT-simulated lateral approach demonstrated a mean skin nerve distance of 128 mm (81173), and a 12 dorsally oriented (522) optimal angle to the skin. The sciatic nerve anteroposterior diameter was 10 mm (715) at the parasacral level, and 7 mm (510) more caudally at the ischial tuberosity level. No signiWcant intra- or inter-observer variability was observed. Conclusion This study describes a new lateral approach to the parasacral sciatic nerve block in supine position. These anatomical results should be conWrmed by further clinical studies. Keywords Sciatic nerve block Sacral plexus Lateral approach Anesthesia

T. Le Corroller (&) N. Pirro P. Champsaur Laboratoire dAnatomie, Facult de Mdecine de Marseille, 27 Boulevard Jean Moulin, 13005 Marseille, France e-mail: Thomas.LeCorroller@ap-hm.fr T. Le Corroller P. Champsaur Service de Radiologie, Hpital Sainte Marguerite, 13009 Marseille, France R. Wittenberg O. Choquet Dpartement dAnesthsie-Ranimation, Hpital de la Conception, 13005 Marseille, France V. Pauly DIM, Hpital Sainte Marguerite, 13009 Marseille, France

Introduction Sciatic nerve block is a commonly used technique for providing anesthesia and analgesia to the lower extremity [5, 7]. This nerve block may be performed at various anatomical levels from pelvis to popliteal fossa [12]. The parasacral approach is widely used for sciatic nerve block in lower limb trauma and surgery [3, 8, 9, 11]. The parasacral injection not only ensures sciatic nerve blockade, but also spreads to the pelvic portion of the obturator nerve and to the sacral roots [14]. It is classically performed via a posterior approach that requires lateral decubitus position

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potentially causing patients discomfort. A lateral approach that would not require moving a supine patient may be of beneWt, especially in trauma cases [2, 13]. Then, the aim of this study was to describe a new lateral approach to the parasacral sciatic nerve block in human cadavers, and to reWne its anatomical description on the basis of CT scan data obtained in a routinely evaluated population.

CT study To reWne the anatomical description of this new lateral approach, a total of 40 consecutive patients (24 men, 16 women; mean age 54 years; age range 1788 years) who underwent in our institution a CT examination including the pelvic region were retrospectively selected for the period between July 2008 and August 2008. Agreement to use the CT data for scientiWc purpose was obtained from each patient. None of these patients had any traumatic or surgical past history. The mean height and weight in the evaluated population were 170.7 cm (152188) and 73 kg (44127), respectively. All CT scans were acquired in supine position by multislice CT (LightSpeed 16, GE Medical Systems, Milwaukee), with routine parameters (slice thickness 1.25 mm, kV 120140, mA 250380). These CT examinations consisted of either abdominal or combined thoracic and abdominal examinations for the purpose of internal or urological diagnosis. All CT examinations were independently analyzed by a staV radiologist with 7 years of experience and an anesthesiologist. CT post-processing was performed on a dedicated workstation (AW Volume Share 2, GE Medical Systems, Milwaukee). First, the site of needle insertion had to be selected on the basis of the same bony landmarks described in the cadaver study. Then, the needle route to the sciatic nerve was simulated bilaterally to determine the skinnerve distance and the optimal angle to the skin. In addition, the sciatic nerve anteroposterior diameter was recorded at the parasacral and ischial tuberosity levels, respectively. The readers were blinded to the patients identity; and, to evaluate the intra-observer variation, each reader performed these measurements twice with a minimum 2-week interval between the two assessments. Statistical analysis was performed using SPSS 15.0 for Windows. Intra- and inter-observer variabilities were assessed using ANOVA test, ACOVA test, and intraclass correlation coeYcient. The minimum probability level for accepting signiWcance (p) was set at 0.05.

Methods Anatomical study This study was conducted bilaterally on four mature adult cadavers (2 males, 2 females; mean age 74 years) embalmed with Wincklers solution (containing 10 L water, 3 L 95% ethanol, 0.5 L formalin, 400 g chloral hydrate, 350 cc glycerin, 330 g sodium sulfate, 250 g potassium nitrate, 200 g zinc chloride). None of these cadavers had any evidence of prior surgery or pathology of the thigh or pelvis. First, the skin entry point was deWned according to bony landmarks easily palpable in supine position. The greater trochanter (GT) and the anterior superior iliac spine (ASIS) were identiWed and then marked. The selected site of needle insertion was located on the vertical line drawn with a marker directly above the GT, at the midpoint between the level of the ASIS and the GT (Fig. 1). A 16gauge 150-mm needle was inserted with a 10 dorsal angle to the skin. If bone contact occurred before the needle was fully inserted, the needle was oriented with a slight more dorsal and more caudal angle of 5. Finally, the cadavers were placed in prone position for anatomical dissection. The gluteal region was opened to observe the location of the needle with respect to piriformis and gluteal muscles. Careful bilateral dissection exposed the sciatic nerve in the infrapiriformis foramen and roots of the sacral plexus without disturbing the adjacent anatomical structures.

Results Anatomical Wndings Cadaver dissection was performed bilaterally in prone position. The needle penetrated through the skin, the gluteal fascia, the gluteus medius muscle and inferior Wbers of piriformis, and reached the sciatic nerve in the infra-piriformis foramen in 8/8 cases (Fig. 2a, b). In all cases, the inferior gluteal nerve and posterior cutaneous nerve of the thigh emerged close to the needle tip. In 2/8 cases, the needle tip

Fig. 1 The selected site of needle insertion (black cross) was located on the vertical line drawn with a marker directly above the greater trochanter (b), at the midpoint between the level of the anterior superior iliac spine (a) and the greater trochanter

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Fig. 2 a Anatomical dissection of the gluteal region showing the piriformis muscle (P), gluteus medius muscle (GM), greater trochanter level (GT), and sciatic nerve (arrowhead). The needle goes through the skin, gluteal fascia, gluteus medius muscle and inferior Wbers of piriformis to reach the sciatic nerve in the infra-piriformis foramen. b After gluteus medius muscle resection, the needle tip is shown penetrating the sciatic nerve itself (arrowhead) and separating tibial and common Wbular Wbers. The inferior gluteal nerve (thick arrow) emerges close to the needle tip

penetrated the sciatic nerve itself separating tibial and common Wbular Wbers. In 1/8 cases, as bone contact occurred before the needle was fully inserted, the needle was oriented with a slight more dorsal and more caudal angle of 5 to reach the infrapiriformis foramen. CT Wndings The mean skinnerve distance was 128 mm (81173) (Fig. 3a; Table 1). This distance was correlated with the patients height (p < 0.005) and weight (p < 0.005). The optimal angle to the skin was 12 dorsally oriented (522) (Fig. 3a; Table 1). Interestingly, a negative correlation was observed between the angle value and the patients weight (p < 0.005). No signiWcant correlation was found with the patients height. The sciatic nerve anteroposterior diameter was 10 mm (715) at the parasacral level, and 7 mm (510) more caudally at the ischial tuberosity level, respectively (Fig. 3b, c;

Fig. 3 a CT scan horizontal image showing the needle route (line) simulated from the skin surface to the sciatic nerve. b, c CT scan horizontal images demonstrating the sciatic nerve (circle) at the parasacral and ischial tuberosity levels, respectively

Table 2). The anteroposterior diameter of the sciatic nerve was signiWcantly higher at the parasacral level than at the ischial tuberosity level (p < 0.005).

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94 Table 1 CT Wndings (angle to the skin and skinnerve distance) Angle to the skin () Mean SD Min Max 11.93 4.148 5 22 Skinnerve distance (mm) 127.71 19.448 81 173

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Table 2 CT Wndings (anteroposterior diameter of the sciatic nerve at the parasacral and ischial tuberosity levels) Parasacral level (mm) Mean SD Min Max 10.1 1.4 7 15 Ischial tuberosity level (mm) 6.8 1.2 5 10

No signiWcant intra- or inter-observer variability was observed for the skinnerve distance, optimal angle to the skin, and sciatic nerve anteroposterior diameter at both parasacral and ischial tuberosity levels.

Discussion Several approaches to the sciatic nerve block have been described [57, 12]. The most frequently performed are probably the Labats classical posterior approach and its modiWcation by Winnie et al. [4, 15]. Another approach to the sciatic nerve providing a high success rate, the posterior parasacral approach, was described by Mansour [8, 9]. The parasacral approach attempts to place the local anesthetic near the sacral plexus. Hence, as the nerves comprising the plexus converge toward the lower part of the sciatic foramen, the parasacral technique targets the sacral plexus just before it emerges as the sciatic nerve below the piriformis muscle [10]. Then, the parasacral block may be considered the only true sacral plexus block [6, 8, 9]. It not only ensures an eYcient sciatic nerve blockade, but also consistently spreads to the inferior and superior gluteal nerves [14]. Nevertheless, the classical parasacral nerve block requires a lateral decubitus position potentially causing patients discomfort. The new lateral approach to the parasacral nerve block we describe here is performed in supine position, which may be of beneWt especially in trauma cases [2, 13]. During the anatomical part of our study, the GT and ASIS bony landmarks were easily palpable in all cases. The needle orientation was slightly dorsal, with an optimal angle to the skin of 10 to reach the infrapiriformis foramen. Here,

please note that, if bone contact occurred before reaching the infrapiriformis foramen, then the needle had to be oriented with a slight more dorsal and more caudal angle of 5. So, the lateral approach can be expected to require a short time only to perform. Hopefully, this new technique will signiWcantly decrease patients discomfort and pain during application of the block to achieve a similar quality of nervous blockade in comparison with the previously described posterior approach. Besides, albeit not documented with the parasacral block, some concerns might be expressed about the risk of penetrating pelvic structures with the needle. This theoretical complication that would be related to an excessively dorsal orientation was not observed in this study. Hence, as the mean distance to the rectum measured during our CT-simulated procedures was more than 200 mm, the lateral approach appears undoubtedly safe with regard to the pelvic structures. The CT-based part of our study provided us with additional data that helped reWning the anatomical description of this new lateral approach. The mean skinnerve distance was logically related to the patients height and weight. Interestingly, the angle to the skin was correlated with the patients weight. These data suggest that the operator should take account of each patients morphology to optimize needle positioning. Besides, the anteroposterior diameter of the sciatic nerve was signiWcantly higher at the parasacral level than at the ischial tuberosity level, which suggests that the target is larger when using the parasacral approach than with the infragluteal approach. Some limitations may be considered inherent to the materials and methods used in this study. First of all, the population evaluated in the anatomical study was limited with eight procedures performed only. Then, for obvious reasons, the correct location of the needle was not conWrmed as it could be in clinical practice with electric nerve stimulation in the evaluated cadavers. In the same way, ultrasonography, that has been reported as useful to locate the sacral plexus, was not evaluated in our work [1]. The needle was positioned using external anatomical landmarks and potential contacting bone exclusively. Besides, in comparison with the classical posterior approach, the new lateral approach to the sciatic nerve block presented both anatomically and radiologically a longer skin to nerve distance with a mean value of 128 mm. Finally, as in most anatomical works, the results obtained should be conWrmed by further clinical studies. In conclusion, this anatomical and radiological study demonstrated that the parasacral sciatic nerve block can be easily and safely performed using a lateral approach according to palpable bony landmarks. Hopefully, this new lateral approach will decrease patients discomfort during application of the block and provide a similar quality of neural blockade as the classical posterior approach. These

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95 6. Hagon BS, Itani O, Bidgoli JH, Van der Linden PJ (2007) Parasacral sciatic nerve block: does the elicited motor response predict the success rate? Anesth Analg 105:263266 7. Liu SS, Salinas FV (2003) Continuous plexus and peripheral nerve blocks for postoperative analgesia. Anesth Analg 96:263272 8. Mansour NY (1993) Reevaluating the sciatic nerve block: another landmark for consideration. Reg Anesth 18:322323 9. Morris GF, Lang SA, Dust WN, Van der Wal M (1997) The parasacral sciatic nerve block. Reg Anesth 22:223228 10. OConnor M, Coleman M, Wallis F, Harmon D (2009) An anatomical study of the parasacral block using magnetic resonance imaging of healthy volunteers. Anesth Analg 108:17081712 11. Ripart J, Cuvillon P, Nouvellon E, Gaertner E, Eledjam JJ (2005) Parasacral approach to block the sciatic nerve: a 400 case survey. Reg Anesth Pain Med 30:193197 12. Tran D, Clemente A, Finlayson RJ (2007) A review of approaches and techniques for lower extremity nerve blocks. Can J Anaesth 54:922934 13. Uz A, Apaydin N, Cinar SO, Apan A, Comert B, Tubbs RS, Loukas M (2010) A novel approach for anterior sciatic nerve block: cadaveric feasibility study. Surg Radiol Anat [Epub ahead of print] 14. Valade N, Ripart J, Nouvellon E, Cuvillon P, Prat-Pradal D, Lefrant JY et al (2008) Does sciatic parasacral injection spread to the obturator nerve? An anatomic study. Anesth Analg 106:664667 15. Winnie AP, Ramamurthy S, Durrani Z, Radonjic R (1974) Plexus blocks for lower extremity surgery. Anesthesiol Rev 1:1116

anatomical results should be conWrmed by further clinical studies.

ConXict of interest The authors declare no conXict of interest.

References
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