Low Volume and High Concentration of Local Anesthetic Is More Efcacious than High Volume and Low Concentration

in Labats Sciatic Nerve Block: A Prospective, Randomized Comparison

Manuel Taboada Mun iz, MD, PhD* Jaime Rodr guez, MD, PhD* Mar a Bermu dez, MD* Cristina Valin o, MD Noemi Blanco, MD* Marcos Amor, MD* Pilar Aguirre, MD* Ana Masid, MD* Joaquin Cortes, MD, PhD* lvarez, MD, PhD* Julia n A Peter G. Atanassoff, MD
BACKGROUND: Various factors markedly affect the onset time and success rate, of peripheral nerve blockade. This prospective, randomized, double-blind study, compared a dose of mepivacaine 300 mg, in a 20 or 30 mL injection volume for sciatic nerve blockade using Labats posterior approach. METHODS: A total of 90 patients undergoing foot surgery were randomly allocated to receive sciatic nerve block with 20 mL of 1.5% mepivacaine (n 45) or 30 mL of 1% mepivacaine (n 45). All blocks were performed with the use of a nerve stimulator (stimulation frequency 2 Hz; intensity 1.5 0.5 mA). In the two groups, appropriate nerve stimulation was elicited at 0.5 mA and the targeted evoked motor response was plantar flexion of the foot. Time required for onset of sensory and motor block in the distribution of the tibial and common peroneal nerves were recorded. A successful block was defined as a complete loss of pinprick sensation in the sciatic nerve distribution with concomitant inability to perform plantar or dorsal flexion of the foot. RESULTS: A greater success rate was observed with 20 mL of 1.5% mepivacaine (96.6%) than with 30 mL of 1% mepivacaine (68.9%; P 0.05). Time to onset of complete sensory and motor block was shorter after injection of 20 mL of 1.5% mepivacaine (11 6 min and 13 7 min, respectively) than after 30 mL of 1% mepivacaine (17 8 min and 19 8 min, respectively, P 0.05). CONCLUSION: In Labats sciatic nerve blockade, administering a low volume and a high concentration of local anesthetic (1.5% mepivacaine) is associated with a higher success rate and a shorter onset time than a high volume and a low concentration of solution (1% mepivacaine).
(Anesth Analg 2008;107:20858)

arious factors have been shown to affect the success rate in sciatic nerve blockade. These include the intensity of the current at which peripheral nerve stimulation is achieved,1 the type of evoked motor

From the *Department of Anesthesiology, University of Santiago de Compostela, Hospital Cl nico Universitario de Santiago, Spain; Department of Anesthesiology, Hospital Meixoeiro, CHUVI, Vigo, Spain; and Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut. Accepted for publication May 11, 2008. Supported by Institutional and Departmental Sources. The work should be attributed to the University of Santiago de Compostela, Department of Anesthesiology, Hospital Cl nico Universitario de Santiago, Spain. Brief summary statement: Low volume and high concentration of local anesthetic predicts higher success rate than high volume and low concentration during Labats posterior sciatic nerve block. Address correspondence and reprint requests to Manuel Taboada Mun iz, MD, PhD, Department of Anesthesiology, Hospital Cl nico Universitario de Santiago, Traves a da Choupana s/n. 15706 Santiago de Compostela, Spain. Address e-mail to manutabo@yahoo.es. Copyright 2008 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e318186641d

response following nerve stimulation,27 the approach,8 11 number of injections,1215 the use of additives,16 as well as the concentration and volume of the injected local anesthetic.1719 Volume of local anesthetic becomes an important aspect when injected into wide anatomic spaces e.g., the epidural, the axillary, or the popliteal space affecting onset time, extension, success rate, and duration of centroneuraxis and peripheral nerve blockade19 24. In contrast, a more concentrated solution may be required preferably in peripheral nerve blockade involving thick peripheral nerves, e.g., the sciatic nerve.17 This prospective, randomized, double-blind study compared the effect of mepivacaine 300 mg diluted in 20 or 30 mL injection volume for sciatic nerve blockade in Labats posterior approach.

METHODS
The study protocol was approved by the Hospital Ethical Committee and written informed consent was obtained from all participants. Ninety American Society of Anesthesiologists physical status I or II patients, aged 18 80 yr and scheduled for foot and ankle
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surgery under sciatic nerve blockade were included in the study. Exclusion criteria were patient refusal, pregnancy, neurologic or neuromuscular disease, anticoagulation, and skin infection at the site of needle insertion. Before the nerve block, IV access was established and continuous electrocardiogram, noninvasive blood pressure and pulse oximetry were monitored during needle insertion and throughout the surgical procedure. All patients received 12 mg midazolam IV as premedication. Using a sealed envelope technique, patients were randomly assigned to receive 20 mL of mepivacaine 1.5% (n 45) or 30 mL of mepivacaine 1% (n 45). The regional anesthetic technique consisted of modified Labats posterior approach to the sciatic nerve with a single injection of anesthetic solution. Patients were positioned in the lateral decubitus position, with the leg to be blocked uppermost and rolled forward and the knee flexed at a 90-degree angle (Sims position). A line was drawn from the posterior superior iliac spine to the midpoint of the greater trochanter and a second perpendicular line was drawn from the midpoint and extended caudally for 4 cm. This point represented the site of needle insertion. After local skin infiltration, an 8 12 cm, 22-gauge short-beveled stimulating needle (Pajunk, Medizintechnologie, Geisingen, Germany) attached to a nerve stimulator (Pajunk, Medizintechnologie, Germany) was inserted perpendicularly to the skin and advanced until either plantar flexion or dorsiflexion of the foot was obtained. The stimulating current was set initially between 1.5 to 2 mA, and the frequency of stimulation was set at 2 Hz (time 100 s). In case of peroneal nerve stimulation, the needle was withdrawn and redirected more medially. The intensity of the stimulating current was gradually decreased as the needle approached the targeted nerve. A plantar flexion of the foot identified the tibial nerve. This was the evoked motor response elicited in all patients to maintain consistency among groups. Then, 20 mL of mepivacaine 1.5% or 30 mL of mepivacaine 1% was slowly injected after careful intermittent aspirations. When necessary, a supplementary femoral or transsartorial saphenous nerve block with 20 mL of mepivacaine 1.5% was performed. Arterial blood pressure, heart rate, pulse oximetry, and progress of both sensory and motor blockade on the operated limb were evaluated every 5 min after local anesthetic injection for a total of 30 min by an independent blinded observer. Time required for onset of complete motor and sensory block were recorded. Sensory block assessments were performed in the distributions of the common peroneal and tibial nerves i.e., the superficial and deep peroneal nerves, the sural, lateral plantar, medial plantar, and calcaneus plantar nerves (totally six peripheral nerves). The extent of sensory blockade of each nerve was classified as follows: 0 normal sensation in the
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respective nerve distribution (no block), 1 blunted sensation (analgesia), and 2 absence of sensation (anesthesia). Sensory block was considered complete when each sensory testing using pinprick test with a 22-gauge hypodermic needle in the sciatic nerve distributions had a score of 2. When the sensory block score was 2 in any of the nerve distributions at the end of the 30 min assessment period, the sciatic block was considered incomplete. Motor block was assessed for voluntary motor responses by asking the patient to plantarflex or dorsiflex the foot. It was classified as follows: 0 normal movement, 1 decreased movement, and 2 no movement. Motor block was considered complete when motor response in both plantarflexion and dorsiflexion had a score of 2; otherwise it was considered incomplete. The success rate was defined as a complete sensory and motor block associated with a pain free surgery. Patients who did not have complete anesthesia at the surgical site by the end of a 30-min period were given a supplemental lateral popliteal sciatic nerve block14 before the beginning of surgery or general anesthesia was induced if the patient reported pain during surgery.

Statistical Analysis
A power analysis estimated that 43 patients per group would be needed to detect 25% difference in the success rate of sciatic nerve block after injection of 20 mL mepivacaine 1.5% compared with 30 mL mepivacaine 1%, with a two-tailed error of 5% with a statistical power of 80%. Two more patients were included in each group for possible dropouts. Statistical analysis was performed by using the Statistical Package for the Social Sciences (SPSS for Windows, version 10.0; SPSS, Chicago, IL). Data distribution was first evaluated using the KolmogorovSmirnov test. Continuous variables were compared between groups using either two-sampled Students t-test or the Mann-Whitney U-test, depending on data distribution. Discrete variables were compared between groups using a 2 or Fishers exact test when numbers were small. A P value 0.05 was considered statistically significant. Continuous variables are presented as mean sd, and qualitative data are displayed as numbers (percentage).

RESULTS
Ninety patients were enrolled in the study, 45 in each group. There were no significant differences between groups in terms of demographic data such as age, weight, and height or surgical procedures (Table 1). No severe untoward event was reported in any patient. The onset of sensory and motor block was shorter in patients receiving 20 mL of 1.5 mepivacaine than those given 30 mL of 1% mepivacaine (P 0.05, Table 2). A higher success rate was achieved in patients receiving 20 mL of 1.5% mepivacaine (96.6%) as compared to those given 30 mL of 1% mepivacaine (68.9%,
ANESTHESIA & ANALGESIA

Table 1. Demographic Data and Surgical Procedures for Each Study Group 20 mL 1.5% mepivacaine (n 45)
Age (yr) Height (cm) Weight (Kg) Sex (men/women) Surgeries Metatarsal osteotomy Foot ostheosynthesis device removal Ankle ORIF Toe amputation Achilles tendon repair Calcaneal excision/ resection Tibial fracture Others 54 16 164 7 71 9 18/27 15 6 7 3 3 2 2 7

Table 2. Anesthetic Data 20 mL 1.5% mepivacaine (n 45)

Intensity of stimulation (mA) Success rate Onset time of sensory block (min) Superficial peroneal nerve distribution Deep peroneal nerve distribution Sural nerve distribution Calcaneus plantar nerve distribution Lateral plantar nerve distribution Medial plantar nerve distribution Onset time of complete sensory block (min) Onset time of motor block (min) Peroneal nerve distribution (dorsiflexion) Tibial nerve distribution (plantar flexion) Onset time of complete motor block (min) Femoral nerve block preformed Transsartorial saphenous nerve block performed 0.40 0.06 43 (96.6%)* 10 5* 11 6* 85 8 5* 9 5* 10 6* 11 6*

30 mL 1% mepivacaine (n 45)
49 17 162 9 70 9 14/31 18 7 4 4 2 2 1 7

30 mL 1% mepivacaine (n 45)
0.39 0.07 31 (68.9%) 16 7 16 8 11 6 13 7 15 8 17 8 17 8

Data are mean standard deviation or number of patients. There were no statistically signicant differences between the two groups.

P 0.05, Table 2). Supplemental lateral popliteal nerve block became necessary in one patient after injection of the more concentrated solution and in six patients given 30 mL of 1% mepivacaine (P ns). A general anesthetic was administered in one patient after 20 mL of 1.5% mepivacaine and in four patients after 30 mL of 1% mepivacaine (P ns).

13 7* 13 7* 13 7* 30 (66.7%) 10 (22.2%)

18 8 19 8 19 8 27 (60%) 11 (24.4%)

DISCUSSION
This randomized, double-blind investigation demonstrated both a shorter latency and a higher success rate in achieving complete sensory and motor blockade of the sciatic nerve after injection of a more concentrated when compared to a more dilute local anesthetic solution. The approach to the sciatic nerve, the intensity of the nerve stimulating current, or the type of evoked motor response remained the same in the two groups. Only the varied volume and concentration of local anesthetic administered may then explain the results obtained. The total injected volume of local anesthetic solution is a crucial factor affecting the success rate of peripheral nerve blockade.19,21 Different volumes of local anesthetic have been used to block the sciatic nerve.8,9,11,12 It could be shown that a large volume of local anesthetic is necessary at a popliteal level compared with a subgluteal level.22 Separation of the two trunks of the sciatic nerve, as well as fat and multiple layers of connective tissue within the popliteal space may explain the larger volume necessary when a popliteal sciatic block is performed. However, in the current study, we used a gluteal (Labats) approach, where the sciatic nerve is surrounded by compact structures such as bone and muscles with a minimal amount of connective tissue. This sciatic anatomy where the anatomic structures surrounding the sciatic
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Data are mean standard deviation or number of patients and percentage. *P 0.05.

nerve are minimally compliant, may explain the high success rate obtained in the present investigation after a single injection of small amount of local anesthetic. Concentration of local anesthetic is another important factor that may influence in success rate and onset time of sciatic nerve blockade. The penetration of local anesthetic molecules into nerve roots is affected by the concentration of the local anesthetic solution.17 Increasing the local anesthetic concentration around the sciatic nerve increases the concentration gradient, facilitating the diffusion of local anesthetic molecules into the nerve and shortening the onset of nerve block. The size of the sciatic nerve at gluteal level (1.52 cm), and the thickness of its epineurium may explain the inability of the local anesthetic to completely penetrate the nerve when low concentration of local anesthetic is used. The anatomical aspects are supported by a recent investigation performed by Cappelleri et al.25 who used an up-and-down staircase method to determine the appropriate concentration of local anesthetic comparing a subgluteal with a popliteal approach to
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the sciatic nerve. Capelleri et al. observed that different concentrations of mepivacaine became necessary at the two injection sites. Injecting 30 mL of mepivacaine at a more proximal subgluteal level, the concentration required to block the sciatic nerve in 95% of patients was 1.12%, in contrast to 1.98% at the popliteal level. As described previously, anatomy at the two injection sites may play a crucial role in explaining the differences in concentrations. The comparatively more proximal subgluteal level similar to the gluteal access performed in the present study displays a tighter anatomy than the more distal popliteal level; thus higher volumes and/or concentrations become necessary at the latter injection site.22,25 To improve the success rate in peripheral nerve blocks with low volume of local anesthetic, same investigators have suggested a multiple injection technique.12 Others have suggested using ultrasound guidance to secure an accurate needle position and monitor the distribution of the local anesthetic solution, with reported smaller volumes of local anesthetic required to produce a successful block compared with nerve stimulation alone.26 One deficiency of present study is that we did not assess duration of blockade. This parameter would be interesting to increase the value of the investigation. In conclusion, the present investigation showed that in sciatic nerve blockade lower volume and higher concentration of local anesthetic (1.5% mepivacaine) increased the success rate of neural blockade and decreased the onset time of complete sensory and motor blockade when compared to a more diluted solution (1% mepivacaine). The ability to extrapolate these results to other local anesthetics and peripheral injection sites is unknown. REFERENCES
1. Vloka JD, Hadzic A. The intensity of the current at which sciatic nerve stimulation is achieved is more important factor in determining the quality of nerve block than the type of motor response obtained. Anesthesiology 1998;88:1408 10 2. Benzon HT, Kim C, Benzon HP, Silverstein ME, Jericho B, Prillaman K, Buenaventura R. Correlation between evoked motor response of the sciatic nerve and sensory blockade. Anesthesiology 1997;87:54752 lvarez J, Corte 3. Taboada M, A s J, Rodr guez J, Atanassoff PG. Lateral approach to the sciatic nerve block in the popliteal fossa: correlation between evoked motor response and sensory block. Reg Anesth Pain Med 2003;28:450 5 4. Sukhani R, Nader A, Candido KD, Doty R Jr, Benzon HT, Yaghmour E, Kendall M, McCarthy R. Nerve stimulatorassisted evoked motor response predicts the latency and success of a single-injection sciatic block. Anesth Analg 2004;99:584 8 5. Taboada M, Atanassoff PG, Rodr guez J, Corte s J, Del Rio S, Lagunilla J, Gude F, Alvarez J. Plantar flexion seems more reliable than dorsiflexion with Labats sciatic nerve block: a prospective, randomized comparison. Anesth Analg 2005;100: 250 4 6. Pianezza A, Gilbert ML, Minville V, Filsinger D, Gobert Q, Gue rot A, Fuzier R, Fourcade O. A modified mid-femoral approach to the sciatic nerve block: a correlation between evoked motor response and sensory block. Anesth Analg 2007;105:528 30 7. Hagon BS, Itani O, Bidgoli JH, Van der Linden PJ. Parasacral sciatic nerve block: does the elicited motor response predict the success rate? Anesth Analg 2007;105:263 6

lvarez J, Corte 8. Taboada M, A s J, Rodr guez J, Rabanal S, Gude F, Atanassoff A, Atanassoff PG. The effects of three different approaches on the onset time of sciatic nerve blocks with 0.75% ropivacaine. Anesth Analg 2004;98:2427 9. Fournier R, Weber A, Gamulin Z. Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia. Acta Anaesthesiol Scand 2005;49:683 6 10. Taboada M, Rodr guez J, Del Rio S, Lagunilla J, Carceller J, Alvarez J, Atanassoff PG. Does the site of injection distal to the greater trochanter make a difference in lateral sciatic nerve blockade? Anesth Analg 2005;101:1188 91 11. Cuvillon P, Ripart J, Jeannes P, Mahamat A, Boisson C, LHermite J, Vernes E, de la Coussaye JE. Comparison of the parasacral approach and the posterior approach, with singleand double-injection techniques, to block the sciatic nerve. Anesthesiology 2003;98:1436 41 12. Bailey SL, Parkinson SK, Little WL, Simmerman SR. Sciatic nerve block. A comparison of single versus double injection technique. Reg Anesth 1994;19:9 13 13. Paqueron X, Bouaziz H, Macalou D, Labaille T, Merle M, Laxenaire MC, Benhamou D. The lateral approach to the sciatic nerve at the popliteal fossa: one or two injections? Anesth Analg 1999;89:12215 14. Taboada M, Alvarez J, Corte s J, Rodr guez J, Atanassoff PG. Is a double-injection technique superior to a single injection in posterior subgluteal sciatic nerve block? Acta Anaesthesiol Scand 2004;48:8837 15. March X, Pineda O, Garcia MM, Carame s D, Villalonga A. The posterior approach to the sciatic nerve in the popliteal fossa: a comparison of single- versus double-injection technique. Anesth Analg 2006;103:15713 16. Bernard JM, Macaire P. Dose-range effects of clonidine added to lidocaine for brachial plexus block. Anesthesiology 1997;87: 277 84 17. Casati A, Fanelli G, Borghi B, Torri G. Ropivacaine or 2% mepivacaine for lower limb peripheral nerve blocks. Anesthesiology 1999;90:104752 18. Taboada M, Corte s J, Rodr guez J, Ulloa B, Alvarez J, Atanassoff PG. Lateral approach to the sciatic nerve in the popliteal fossa: a comparison between 1.5% mepivacaine and 0.75% ropivacaine. Reg Anesth Pain Med 2003;28:516 20 19. Vester-Andersen T, Husum B, Lindeburg T, Borrits L, Gthgen I. Perivascular axillary block IV: blockade following 40, 50 or 60 mL of mepivacaine 1% with adrenaline. Acta Anaesthesiol Scand 1984;28:99 105 20. Rucci FS, Barbagli R, Pippa P, Boccaccini A. The optimal dose of local anesthetic in the orthogonal two-needle technique. Extent of sensory block after the injection of 20, 20 and 40 mL of anesthetic solution. Eur J Anaesthesiol 1997;14:281 6 21. Shirmek F, Deusch H. New technique of sciatic nerve block in the popliteal fossa. Eur J Anaesthesia 1995;12:1639 22. Taboada M, Rodriguez J, Valin o C, Carceller J, Bascuas B, Oliveira J, Alvarez J, Gude F, Atanassoff PG. What is the minimum effective volume of local anesthetic required for sciatic nerve blockade? A prospective, randomized comparison between a popliteal and a subgluteal approach. Anesth Analg 2006;102:5937 23. Nakayama M, Yamamoto J, Ichinose H, Yamamoto S, Kanaya N, Namiki A. Effects of volume and concentration of lidocaine on epidural anesthesia in pregnant females. Eur J Anaesthesiol 2002;19:808 11 24. Krenn H, Deusch E, Balogh B, Jellinek H, Oczenski W, PlainerZo chling E, Fitzgerald RD. Increasing the injection volume by dilution improves the onset of motor blockade, but not sensory blockade of ropivacaine for brachial plexus block. Eur J Anaesthesiol 2003;20:215 25. Cappelleri G, Aldegheri G, Ruggieri F, Mamo D, Fanelli G, Casati A. Minimum effective anesthetic concentration (MEAC) for sciatic nerve block: subgluteus and popliteal approaches. Can J Anaesth 2007;54:2839 26. Casati A, Baciarello M, Di Cianni S, Danelli G, De Marco G, Leone S, Rossi M, Fanelli G. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth 2008;98:8237

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