Sural Nerve Block

http://emedicine.medscape.com/article/83199-overview

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Sural Nerve Block

Author: Heather Tassone, DO; Chief Editor: Meda Raghavendra (Raghu), MD more... Updated: Sep 17, 2013

Overview
Background
Practitioners in the emergency department frequently encounter patients who have sustained trauma to the lower leg or foot and require anesthesia for repair. The regional sural nerve block allows for rapid anesthetization of the posterolateral calf and laterodorsal foot, including part of the dorsal fifth digit. Regional blocks have several advantages compared to local infiltration, such as fewer injections required to attain adequate anesthesia, smaller volume of anesthetic required, and less distortion of the wound site.[1] Because of the lower number of injections, regional block is better tolerated by the patient and limits the chance of a needle stick injury to the provider. This procedure, often overlooked in the emergency department, is safe, is relatively easy to perform, and can provide excellent anesthesia to the foot and lower leg.[2] In one study, regional anesthesia of the foot and ankle, when performed by surgeons, was completely successful 95% of the time.[3] Because the sural nerve is relatively superficial, it is easily blocked at multiple levels at or above the ankle. In fact, because the nerve is so accessible, sural nerve biopsy specimens have been used to study inflammatory demyelinating peripheral neuropathies.[4]

Indications
Indications for sural nerve block include the following: Wound repair or exploration of the lateral posterior calf or dorsolateral fifth digit As part of an ankle block required to manipulate a fractured or dislocated ankle Incision and drainage of an abscess in the lateral posterior calf or laterodorsal fifth digit Removal of a foreign body in the lateral posterior calf or dorsolateral fifth digit A combination of posterior tibial, saphenous, superficial peroneal, deep peroneal, and sural nerve blocks results in complete block of sensory perception beneath the ankle (see the image below).

Areas of anesthetization to complete an ankle block. This block requires anesthetization of 5 nerves for complete sensory block below the ankle. The areas to anesthetize include a line along the anterior ankle for the superficial peroneal nerve (blue line), the deep

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peroneal nerve (red star), the saphenous nerve (pink star), the sural nerve (green arrow), and the posterior tibial nerve (orange arrow).

Contraindications
Contraindications to sural nerve block include the following: Allergy to anesthetic solution or additives (eg, ester, amide) Injection through infected tissue Severe bleeding disorder or coagulopathy Preexisting neurological damage Patient uncooperativeness (pediatric or elderly patients may need sedation)

Technical Considerations
Procedure Planning Understanding the arborization of the sural nerve is crucial to a regional block of this nerve. The sural nerve has a contribution from both the tibial nerve and the common peroneal nerve, each of which originates from the sciatic nerve. The contribution from the tibial nerve is the medial sural cutaneous nerve; the common peroneal nerves contribution is the sural communicating branch. These two contributions come together to form the sural nerve, which arises in the popliteal fossa and courses superficially after piercing the deep fascia in the posterior calf (see the image below).

The sural nerve as it travels down the posterior calf.

The sural nerve continues down the posterior calf and supplies the skin of the posterolateral lower third of the lower leg. Entering the foot posterior to the lateral malleolus, this nerve supplies the lateral aspect of the foot, including the lateral fifth digit, via the lateral dorsal cutaneus nerve. It supplies the lateral heel via the lateral calcaneal branches. See the images below.

Sural nerve dermatome at the level of the posterior calf.

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Sural nerve dermatome at the level of the sole of the foot.

Complication Prevention Infection occurs when the puncture site is not clean. Avoid puncture through infected skin or skin lesion. Be sure to use sterile technique during the procedure, as the risk of infection is insignificant when sterility is properly maintained. Intra-arterial injection[5] may result in vasospasm and lead to ischemia of the limb tissue. Intravenous injection can lead to systemic toxicity in high doses. Tissue texture changes revealing pallor, bogginess, and cool temperature may indicate that either intravascular injection or vascular compression has occurred. Always draw back on the plunger of the syringe prior to injection to ensure that intravascular placement has not taken place. Alpha-adrenergic antagonists (eg, phentolamine 0.5-5 mg diluted 1:1 with NaCl 0.9%) can be administered by local infiltration to relieve arterial vasospasm secondary to intra-arterial injection.[6] Patients may develop paresthesia, sensory deficits, or motor deficits secondary to inflammation of the nerve. Most often, this type of neuritis is transient and resolves completely. During the procedure, pull back gently after inducing a paresthesia so as to not inject the nerve directly. Make sure to document a complete neuromuscular examination both before and after the procedure.[7] Reports of significant hemorrhage during regional anesthesia are rare, even in patients with blood coagulopathies.[8] A hematoma may develop with intravascular puncture. If prolonged bleeding occurs, apply direct pressure and elevate the limb. Allergic reactions to local anesthetics occur at a rate of 1%.[6, 9] Reactions range from delayed hypersensitivity (type IV) to anaphylactic (type I).[10] Although rare, the most common cause of such allergic reaction is the preservative in the local anesthetic solution. Preservative-free lidocaine (found in cardiac preparations) is an alternative because it does not contain the preservative. Alternatively, a 1-2% diphenhydramine solution can be used as a local anesthetic.[6] The dose of 1% lidocaine without epinephrine should not exceed 5 mg/kg. If lidocaine with epinephrine is used, total dose should not exceed 7 mg/kg. Systemic toxicity manifests in the central nervous and cardiovascular systems.[9, 11] Signs such as tremors, convulsions, tachycardia, or respiratory compromise should alert the physician to stop the procedure and reassess the patient.

Periprocedural Care
Patient Education & Consent
Explain the procedure, benefits, risks, and complications to the patient and/or patients representative, and inform the patient of the possibility of paresthesia during the procedure. Obtain informed consent in accordance with hospital protocol.

Equipment
Equipment for sural nerve block includes the following: Needle, 4 cm, 25 G Needle, 18 G Syringe, 10 mL Marking pen Sterile gloves Antiseptic solution (eg, povidone iodine [Betadine] or chlorhexidine gluconate [Hibiclens]) with skin swabs Alcohol swabs Sterile drape Lidocaine 1%, 10 mL Facial mask with eye shield

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Sterile gauze Equipment is shown in the image below.

Equipment needed for regional block.

Patient Preparation
Anesthesia The 2 main classes of local anesthetics currently in use are amino esters and amino amides. Both inhibit ionic fluxes required for the initiation and conduction of nerve impulses.[12] Lidocaine, the most commonly used anesthetic, has a fast onset of action and a duration of action of 30-120 minutes, which is increased to 60-400 minutes with the addition of epinephrine. The total cumulative dose of lidocaine to be infiltrated is 5 mg/kg (not to exceed 300 mg) if lidocaine without epinephrine is used, and 7 mg/kg (not to exceed 500 mg) if lidocaine with epinephrine is used. Anesthetic preparations that contain epinephrine are commonly used in the emergency department. Epinephrine induces vasoconstriction, which decreases the amount of local bleeding at the site of injection. In addition, it increases the duration of action of the anesthetic with which it is combined. Despite these advantages, the vasoconstrictive properties of epinephrine may contribute to tissue hypoxia, and its use should be avoided in areas of poor perfusion (ie, fingers, toes, penis, ears, nose). Topical anesthetics may be needed in children or uncooperative adults. Consider the use of a lidocaine, epinephrine, and tetracaine topical preparation or lidocaine/prilocaine emulsion (EMLA) cream. Pediatric or elderly patients may require additional sedation for compliance. Consider a hematoma block or bier block to attain more effective analgesia when a fracture exists or when more extensive manipulation of the foot is expected.[13, 14] Adding a buffering solution, like sodium bicarbonate, can significantly decrease the pain of the injection when performing a nerve block.[8, 6] Add 1 mL of sodium bicarbonate (44 meQ/50 mL) to 9 mL of lidocaine. Warming the anesthetic solution to body temperature can significantly decrease the pain of the injection.[6] When unassisted, tape a bottle of lidocaine upside down to the wall before starting the procedure. If more anesthetic is needed during the procedure, it can be obtained from this bottle without compromising the sterility of gloves and equipment. Positioning Position the patient prone, with the ankle elevated by a pillow or rolled sheet to optimize comfort. Alternatively, the patient may sit or lay supine with the affected leg internally rotated and the ankle elevated on pillow or rolled sheet. Equipment preparation and proper patient positioning may make the difference between success and failure.

Technique
Approach Considerations
Perform and document neurovascular and musculoskeletal examinations prior to the procedure. Testing the sural nerve prior to block includes sensation of posterolateral calf and sensation of the lateral fifth digit (see the images below).

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Sural nerve dermatome at the level of the posterior calf.

Dermatome map of sural nerve contributions at the level of the anterior lower leg and anterior foot.

Approach for Sural Nerve Block

Using nonsterile gloves, expose the area of injection and identify the landmarks. Locate the posterior border of the lateral malleolus and the Achilles tendon (see the image below).

Site adjacent to the Achilles tendon.

Mark the site just lateral to the Achilles tendon, between the 2 landmarks, as shown in the images below.

Mark the site adjacent to the Achilles tendon.

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Marked site adjacent to the Achilles tendon.

Be sure to not inject within the Achilles tendon. Wipe the area with an alcohol pad and clean the site thoroughly with antiseptic solution, moving outward in a circular fashion (see the image below).

Betadine preparation.

Open a sterile drape and place the syringe, needle, and gauze on the tray, maintaining sterility. Put on sterile gloves. Attach the 18-G needle to the 10-mL syringe and draw up the lidocaine. Then, change to the 25-G needle. Place a skin wheal at the site marked. Advance the needle through the skin wheal, angling toward the lateral malleolus. Inject 5-7 mL of lidocaine in a transverse line until the lateral malleolus is reached. See the image below.

Advance the needle toward the lateral malleolus.

Calor and rubor of the foot from loss of sympathetic tone may be noted initially. Successful anesthesia of the areas noted heralds a successful sural nerve block.

Contributor Information and Disclosures

Author Heather Tassone, DO Attending Physician, Department of Emergency Medicine, Albert Einstein School of Medicine, Jacobi and Montefiore Medical Centers Disclosure: Nothing to disclose. Coauthor(s) Matthew A Silver, MD Staff Physician, Department of Emergency Medicine, Kaiser Permanente, San Diego Medical Center; Voluntary Clinical Instructor, University of California, San Diego, School of Medicine Matthew A Silver, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

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Specialty Editor Board Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Chief Editor Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American Society of Anesthesiologists, and American Society of Regional Anesthesia and Pain Medicine Disclosure: Nothing to disclose. Additional Contributors Medscape Reference gratefully acknowledges the assistance of Lars Grimm with the literature review and referencing for this article.

References
1. Crystal CS, Blankenship RB. Local anesthetics and peripheral nerve blocks in the emergency department. Emerg Med Clin North Am . May 2005;23(2):477-502. [Medline]. 2. Salam GA. Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries. Am Fam Physician. Feb 15 2004;69(4):896-900. [Medline]. 3. Myerson MS, Ruland CM, Allon SM. Regional anesthesia for foot and ankle surgery. Foot Ankle. Jun 1992;13(5):282-8. [Medline]. 4. Younger DS. Peripheral nerve disorders. Prim Care. Mar 2004;31(1):67-83. [Medline]. 5. Greensmith JE, Murray WB. Complications of regional anesthesia. Curr Opin Anaesthesiol . Oct 2006;19(5):531-7. [Medline]. 6. McGee D. Local and topical anesthesia. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004:541-5. 7. Borgeat A. Neurologic deficit after peripheral nerve block: what to do?. Minerva Anestesiol . Jun 2005;71(6):353-5. [Medline]. 8. Reichman EF, Tolson DR. Regional nerve blocks (regional anesthesia). In: Reichman EF, Simon RR, eds. Emergency Medicine Procedures . New York, NY: McGraw-Hill; 2004:965-81. 9. Gmyrek R. Local anesthesia and regional nerve block anesthesia. Medscape Reference [serial online]. February 7, 2007;Accessed September 6, 2006. Available at http://emedicine.medscape.com/article /1127490-overview. 10. Haugen RN, Brown CW. Case reports: type I hypersensitivity to lidocaine. J Drugs Dermatol . Dec 2007;6(12):1222-3. [Medline]. 11. Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. May 2008;106(5):1572-4, table of contents. [Medline].

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12. Norris RL Jr. Local anesthetics. Emerg Med Clin North Am . Nov 1992;10(4):707-18. [Medline]. 13. Crystal CS, Miller MA, Young SE. Ultrasound guided hematoma block: a novel use of ultrasound in the traumatized patient. J Trauma. Feb 2007;62(2):532-3. [Medline]. 14. [Best Evidence] Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. Oct 2006;118(4):e1078-86. [Medline]. Medscape Reference 2011 WebMD, LLC

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