Distal Sciatic Nerve Block

1. See Also
   1. Anterior Ankle Nerve Block
   2. Posterior Ankle Nerve Block
   3. Regional Anesthesia (Nerve Block)
   4. Local Skin Anesthesia
   5. Field Block
   6. Hematoma Block
   7. Digital Block
   8. Point of Care Ultrasound (POCUS)
2. Indications
   1. Regional Anesthesia of the common peroneal nerve and tibial nerve
   2. Nerve Block covers everything below the knee except the saphenous nerve (medial calf to heal)
      1. Often combined with the Saphenous Nerve Block for complete ankle and foot Anesthesia
3. Contraindications
   1. See Regional Anesthesia
4. Precautions
   1. Avoid injecting directly into nerves
   2. See Regional Anesthesia for complications
5. Preparation
   1. Needle: 22 to 25 gauge, 3.5 inch long spinal needle
   2. Skin Preparation (e.g. Hibiclens or Betadine)
      1. See Regional Anesthesia
   3. Anesthetic
      1. See Regional Anesthesia for Anesthetic options
      2. Local Anesthetic 2-5 ml (Ultrasound) or 5-10 ml (landmark)
6. Technique: Ultrasound Guided
   1. Images
      1. 
   2. Position
      1. Prone position
   3. Precautions
      1. As with all Nerve Blocks, needle tip visualization is critical (Do not inject into sciatic nerve!)
      2. Hydrodissection around the nerve is the goal
   4. Ultrasound probe
      1. Linear probe transverse at posterior thigh, at least 5 cm above femoral condyles
      2. Injection site will lie between the biceps femoris and semiteninosus Muscles and tendons
      3. Visualize the sciatic nerve bifurcation
   5. Landmarks
      1. Popliteal Artery and Vein are medial to the nerve
      2. Sciatic nerve bifurcates into peroneal nerve and tibial nerve at 5-12 cm above popliteal space
         1. Inject at or above the bifurcation into the peroneural sheath
         2. Authors describe injecting immediately below the bifurcation at the "crotch"
   6. Injection
      1. Prepare needle site (e.g. Hibiclens, drape)
      2. Insert needle inline with Ultrasound pobe from posterior or lateral approach
         1. Visualize needle enter perineural sheath near the nerve trunks (but not within nerves)
         2. Inject small amounts of Anesthetic at a time watching the fluid hydro-dissect tissue
         3. Inject up to 10 ml for block
            1. Do not exceed local Anesthetic limits to prevent LAST Reaction
   7. Post-procedure
      1. Reassess neurovascular exam
      2. Await Anesthetic effect within 10-30 minutes (see below)
7. Pharmacokinetics
   1. See Ropivacaine
   2. Lidocaine with 2% Epinephrine
      1. Onset: 10-20 minutes
      2. Duration: 2-5 hours
   3. Bupivacaine (0.5%)
      1. Onset 15-30 minutes
      2. Duration: 6 to 30 hours
8. Resources
   1. Ultrasound-Guided Popliteal Sciatic Block (NYSORA)
      1. https://www.nysora.com/regional-anesthesia-for-specific-surgical-procedures/lower-extremity-regional-anesthesia-for-specific-surgical-procedures/foot-and-anckle/ultrasound-guided-popliteal-sciatic-block/
9. References
   1. Warrington (2020) Crit Dec Emerg Med 34(3):12-3
   2. Yurgil (2020) Am Fam Physician 101(11):654-64 [PubMed]