How to: Subgluteal Sciatic Nerve Block
How to: Subgluteal Sciatic Nerve Block
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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .
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<p begin="00:00:13.416" end="00:00:16.833" style="s2">- The Sciatic Nerve Block can<br />be used for surgery of the</p>
<p begin="00:00:16.833" end="00:00:19.000" style="s2">leg, knee, foot and ankle.</p>
<p begin="00:00:21.010" end="00:00:22.168" style="s2">To do the Sciatic Nerve Block,</p>
<p begin="00:00:22.168" end="00:00:24.639" style="s2">you can block it at the Popliteal region</p>
<p begin="00:00:24.639" end="00:00:26.299" style="s2">or you can block it higher.</p>
<p begin="00:00:26.299" end="00:00:28.048" style="s2">Some benefits of blocking it higher</p>
<p begin="00:00:28.048" end="00:00:30.191" style="s2">are to be above the tourniquet,</p>
<p begin="00:00:30.191" end="00:00:33.888" style="s2">so you don't have to worry<br />so much about nerve ischemia.</p>
<p begin="00:00:33.888" end="00:00:37.273" style="s2">You may also get the Posterior<br />Femoral Cutaneous nerve</p>
<p begin="00:00:37.273" end="00:00:40.735" style="s2">of the thigh, which comes off<br />very high on the Sciatic nerve</p>
<p begin="00:00:40.735" end="00:00:45.132" style="s2">and it's also medial to the<br />Sciatic nerve, as well high up.</p>
<p begin="00:00:45.132" end="00:00:48.664" style="s2">This way, you can cover any<br />kind of pain of incision</p>
<p begin="00:00:48.664" end="00:00:50.707" style="s2">in the upper thigh area.</p>
<p begin="00:00:50.707" end="00:00:54.206" style="s2">To position patients for<br />Subgluteal Sciatic Nerve Block,</p>
<p begin="00:00:54.206" end="00:00:56.776" style="s2">we position the patient lateral.</p>
<p begin="00:00:56.776" end="00:00:59.104" style="s2">This way, the patient is comfortable,</p>
<p begin="00:00:59.104" end="00:01:02.648" style="s2">they can be well-sedated<br />and you can place a probe</p>
<p begin="00:01:02.648" end="00:01:05.750" style="s2">on the posterior side of the<br />leg and advance the needle</p>
<p begin="00:01:05.750" end="00:01:07.448" style="s2">from lateral to medial.</p>
<p begin="00:01:07.448" end="00:01:09.464" style="s2">The probe we use for a Sciatic Nerve Block</p>
<p begin="00:01:09.464" end="00:01:12.323" style="s2">is a curvilinear low-frequency probe.</p>
<p begin="00:01:12.323" end="00:01:14.714" style="s2">The reason we use this probe is because</p>
<p begin="00:01:14.714" end="00:01:18.881" style="s2">it penetrates deeper and this<br />is useful in larger patients.</p>
<p begin="00:01:20.619" end="00:01:22.715" style="s2">So some of the landmarks we use</p>
<p begin="00:01:22.715" end="00:01:26.390" style="s2">for the Subgluteal Sciatic Nerve Block</p>
<p begin="00:01:26.390" end="00:01:29.165" style="s2">are the Greater Trochanter laterally,</p>
<p begin="00:01:29.165" end="00:01:31.717" style="s2">the Ischial Tuberosity medially, and</p>
<p begin="00:01:31.717" end="00:01:36.629" style="s2">directly in between these two<br />is where we place the probe</p>
<p begin="00:01:36.629" end="00:01:40.582" style="s2">The initial view we see<br />is the Greater Trochanter</p>
<p begin="00:01:40.582" end="00:01:42.893" style="s2">on the left side of the screen.</p>
<p begin="00:01:42.893" end="00:01:44.498" style="s2">On the right side of the screen,</p>
<p begin="00:01:44.498" end="00:01:46.998" style="s2">we see the Ischial Tuberosity.</p>
<p begin="00:01:47.985" end="00:01:50.572" style="s2">There is a large muscle,<br />the Gluteus Maximus</p>
<p begin="00:01:50.572" end="00:01:54.132" style="s2">at the superficial level of the screen.</p>
<p begin="00:01:54.132" end="00:01:58.208" style="s2">Underneath the Gluteus Maximus<br />is a hyperechoic nerve,</p>
<p begin="00:01:58.208" end="00:01:59.708" style="s2">the Sciatic Nerve.</p>
<p begin="00:02:01.269" end="00:02:05.436" style="s2">Between the two bony landmarks<br />is the Quadratus Femoris.</p>
<p begin="00:02:06.716" end="00:02:09.360" style="s2">So on this level, the<br />nerve is sandwiched between</p>
<p begin="00:02:09.360" end="00:02:13.051" style="s2">the Gluteus Maximus and<br />the Quadratus Femoris.</p>
<p begin="00:02:13.051" end="00:02:17.618" style="s2">The nerve here can appear<br />wide, flat or triangular.</p>
<p begin="00:02:17.618" end="00:02:21.146" style="s2">It is not a circular structure<br />like some people imagine.</p>
<p begin="00:02:21.146" end="00:02:23.691" style="s2">Needle approaches for<br />the Sciatic Nerve Block,</p>
<p begin="00:02:23.691" end="00:02:26.586" style="s2">whether is be here, at<br />the Mid-Femoral region,</p>
<p begin="00:02:26.586" end="00:02:29.050" style="s2">or higher up at the Subgluteal region,</p>
<p begin="00:02:29.050" end="00:02:33.748" style="s2">are performed from a<br />lateral-to-medial approach.</p>
<p begin="00:02:33.748" end="00:02:37.036" style="s2">The lateral-to-medial<br />approach usually starts</p>
<p begin="00:02:37.036" end="00:02:41.082" style="s2">three to four centimeters away<br />from the probe in this angle.</p>
<p begin="00:02:41.082" end="00:02:44.836" style="s2">Now, higher up we'll use<br />the same needle approach.</p>
<p begin="00:02:44.836" end="00:02:48.031" style="s2">We can see the triangular<br />Sciatic Nerve here,</p>
<p begin="00:02:48.031" end="00:02:50.695" style="s2">and we'll start the<br />needle angle about here.</p>
<p begin="00:02:50.695" end="00:02:52.750" style="s2">Now you typically put my nerve</p>
<p begin="00:02:52.750" end="00:02:55.685" style="s2">on the distal side of the<br />screen from where my needle</p>
<p begin="00:02:55.685" end="00:02:59.214" style="s2">is entering, in order<br />to see the needle better</p>
<p begin="00:02:59.214" end="00:03:02.718" style="s2">and travelling across<br />the screen to the nerve.</p>
<p begin="00:03:02.718" end="00:03:05.109" style="s2">Typical volumes are 20 to 30 milliliters</p>
<p begin="00:03:05.109" end="00:03:07.446" style="s2">of local anesthetic.</p>
<p begin="00:03:07.446" end="00:03:09.916" style="s2">Because this nerve is<br />so deep in some people,</p>
<p begin="00:03:09.916" end="00:03:13.841" style="s2">some anesthesiologists<br />like to approach this nerve</p>
<p begin="00:03:13.841" end="00:03:16.112" style="s2">from an Out-of-Plane needle angle.</p>
<p begin="00:03:16.112" end="00:03:19.312" style="s2">And Out-of-Plane needle angle<br />would be in this direction</p>
<p begin="00:03:19.312" end="00:03:20.759" style="s2">into the Sciatic Nerve.</p>
<p begin="00:03:20.759" end="00:03:24.922" style="s2">Other people like to turn<br />this probe in a longitudinal</p>
<p begin="00:03:24.922" end="00:03:27.360" style="s2">direction and see the nerve in long axis.</p>
<p begin="00:03:27.360" end="00:03:30.352" style="s2">So here we are turning<br />the probe in the long axis</p>
<p begin="00:03:30.352" end="00:03:34.519" style="s2">and following that nerve in<br />the longitudinal pattern here.</p>
<p begin="00:03:35.426" end="00:03:40.030" style="s2">So now we see the Sciatic<br />Nerve going down the leg.</p>
<p begin="00:03:40.030" end="00:03:44.126" style="s2">The needle approach in this<br />orientation would be in</p>
<p begin="00:03:44.126" end="00:03:47.874" style="s2">this angle in plane of the ultrasound beam</p>
<p begin="00:03:47.874" end="00:03:50.041" style="s2">down to the Sciatic nerve.</p>
<p begin="00:03:55.166" end="00:03:58.236" style="s2">- (Dr. Auyong) Here you can<br />see the Greater Trochanter</p>
<p begin="00:03:58.236" end="00:04:01.102" style="s2">on the left side of the<br />screen, the Ischial Tuberosity</p>
<p begin="00:04:01.102" end="00:04:04.720" style="s2">on the right side of the<br />screen, the Gluteus Maximus</p>
<p begin="00:04:04.720" end="00:04:08.137" style="s2">superficial and a 21 gauge needle</p>
<p begin="00:04:08.137" end="00:04:11.452" style="s2">advancing to the Sciatic Nerve.</p>
<p begin="00:04:11.452" end="00:04:14.093" style="s2">The Sciatic Nerve is<br />below the Gluteus Maximus</p>
<p begin="00:04:14.093" end="00:04:16.760" style="s2">and above the Quadratus Femoris.</p>
<p begin="00:04:17.753" end="00:04:20.571" style="s2">Our needle is advancing<br />above the Sciatic Nerve</p>
<p begin="00:04:20.571" end="00:04:23.041" style="s2">to attempt to get local<br />anesthetic to spread</p>
<p begin="00:04:23.041" end="00:04:25.229" style="s2">to the medial side of the nerve.</p>
<p begin="00:04:25.229" end="00:04:27.975" style="s2">Which would be more<br />likely to get the larger</p>
<p begin="00:04:27.975" end="00:04:31.028" style="s2">Tibial component, as well<br />as the posterior femoral</p>
<p begin="00:04:31.028" end="00:04:33.445" style="s2">cutaneous nerve of the thigh.</p>
<p begin="00:04:34.624" end="00:04:37.829" style="s2">Now you can see the nerve,<br />which very hyperechoic,</p>
<p begin="00:04:37.829" end="00:04:40.079" style="s2">below the local anesthetic.</p>
<p begin="00:00:16.833" end="00:00:19.000" style="s2">leg, knee, foot and ankle.</p>
<p begin="00:00:21.010" end="00:00:22.168" style="s2">To do the Sciatic Nerve Block,</p>
<p begin="00:00:22.168" end="00:00:24.639" style="s2">you can block it at the Popliteal region</p>
<p begin="00:00:24.639" end="00:00:26.299" style="s2">or you can block it higher.</p>
<p begin="00:00:26.299" end="00:00:28.048" style="s2">Some benefits of blocking it higher</p>
<p begin="00:00:28.048" end="00:00:30.191" style="s2">are to be above the tourniquet,</p>
<p begin="00:00:30.191" end="00:00:33.888" style="s2">so you don't have to worry<br />so much about nerve ischemia.</p>
<p begin="00:00:33.888" end="00:00:37.273" style="s2">You may also get the Posterior<br />Femoral Cutaneous nerve</p>
<p begin="00:00:37.273" end="00:00:40.735" style="s2">of the thigh, which comes off<br />very high on the Sciatic nerve</p>
<p begin="00:00:40.735" end="00:00:45.132" style="s2">and it's also medial to the<br />Sciatic nerve, as well high up.</p>
<p begin="00:00:45.132" end="00:00:48.664" style="s2">This way, you can cover any<br />kind of pain of incision</p>
<p begin="00:00:48.664" end="00:00:50.707" style="s2">in the upper thigh area.</p>
<p begin="00:00:50.707" end="00:00:54.206" style="s2">To position patients for<br />Subgluteal Sciatic Nerve Block,</p>
<p begin="00:00:54.206" end="00:00:56.776" style="s2">we position the patient lateral.</p>
<p begin="00:00:56.776" end="00:00:59.104" style="s2">This way, the patient is comfortable,</p>
<p begin="00:00:59.104" end="00:01:02.648" style="s2">they can be well-sedated<br />and you can place a probe</p>
<p begin="00:01:02.648" end="00:01:05.750" style="s2">on the posterior side of the<br />leg and advance the needle</p>
<p begin="00:01:05.750" end="00:01:07.448" style="s2">from lateral to medial.</p>
<p begin="00:01:07.448" end="00:01:09.464" style="s2">The probe we use for a Sciatic Nerve Block</p>
<p begin="00:01:09.464" end="00:01:12.323" style="s2">is a curvilinear low-frequency probe.</p>
<p begin="00:01:12.323" end="00:01:14.714" style="s2">The reason we use this probe is because</p>
<p begin="00:01:14.714" end="00:01:18.881" style="s2">it penetrates deeper and this<br />is useful in larger patients.</p>
<p begin="00:01:20.619" end="00:01:22.715" style="s2">So some of the landmarks we use</p>
<p begin="00:01:22.715" end="00:01:26.390" style="s2">for the Subgluteal Sciatic Nerve Block</p>
<p begin="00:01:26.390" end="00:01:29.165" style="s2">are the Greater Trochanter laterally,</p>
<p begin="00:01:29.165" end="00:01:31.717" style="s2">the Ischial Tuberosity medially, and</p>
<p begin="00:01:31.717" end="00:01:36.629" style="s2">directly in between these two<br />is where we place the probe</p>
<p begin="00:01:36.629" end="00:01:40.582" style="s2">The initial view we see<br />is the Greater Trochanter</p>
<p begin="00:01:40.582" end="00:01:42.893" style="s2">on the left side of the screen.</p>
<p begin="00:01:42.893" end="00:01:44.498" style="s2">On the right side of the screen,</p>
<p begin="00:01:44.498" end="00:01:46.998" style="s2">we see the Ischial Tuberosity.</p>
<p begin="00:01:47.985" end="00:01:50.572" style="s2">There is a large muscle,<br />the Gluteus Maximus</p>
<p begin="00:01:50.572" end="00:01:54.132" style="s2">at the superficial level of the screen.</p>
<p begin="00:01:54.132" end="00:01:58.208" style="s2">Underneath the Gluteus Maximus<br />is a hyperechoic nerve,</p>
<p begin="00:01:58.208" end="00:01:59.708" style="s2">the Sciatic Nerve.</p>
<p begin="00:02:01.269" end="00:02:05.436" style="s2">Between the two bony landmarks<br />is the Quadratus Femoris.</p>
<p begin="00:02:06.716" end="00:02:09.360" style="s2">So on this level, the<br />nerve is sandwiched between</p>
<p begin="00:02:09.360" end="00:02:13.051" style="s2">the Gluteus Maximus and<br />the Quadratus Femoris.</p>
<p begin="00:02:13.051" end="00:02:17.618" style="s2">The nerve here can appear<br />wide, flat or triangular.</p>
<p begin="00:02:17.618" end="00:02:21.146" style="s2">It is not a circular structure<br />like some people imagine.</p>
<p begin="00:02:21.146" end="00:02:23.691" style="s2">Needle approaches for<br />the Sciatic Nerve Block,</p>
<p begin="00:02:23.691" end="00:02:26.586" style="s2">whether is be here, at<br />the Mid-Femoral region,</p>
<p begin="00:02:26.586" end="00:02:29.050" style="s2">or higher up at the Subgluteal region,</p>
<p begin="00:02:29.050" end="00:02:33.748" style="s2">are performed from a<br />lateral-to-medial approach.</p>
<p begin="00:02:33.748" end="00:02:37.036" style="s2">The lateral-to-medial<br />approach usually starts</p>
<p begin="00:02:37.036" end="00:02:41.082" style="s2">three to four centimeters away<br />from the probe in this angle.</p>
<p begin="00:02:41.082" end="00:02:44.836" style="s2">Now, higher up we'll use<br />the same needle approach.</p>
<p begin="00:02:44.836" end="00:02:48.031" style="s2">We can see the triangular<br />Sciatic Nerve here,</p>
<p begin="00:02:48.031" end="00:02:50.695" style="s2">and we'll start the<br />needle angle about here.</p>
<p begin="00:02:50.695" end="00:02:52.750" style="s2">Now you typically put my nerve</p>
<p begin="00:02:52.750" end="00:02:55.685" style="s2">on the distal side of the<br />screen from where my needle</p>
<p begin="00:02:55.685" end="00:02:59.214" style="s2">is entering, in order<br />to see the needle better</p>
<p begin="00:02:59.214" end="00:03:02.718" style="s2">and travelling across<br />the screen to the nerve.</p>
<p begin="00:03:02.718" end="00:03:05.109" style="s2">Typical volumes are 20 to 30 milliliters</p>
<p begin="00:03:05.109" end="00:03:07.446" style="s2">of local anesthetic.</p>
<p begin="00:03:07.446" end="00:03:09.916" style="s2">Because this nerve is<br />so deep in some people,</p>
<p begin="00:03:09.916" end="00:03:13.841" style="s2">some anesthesiologists<br />like to approach this nerve</p>
<p begin="00:03:13.841" end="00:03:16.112" style="s2">from an Out-of-Plane needle angle.</p>
<p begin="00:03:16.112" end="00:03:19.312" style="s2">And Out-of-Plane needle angle<br />would be in this direction</p>
<p begin="00:03:19.312" end="00:03:20.759" style="s2">into the Sciatic Nerve.</p>
<p begin="00:03:20.759" end="00:03:24.922" style="s2">Other people like to turn<br />this probe in a longitudinal</p>
<p begin="00:03:24.922" end="00:03:27.360" style="s2">direction and see the nerve in long axis.</p>
<p begin="00:03:27.360" end="00:03:30.352" style="s2">So here we are turning<br />the probe in the long axis</p>
<p begin="00:03:30.352" end="00:03:34.519" style="s2">and following that nerve in<br />the longitudinal pattern here.</p>
<p begin="00:03:35.426" end="00:03:40.030" style="s2">So now we see the Sciatic<br />Nerve going down the leg.</p>
<p begin="00:03:40.030" end="00:03:44.126" style="s2">The needle approach in this<br />orientation would be in</p>
<p begin="00:03:44.126" end="00:03:47.874" style="s2">this angle in plane of the ultrasound beam</p>
<p begin="00:03:47.874" end="00:03:50.041" style="s2">down to the Sciatic nerve.</p>
<p begin="00:03:55.166" end="00:03:58.236" style="s2">- (Dr. Auyong) Here you can<br />see the Greater Trochanter</p>
<p begin="00:03:58.236" end="00:04:01.102" style="s2">on the left side of the<br />screen, the Ischial Tuberosity</p>
<p begin="00:04:01.102" end="00:04:04.720" style="s2">on the right side of the<br />screen, the Gluteus Maximus</p>
<p begin="00:04:04.720" end="00:04:08.137" style="s2">superficial and a 21 gauge needle</p>
<p begin="00:04:08.137" end="00:04:11.452" style="s2">advancing to the Sciatic Nerve.</p>
<p begin="00:04:11.452" end="00:04:14.093" style="s2">The Sciatic Nerve is<br />below the Gluteus Maximus</p>
<p begin="00:04:14.093" end="00:04:16.760" style="s2">and above the Quadratus Femoris.</p>
<p begin="00:04:17.753" end="00:04:20.571" style="s2">Our needle is advancing<br />above the Sciatic Nerve</p>
<p begin="00:04:20.571" end="00:04:23.041" style="s2">to attempt to get local<br />anesthetic to spread</p>
<p begin="00:04:23.041" end="00:04:25.229" style="s2">to the medial side of the nerve.</p>
<p begin="00:04:25.229" end="00:04:27.975" style="s2">Which would be more<br />likely to get the larger</p>
<p begin="00:04:27.975" end="00:04:31.028" style="s2">Tibial component, as well<br />as the posterior femoral</p>
<p begin="00:04:31.028" end="00:04:33.445" style="s2">cutaneous nerve of the thigh.</p>
<p begin="00:04:34.624" end="00:04:37.829" style="s2">Now you can see the nerve,<br />which very hyperechoic,</p>
<p begin="00:04:37.829" end="00:04:40.079" style="s2">below the local anesthetic.</p>
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https://youtube.com/watch?v=IL4qqETpb0k
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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .