title: Continuous Popliteal Sciatic Blocks: Does Varying Perineural Catheter Location Relative to the Sciatic Bifurcation Influence Block Effects? A Dual-Center, Randomized, Subject-Masked, Controlled Clinical Trial.
abstract: BACKGROUND
  Multiple studies have demonstrated that, for single-injection popliteal sciatic nerve blocks, block characteristics are dependent upon local anesthetic injection relative to the sciatic nerve bifurcation. In contrast, this relation remains unexamined for continuous popliteal sciatic nerve blocks. We, therefore, tested the hypothesis that postoperative analgesia is improved with the perineural catheter tip at the level of the bifurcation compared with 5 cm proximal to the bifurcation.
  
  
  METHODS
  Preoperatively, subjects having moderately painful foot or ankle surgery were randomly assigned to receive an ultrasound-guided subepimyseal perineural catheter inserted either at or 5 cm proximal to the sciatic nerve bifurcation. Subjects received a single injection of mepivacaine 1.5% either via the insertion needle preoperatively or the perineural catheter postoperatively, followed by an infusion of ropivacaine 0.2% (6 mL/h basal, 4 mL bolus, and 30-min lockout) for the study duration. The primary end point was the average pain measured on a numeric rating scale (0-10) in the 3 hours before a data collection telephone call the morning after surgery.
  
  
  RESULTS
  The average numeric rating scale of subjects with a catheter inserted at the sciatic nerve bifurcation (n = 64) was a median (10th, 25th to 75th, and 90th quartiles) of 3.0 (0.0, 2.4-5.0, and 7.0) vs 2.0 (0.0, 1.0-4.0, and 5.0) for subjects with a catheter inserted proximal to the bifurcation (n = 64; P = 0.008). Similarly, maximum pain scores were greater in the group at the bifurcation: 6.0 (3.0, 4.4-8.0, and 9.0) vs 5.0 (0.0, 3.0-8.0, and 10.0) (P = 0.019). Differences between the groups for catheter insertion time, opioid rescue dose, degree of numbness in the foot/toes, catheter dislodgement, and fluid leakage did not reach statistical significance.
  
  
  CONCLUSIONS
  For continuous popliteal sciatic nerve blocks, a catheter inserted 5 cm proximal to the sciatic nerve bifurcation provides superior postoperative analgesia in subjects having moderately painful foot or ankle surgery compared with catheters located at the bifurcation. This is in marked contrast with single-injection popliteal sciatic nerve blocks for which benefits are afforded to local anesthetic injection distal, rather than proximal, to the bifurcation.
authors.affiliation: From the *Department of Anesthesiology, University of California San Diego, San Diego, California; †Department of Orthopedics, University of California San Diego, San Diego, California; ‡Division of Biostatistics and Bioinformatics, University of California San Diego, San Diego, California; §School of Medicine, University of California San Diego, San Diego, California; ‖Department of Ophthalmology, University of California San Diego, San Diego, California; and ¶OUTCOMES RESEARCH Consortium, Cleveland, Ohio.
authors.forename: Amanda M
authors.initials: AM
authors.lastname: Monahan
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Madison
authors.forename: Vanessa J
authors.initials: VJ
authors.lastname: Loland
authors.forename: Jacklynn F
authors.initials: JF
authors.lastname: Sztain
authors.forename: Michael L
authors.initials: ML
authors.lastname: Bishop
authors.forename: NavParkash S
authors.initials: NS
authors.lastname: Sandhu
authors.forename: Richard H
authors.initials: RH
authors.lastname: Bellars
authors.forename: Bahareh
authors.initials: B
authors.lastname: Khatibi
authors.forename: Alexandra K
authors.initials: AK
authors.lastname: Schwartz
authors.forename: Sonya S
authors.initials: SS
authors.lastname: Ahmed
authors.forename: Michael C
authors.initials: MC
authors.lastname: Donohue
authors.forename: Scott T
authors.initials: ST
authors.lastname: Nomura
authors.forename: Cindy H
authors.initials: CH
authors.lastname: Wen
authors.forename: Brian M
authors.initials: BM
authors.lastname: Ilfeld
mesh_terms: D000328:Adult; D000577:Amides / Q000008:administration & dosage* / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002140:California; D057785:Catheters; D005260:Female; D005528:Foot / Q000294:innervation / Q000601:surgery*; D006801:Humans; D008297:Male; D008619:Mepivacaine / Q000008:administration & dosage; D008875:Middle Aged; D009407:Nerve Block / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D019637:Orthopedic Procedures / Q000009:adverse effects; D010147:Pain Measurement; D017288:Pain Threshold / Q000187:drug effects; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D011446:Prospective Studies; D000077212:Ropivacaine; D012584:Sciatic Nerve / Q000000981:diagnostic imaging / Q000187:drug effects*; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chemical_list: D000577:Amides; D000779:Anesthetics, Local; D000077212:Ropivacaine; D008619:Mepivacaine