5. Needle Entry
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ACEP Now: Vol 41 – No 06 – June 2022PICTURE 4 (click to enlarge): Schematic of an in-plane lateral to medial approach with a blunt block needle. Note that the anesthetic is placed in the fascial plane adjacent to the sciatic nerve. Note the nerve encompasses the yellow circles and the anesthetic is the green/blue circles.
With the transducer fixed over the targeted nerve, using an in-plane approach, insert a block needle and/or blunt tip needle and advance at approximately 70 degrees from the greater trochanter down toward the sciatic nerve (Picture 4). After the 1–2 cm of insertion, stop further needle advancement and make subtle probe adjustments until the needle is visualized. Continue advancing with in-plane ultrasound guidance to position the needle tip approximately 1–2 cm away from the nerve. Once the needle tip is visualized adjacent to the sciatic nerve, aspirate prior to injecting small aliquots of sterile saline to hydro-dissect the gluteal maximus fascial plane. Anechoic fluid should be seen separating the fascial plane away from the sciatic nerve.(Picture 4) After aspiration to ensure no vascular puncture, small aliquots of anesthetic are first injected deep to the sciatic nerve followed by the medial aspect of the nerve. Afterwards, advance the needle to the far side of the nerve, aspirate to ensure no vascular puncture, and inject small aliquots of anesthetic on the far side then the proximal aspect of the nerve. In our experience, this order of injection helps prevent any obscuring of the nerve of interest in case there is a small amount of air that was not fully expressed from the needle or tubing prior to initiating the procedure. Ensure that the injected anechoic fluid is not placed in the gluteus maximus muscle or into the sciatic nerve itself.
Summary
The TGSNB is a simple, safe block that can provide pain relief to a large number of patients in your ED. Given its effectiveness, this can be a valuable tool for acute multimodal pain control for a condition that usually can be difficult to manage with traditional oral analgesics. The combination of dexamethasone to a long-acting anesthetic may provide longer pain relief and further provide additional time for your patient to get ahead of their pain cycle.
Andrew J Goldsmith, MD, MBA, is Ultrasound director at Brigham and Women’s Hospital
Joseph Brown, MD, is a part of the Ultrasound Division at the University of Colorado.
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