BJA Advance Access originally published online on May 6, 2009
British Journal of Anaesthesia 2009 102(6):855-861; doi:10.1093/bja/aep097
Intraneural injection during nerve stimulator-guided sciatic nerve block at the popliteal fossa
1 Department of Anesthesiology, Hospital Clinic, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
2 Department of Anesthesia, St Luke's-Roosevelt Hospital Center, University Hospital of Columbia University, New York, NY, USA
3 Department of Human Anatomy and Embryology, Universitat de Barcelona, Spain
4 Department of Radiology, Hospital Clínic, Universitat de Barcelona, Spain
5 Electromyography Unit, Department of Neurology, Hospital Clinic, Universitat de Barcelona, Spain
* Corresponding author. E-mail: xsala{at}clinic.ub.es
Background: Exact location of the needle tip during nerve stimulation-guided peripheral nerve blocks is unknown. Using high-frequency ultrasound imaging, we tested the hypothesis that intraneural injection is common with nerve stimulator-guided sciatic nerve (SN) block in popliteal fossa.
Methods: Forty-two patients scheduled for hallux valgus repair were studied. Sciatic block at the popliteal fossa was accomplished using nerve stimulation. When a motor response was elicited at <0.5 mA (2 Hz, 0.1 ms), 40 ml of local anaesthetic (LA) was injected. Using ultrasound (Titan, Sonosite, 5–10 MHz), the diameters and area of the SN were measured before and after the injection. The presence of nerve swelling and proximal or distal diffusion of LA were also assessed. Intraneural injection was defined as nerve area (NA) increase of 
15% and one or more additional ultrasonographic markers (nerve swelling, proximal–distal diffusion within epineural tissue). Clinical neurological evaluation was performed 1 week after the block.
Results: Post-injection NA increase 15% was seen in 32 (76%) patients [0.54 (SD 0.19) cm–2 vs 0.76 (0.24) cm–2; P<0.05]. Nerve swelling with fascicular separation was observed in 37 (88%) patients; proximal and distal diffusion of LA were present in six (14%) and 14 (38%) patients, respectively. Intraneural injection criteria were met in 28 (66%) patients. Greater NA increase was present in patients with fast block onset [61 (45) vs 25 (33)%; (Dif 35% 95% CI 61–9%); P<0.05]. No patient developed neurological complications.
Conclusions: Intraneural (subepineural) injection is a common occurrence after nerve stimulator-guided SN block at the popliteal fossa, yet it may not inevitably lead to neurological complications.
Keywords: anaesthetic techniques, regional, sciatic; monitoring, ultrasound; nerve, damage
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