The ‘Right’ Way

January 23, 2012
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     I have come in contact at more than one practice lately with an application for a block that I would not have thought reasonable before now. It is the use of a popliteal sciatic nerve block (as a single injection) for posterior knee pain for total knee arthroplasty. I wouldn’t have chosen this option with the concern being that if the block were too low, maybe I would miss articular fibers to the knee, and I would end up with a foot drop temporarily AND inadequate analgesia. Plus, I know how to do the other blocks anyway. Why look for something else? What I have encountered is people performing a ‘high’ popliteal block because they were not yet adept at the subgluteal or anterior approach. Now I know for certain that this is a very reasonable option. In fact, some are using a selective tibial nerve block to avoid the various concerns of getting a common peroneal palsy.

     This may be a reasonable application for this nerve block approach especially for the practitioner or practice that is making strides but hasn’t made all of the strides yet. Maybe try one of the other ‘usual’ approaches or at least have a look, then go to this ‘Plan B’ if needed. For that matter, it may be better than what most people are doing currently. There’s less of a positioning issue than the subgluteal approach, and there’s likely less risk of damaging peripheral structures than an anterior approach (especially for the novice to intermediate level practitioner). The needle path is more shallow and perpendicular than with either of the other two.

     This is the point I would like to make apparent: a lot of the ‘answers’ and best applications and optimal methods or most reliable techniques are yet to be determined. ‘THE’ answer is not out there for many things, and if they are out there, they may not be the ‘best’ for you or for your facility. There are certainly many wheels that have already been invented, and I don’t want you to work to reinvent all of them. What I’m saying is that many practices ‘evolved’ to where they are by trial and error, by finding out what works ‘here’ and to some degree, personal preference. Don’t assume that if they do it that way at that particular place that you would be crazy to try it another way. They may even want to change, but habit has set in, and it takes energy to change. Maybe they have constraints that are not the same as yours. Or maybe they just haven’t thought of your idea yet or don’t think it would work. My pride will shine through as I say that I have also been on the other side of this situation, discovering something that an expert didn’t think would work.

     I am so fortunate to be able to evaluate anesthesia programs all over the country because it exposes me to many of the dogmas that I maintain. Those dogmas can happen easily because we tend to practice in a ‘silo’ and rarely hear what other practices are doing. Sometimes, we’re lucky to know what some of our own partners are doing! Keep looking, keep talking, keep asking questions, and keep looking for solutions for your facility, for your group and for your patients. PS, I can’t wait to run into that expert to tell them that it did work after all.

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