Popliteal Block as an Alternative to Labat’s Approach

Abstract

Popliteal Block as an Alternative to Labat’s Approach In Response: We would like to thank Dr. Fernàndez-Guisasola for his interest in our work (1) as well as his practical comments, which remind us once more, if needed, that the sciatic nerve can be blocked at several levels along its pathway with a lot of “different” posterior and lateral approaches. Popliteal blocks undoubtedly provide a good and effective anesthesia (2,3). In our daily practice we use them frequently, not only for single shot blockades but also for postoperative pain relief, by placing a perineural catheter close to the sciatic nerve and infusing it with local anesthetic solutions after surgery (4). Nonetheless, Dr. Fernàndez-Guisasola should recognize that the aim of our study was “to describe a new posterior approach to the sciatic nerve at the level of the proximal thigh and compare…the effectiveness, performance time, and patient’s acceptance of this new approach with the classic posterior approach”(1). In fact, results of our study demonstrated that this new posterior approach is easier and less painful to the patient as compared to the classic Labat’s approach only. This allows us to suggest that the subgluteus sciatic nerve block can be considered a useful alternative to Labat’s approach, but we never stated that the sublguteus posterior block is the best alternative to the Labat’s approach, disregarding the popliteal blocks. On the other hand, we must also consider that the Dr. Fernàndez-Guisasola’s hypothesis that the posterior popliteal block is easier than other approaches in the obese patient is as much theoretical as intriguing, and it is not supported by properly conducted, randomized studies. Irrespective from discussing the distribution of adipose tissues in the obese patient, what about turning prone an obese patient to place the block and then turning it back to the supine position? Further, very often a more proximal approach than the popliteal one is required because of surgical site (e.g., surgery at the level of the knee) or surgeon’s needs (e.g., thigh tourniquet). However, this is a matter of other new studies, and we look forward to reading them to better understand the best indication for each approach to the sciatic nerve according to both patient and surgery. In conclusion, we completely agree with Dr. Fernandez-Guisasola that the physician must choose and titrate the best nerve block according to patient characteristics, the type of surgery, and the surgeon’s needs. However, personal skills and expertise also play an important role: the more techniques we know and practice, the more flexible is our practice, helping us to get all the benefits of peripheral nerve blocks in different clinical situations. In this view, the description of our new posterior approach to the sciatic nerve is only an attempt to improve the comfort of both the patient and physician when a proximal sciatic nerve block is required: just another arrow in our quiver. Andrea Casati, MD Pia di Benedetto, MD