Posterior Tibial Nerve Block Research Articles

Pain Management of Sciatic Nerve Injury Induced by Intramuscular Injection Using Distal Nerve Block

Abstract Injury to the sciatic nerve from dorsogluteal intramuscular (IM) injection is not an uncommon iatrogenic cause. This case report discusses the successful management of a child with sciatic nerve injury due to an IM injection in the left gluteal region. The child experienced severe pain that was not responding to pharmacological therapy and was limiting physiotherapy, which forms an important step in the management of patients with peripheral nerve injuries. The case report outlines the use of a posterior tibial nerve block, which provided immediate relief of pain sensations in the sole of the foot, allowing the child to walk and eventually improving sleep and appetite. The report suggests that distal nerve blocks may be an effective treatment option for patients with severe neuropathic symptoms resulting from peripheral nerve injury.

Posterior Tibial Nerve Block for the Treatment of Plantar Fasciitis in the Emergency Department

BackgroundPlantar fasciitis (PF) is a common, painful condition for which patients sometimes seek treatment in the emergency department. Although corticosteroid injections are helpful for PF, they are painful. DiscussionA posterior tibial nerve block provides immediate pain relief and allows the physician to also perform a corticosteroid injection into the heel, which could provide up to 1 month of analgesia. ConclusionsPatients may not have to wait until an appointment with a specialist to begin experiencing analgesia for PF.

Lower extremity puncture wound.

A 58-year-old woman presented with pain after sustaining a right foot wound from a damaged wooden floor. Physical examination was remarkable for a 0.3-cm puncture wound between the first webspace on the plantar aspect of the foot with tenderness to palpation, but no visible or palpable foreign body. Plain radiographs were negative, and computed tomography of the foot noted the small puncture wound with a proximally extending linear tract. Orthopedic surgery was consulted but did not appreciate any foreign body and thus recommended conservative management without wound exploration in the emergency department (ED). Bedside ultrasound was then performed by emergency physicians that visualized a linear 4-cm hyperechoic foreign body with posterior acoustic shadowing (Figure 1, Video 1). Ultrasound-guided deep peroneal and posterior tibial nerve blocks were performed for anesthesia (Video 2). Under ultrasound guidance, curved forceps were used to grasp and remove a large wooden fragment (Figure 2, Video 3). The patient was discharged with oral antibiotics. Traumatic wounds are responsible for 11 million ED visits annually, and foreign bodies are involved in 7% to 15%.1 Many foreign bodies are missed on initial evaluation, and because of their risk for complications, they are frequently implicated in malpractice litigation.2 Plain film radiographs are considered first line and detect 80% of all foreign bodies but have a mere sensitivity of 15% for radiolucent objects, such as wood or other vegetative material.1, 3 Therefore, multimodal imaging is frequently necessary. Ultrasonography, performed in the ED setting, has an overall sensitivity and specificity of 91% for identifying foreign bodies.2 These will appear hyperechoic and may have additional clues, such as posterior acoustic shadowing, reverberation artifact, or hypoechoic halo. Using ultrasound to guide percutaneous foreign body removal can increase success in the ED to nearly 100%.4 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Ultrasound-Guided Posterior Tibial Nerve Block for Frostbite of the Plantar Surfaces: A Case Series.

Frostbite is a painful condition that requires rapid identification and wound care to optimize outcomes. The posterior tibial nerve (PTN) block, however, has yet to be described in the literature for pain control of frostbite injuries on the plantar surfaces. In this case series we discuss three patients who presented with bilateral frostbite on the plantar surfaces. Ultrasound-guided PTN blocks were performed on these patients and pain control was achieved in under 10 minutes, facilitating burn care. No patient experienced adverse effects. All patients had been scheduled for future debridement that was either not performed or performed using intravenous (IV) medications due to pain control issues. The ultrasound-guided PTN block facilitated proper wound debridement that was previously intolerable with oral and IV pain medications. This case series highlights the efficacy, safety, and accessibility of this block for frostbite pain control in the emergency department. Additionally, it emphasizes the potential role of ultrasound-guided PTN blocks as part of a multi-modal pain control strategy in other clinical settings.

Pain Management Optimisation by an Ultrasound-Guided Analgesic Technique in Outpatients with Plantar Fasciitis during High-Energy Extracorporeal Shock Wave Therapy.

Several studies have demonstrated the efficacy of high-energy extracorporeal shock wave therapy (HESWT) for the treatment of painful foot diseases. A crucial complication of HESWT is the appearance of pain with the subsequent interruption of the procedure. The aim of this study was the evaluation of ultrasound (US)-guided posterior tibial nerve block (PTNB) efficacy in outpatients who discontinued the first application of HESWT due to surge of moderate-severe pain. Twenty-one patients, scheduled for HESWT due to plantar fasciitis, who interrupted the treatment for surge of pain (numeric rating scale [NRS] 5), were enrolled. After interruption of the first treatment, the patients received US-guided PTNB for every subsequent HESWT session. The same skilled anaesthesiologist performed an US-guided PTNB all the times. Once the nerve was identified, the needle was inserted and 5ml mepivacaine 1% were injected. Intensity of pain during each procedure by NRS and evaluation of patient's adherence to the treatment were detected. The HESWT was split into only three applications giving in average about 0.25 mJ mm-2, and all patients completed the treatment sessions. US-guided PTNB showed a significant reduction of NRS (P < 0.01) between the first HEWST without anaesthesia and the three subsequent treatments under peripheral block. US-guided PTNB resulted a valid support for the HEWST in outpatients with plantar fasciitis because it reduced the pain during the procedure, allowing to minimise the patient discomfort and to give the therapeutic doses just in three sessions.

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine.

Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.

The success rate of posterior tibial nerve block in the ankle with and without ultrasound guidance: A clinical trial study for pain management in emergency departments

Objective: The purpose of the current study was to assess the success rate of posterior tibial nerve block in the ankle with and without ultrasound guidance for pain management in emergency departments. Methods: This clinical trial was conducted on 80 individuals who needed posterior tibial nerve block in the ankle at the emergency department of Hashemi Nejad hospital and Edalatian emergency center in Mashhad, Iran. The eligible individuals were randomly assigned to one of two groups, designated the control (landmark-based nerve block) and the case group (ultrasound-guided nerve block). The two groups were compared in terms of the main measurable outcomes. The data were analyzed using SPSS software (version 20) by nonparametric tests. Results: According to the findings, the mean and median of nerve block success in the landmark-based and ultrasound-guided methods were significantly different between the two groups, both 15 (P=0.02) and 30 (P=0.001) min post-intervention. In this regard, nerve block with ultrasound guidance had a higher success rate compared to the landmark method. However, no significant difference between the two interventions was found in terms of the mean and median of the procedure duration (P=0.8) and injection frequency (P=0.4). On the other hand, the two groups were significantly different regarding the median and mean of patient satisfaction (P=0.00), duration of analgesia (P=0.004), and nerve block-related complications (P=0.03). Conclusion: The findings revealed that the relatively new technique of nerve block by ultrasound-guide resulted in better outcomes than the landmark-based method. Consequently, this method could be adopted to control acute pain in the emergency departments and improve patient care.

Landmark Technique vs Ultrasound-Guided Approach for Posterior Tibial Nerve Block in Cadaver Models.

The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the accuracy and efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged behind in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. The objective of this study was to compare the accuracy of traditional anatomical landmark-guided technique with an ultrasound-guided approach for ankle block by assessing the spread of injectate along the posterior tibial nerve (PTN) in cadaver models. Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo anatomical landmark-guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The anatomical landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN, with the needle subsequently advanced in-plane with a posterior to anterior trajectory until the tip was adjacent to the nerve. Each specimen was injected with 2mL of acrylic dye. All the specimens were dissected following injection to determine which nerves had been successfully coated with dye. The PTN was successfully coated with dye in all five (100%) ultrasound-guided blocks. In the anatomical landmark group, two (40%) PTN were successfully coated with dye. Of the three unsuccessful attempts, two specimens were noted to have dye injected posterior to the PTN; dye was injected into the flexor digitorum longus tendon in one. The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate of delivering a simulated nerve block to the correct anatomic location.

Ultrasound Guided Posterior Tibial Nerve Block to Facilitate Foreign Body Removal in a School-Aged Child.

Ultrasound Guided Posterior Tibial Nerve Block to Facilitate Foreign Body Removal in a School-Aged Child.

Landmark Technique vs Ultrasound Guided Approach for Posterior Tibial Nerve Block in Cadaver Models

Category:Ankle, Basic Sciences/BiologicsIntroduction/Purpose:Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models.Methods:Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye.Results:100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon.Conclusion:The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.

(275) - Ultrasound guided posterior tibial nerve block for the management of chronic peripheral neuropathic foot pain secondary to sarcoidosis

Sarcoidosis is a systemic inflammatory disease of unknown etiology involving multiple organ systems. Sarcoidosis affecting the central and/or peripheral nervous system is called neurosarcoidosis. The case presented focuses on the use of a single interventional therapy for the management of sarcoidosis-induced bilateral lower extremity peripheral neuropathy. A 53 year-old Caucasian male with a 14 year history of steroid-dependent, refractory pulmonary sarcoidosis, and neurosarcoidosis with resulting lower extremity pain secondary to peripheral neuropathy was referred for pain management. Prior to presentation, the patient had been tried on various pharmacological therapies, including but not limited to high doses of opioids (methadone/oxycodone), steroids, pregabalin, and duloxetine. Patient's severe bilateral plantar foot pain continued to adversely affect his functionality to the point of placing him on disability. Three sets of bilateral ultrasound guided posterior tibial nerve blocks were performed three months apart. The patient experienced significant pain relief after each block. His daily methadone consumption decreased by over 50% and his functionality improved significantly allowing him to return to work full-time as he was able to tolerate prolonged periods of standing and walking. Ultrasound guided posterior tibial nerve blocks should be considered as a first-line treatment option for peripheral neuropathic pain secondary to sarcoidosis, as it can diminish dependence on opioids, while simultaneously increasing functionality and quality of life of patients.

Short-term Benefits of Ultrasound-Guided Corticosteroid Injection in Plantar Fasciitis

To determine the effectiveness of ultrasound (US)-guided corticosteroid injection in the treatment of plantar fasciitis. Randomized, placebo-controlled, double-blind trial with 12-week followup. Sample size was calculated with 80% power to show, after 4 weeks, a minimum clinically important difference of 13 points on the pain domain of the Foot Health Status Questionnaire (FHSQ) at P # 0.05. Community study at a university clinic in Melbourne, Australia between June 2010 and February 2011. Participants were recruited using local newspaper advertisements. Eligibility criteria were a history of inferior heel pain for $8 weeks, heel pain of $20 mm on a 100-mm visual analog scale, pain on palpation of the medial calcaneal tubercle or the proximal plantar fascia, and a dorsal plantar fascia thickness of $4.0 mm measured ata standard location by diagnostic US. Reasons for exclusion were pregnancy,a corticosteroid injection within 6 months or other treatment within 4 weeks, sensitivity to any of the substances used, additional conditions near the heel, a history of previous local surgery or trauma, systemic inflammatory disease or diabetes, and an inability to walk short distances unaided. All 82 participants were given a US-guided posterior tibial nerve block with 2% lidocaine. Patients then received either a US-guided injection of 1 mL of 4 mg/mL dexamethasone sodium phosphate (corticosteroid group) or 1 mL saline solution (placebo group). Both feet could be treated at the same appointment. Participants were advised not to do high-impact activities and to do stretching exercises for the first 8 weeks. The primary outcome measures at 4, 8, and 12 weeks were changes in pain scores on the FHSQ (0-100 points; worst pain to no pain) and plantar fascia thickness where the fascia crosses the anterior aspect of the inferior calcaneal border. In the case of bilateral fasciitis, the participant was asked to report pain for both feet together, and fascial thicknesses were averaged between the feet. Pain on first step in the morning and function were measured, and adverse events reported. The improvement in pain scores in the corticosteroid group was greater than that in the placebo group at 4 weeks (adjusted difference between change in group means, 10.9; 95% confidence interval [CI], 1.4-20.4),but at 8 and 12 weeks, the difference did not persist (difference, 5.6; 95% CI, 24.5-15.6 and difference, 5.3; 95% CI, 25.7-16.3, respectively). Plantar fascia thickness was reduced for the corticosteroid group compared with the placebo group at each time period (mean difference at 4 weeks, 20.35 mm; 95% CI, 20.67 to 20.03; at 8 weeks, 20.30 mm; 95% CI, 20.73 to 20.05; and at 12 weeks, 20.43 mm; 95% CI, 20.85 to 20.01). First-step pain was less for the corticosteroid group at 4 weeks, but function was not significantly different between groups. For participants in both groups, improvements in FHSQ pain scores at 12 weeks were correlated with reductions in plantar fascia swelling (r =20.30; P = 0.007). No adverse events such as nerve injury, postinjection flare, soft tissue infection, or rupture of the plantar fascia were reported. Adherence to the stretching program did not differ between groups. A single US-guided injection of dexamethasone reduced pain in plantar fasciitis at 4 weeks, without complications. Dexamethasone was effective in reducing plantar fascia swelling throughout the 12 weeks. Pain and swelling of the fascia subsided in both groups.

Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial

Objective To investigate the effectiveness of ultrasound guided corticosteroid injection in the treatment of plantar fasciitis.Design Randomised, investigator and participant blinded, placebo controlled trial.Setting University clinic in Melbourne, Australia.Participants 82...

Musculoskeletal Pain as a Novel Complication After Posterior Tibial Nerve Block in Stroke and Traumatic Brain Injury Patients

Percutaneous neurolysis of the posterior tibial nerve is a known treatment for spasticity that causes equinovarus deformity. Although dysesthesia is a known complication of phenol nerve blocks, this case series describes 3 cases of musculoskeletal foot pain that developed as a novel complication of posterior tibial nerve blocks and was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and foot arch enhancement of the patients’ ankle-foot orthosis (AFO).

Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial

Plantar fasciitis (PF) is a common clinical condition that usually resolves with non-operative treatments. Extracorporeal shock wave therapy (ESWT) has been used in the treatment of chronic PF not responding to other conservative measures; however, ESWT devices are expensive and available for daily practice in only few centers (In developing countries). A pneumatic lithotripter is a cheap and readily available device which uses pneumatic shock application for the intracorporeal lithotripsy. The aim of this study was to investigate the clinical efficacy of intracorporeal pneumatic shock therapy (IPST) application for the treatment of chronic PF using a cheap and readily available pneumatic lithotripter. A randomized, double-blind, placebo-controlled study was conducted. A total of 50 patients with clinically and radiologically confirmed PF were randomly allocated to either an active- (treatment) (n = 25) or inactive (placebo) (n = 25) group. Under local anesthesia and posterior tibial nerve block, a rigid probe was directly introduced into the calcaneal spur under fluoroscopic control; a standard protocol of 1,000 shock was applied during a single session into the calcaneal spur. The main outcome measure was the patients' subjective assessment of pain by means of a Visual Analog Scale (VAS) and the Roles and Maudsley Score before the treatment and 6 months later. At the 6 months, the rate of successful outcomes (excellent + good results) in the treatment group (92%) were significantly higher comparing to the control group (24%) (P < 0.001). Heel pain measured 6 months after using the VAS were 2.04 +/- 1.67 in treatment group and 7.16 +/- 1.57 in control group as compared to 8.92 +/- 1.22 and 9.12 +/- 1.23 before the commencement of the treatment. No complications attributable to the procedure such as rupture of the planter fascia, hematoma, or infection were observed during the study. This pilot study showed that IPST is an effective and safe method of treatment of patients with chronic PF not responding to conservative measures. IPST application should be considered before surgical intervention when the extracorporeal shock devices are not available for daily practice. However, further evaluation of this novel treatment is necessary to understand the exact mechanism of action.

(232) CG100649, a novel dual-acting COX-2 and carbonic anhydrase inhibitor: Ascending single dose and multi-dose pharmacokinetics and safety evaluation in healthy male subjects

Stroke can be a condition causing damage to the descending corticospinal fibers that may result in symptoms of the Upper Motor Neuron Syndrome. This syndrome can include signs of abnormal antagonist cocontraction; abnormal cutaneomotor reflexes, spastic dystonia and synergistic motor patterning. Management of these abnormal motor behaviors will be determined by how they impact a patient’s life style, regardless of the etiology. When considering treatment options, the following should be considered: duration, severity and location of spasticity along with functional status and goals. Management strategies often include a combination of interventions such as reducing noxious stimuli, stretching, oral or intrathecal medications or neurolysis with phenol. Neurolytic procedures including nerve blocks and motor branch blocks reduce focal or regional muscular over activity. Side effects of phenol nerve blocks can include parasthesia, yet vary rarely cause musculoskeletal pain. The following case report describes two patients with lower extremity spasticity that resulted in equinovarus deformity. This deformity can prevent and limit functional ambulation and transfers. The two patients in the study were treated with posterior tibial nerve blocks for the equinovarus deformity. Both patients developed musculoskeletal foot pain, which is unusual after posterior tibial nerve blocks. Each patient responded well to a combination treatment of a two week course of NSAIDS as well as foot plate brace padding to enhance arch support. Dysesthesia is a well known complication of phenol nerve blocks. This case study describes two cases of musculoskeletal foot pain as a novel complication of posterior tibial nerve blocks that was successfully treated with NSAIDs and foot orthoses. (234) CG100649, a novel dual-acting COX-2 and carbonic anhydrase inhibitor: Multi-dose pharmacokinetics and safety evaluation in healthy male and female subjects

Teaching an old block a new trick: ultrasound‐guided posterior tibial nerve block

Acta Anaesthesiologica ScandinavicaVolume 52, Issue 3 p. 446-447 Teaching an old block a new trick: ultrasound-guided posterior tibial nerve block L. G. Soares, L. G. Soares Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this authorR. Brull, R. Brull Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this authorV. W. Chan, V. W. Chan Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this author L. G. Soares, L. G. Soares Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this authorR. Brull, R. Brull Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this authorV. W. Chan, V. W. Chan Rua Moura Brasil 31 apt 301, Rio de Janeiro, 22231200, BrazilSearch for more papers by this author First published: 05 February 2008 https://doi.org/10.1111/j.1399-6576.2007.01515.xCitations: 10 Address:Luiz Guilherme SoaresRua Moura Brasil 31 apt 301Rio de Janeiro22231200Brazile-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume52, Issue3March 2008Pages 446-447 RelatedInformation

Evaluation of a Proximal Block Site and the Use of Nerve-Stimulator-Guided Needle Placement for Posterior Tibial Nerve Block

Posterior tibial nerve (PTN) block has traditionally been performed in the para-medial malleolar area without nerve stimulator (NS) guidance. The PTN can also be blocked proximally (7 cm) above the medial malleolus in the subfascial plane between the flexor hallucis longus and flexor digitorum longus tendons. In this study we compared the frequency of successful PTN block at the traditional distal (D) site (2 cm above the medial malleolus) with and without NS guidance. We also compared block success and latency at the D site versus the proximal (P) block site. Subjects were randomized to P-NS (n = 45), D-NS (n = 45), or D without NS (n = 45). Levobupivacaine 0.625%, 0.15 mL/kg was used for all blocks. Pinprick sensory anesthesia was evaluated in the distribution of the medial plantar, lateral plantar, and medial calcaneal nerves. PTN block was considered successful if surgical anesthesia was achieved in all PTN distributions. The frequency of successful PTN block was greater for D-NS (100%) and P-NS (93.5%), compared with D (73.3%) (P = 0.02). Median latency to complete block was less for D-NS (8 min, 95% CI 7-9 min) than D (20 min, 95% CI 13-26 min) (P < 0.01) and P-NS (15 min, 95% CI 12-18 min) (P = 0.04). NS-guided needle placement improves the success and decreases the latency to onset of complete PTN block at the D site. The P approach to PTN block may be a useful alternative to the traditional D site approach, particularly in patients with restricted access to the D site.

Poster 233 Treatment of post traumatic brain injury balance disorder with percutaneous posterior tibial nerve block measured with posturography: A case report: Allen M. Khademi, MD (JFK Johnson Rehabilitation Institute, Edison, NJ); Elie P. Elovic, MD; Thomas E. Strax, MD

Poster 233 Treatment of post traumatic brain injury balance disorder with percutaneous posterior tibial nerve block measured with posturography: A case report: Allen M. Khademi, MD (JFK Johnson Rehabilitation Institute, Edison, NJ); Elie P. Elovic, MD; Thomas E. Strax, MD

Management of Acute Gouty Arthritis-Reply

In Reply.— A review of the references cited by Dr Fox suggests that induction of a sympathectomy of the foot involves, in essence, performing a posterior tibial nerve block. To our knowledge, there are no controlled studies showing that this procedure shortens the normal course of a gouty attack. A posterior tibial nerve block may well be beneficial for temporary pain relief when (1) gouty arthritis is limited to the foot and (2) the administration of colchicine or a nonsteroidal anti-inflammatory drug is contraindicated. Care must be taken to avoid hitting the posterior tibial nerve, which might result in a traumatic neuritis. In addition, one must be careful to avoid intravascular injection of the posterior tibial artery (a landmark for this procedure). We do not think that this technique can be easily duplicated by physicians without previous experience in performing nerve blocks.