March 2009

H.K. Baddoo

Peripheral nerve block in limb amputation

A PRELIMINARY REPORT ON THE USE OF PERIPHERAL NERVE

BLOCKS FOR LOWER LIMB AMPUTATIONS
H.K. BADDOO
Department of Anaesthesia, University of Ghana Medical School, Accra
Author for correspondence: Dr Henry K Baddoo

E- mail: hbaddoo@yahoo.com

Conflict of interest: None declared

using a combination of a sciatic nerve block with either

a femoral nerve block, a 3-in-1 block, or a psoas compartment lumbar plexus block. A combination of the
two blocks means that relatively large doses of local
anaesthetic agents are going to be used and one should
bear in mind the maximum safe dose of the agent.
Technically it is generally easier to perform spinal or
epidural rather than peripheral nerve blocks for the
lower limb. The onset of action of a peripheral nerve
block is longer than a spinal (subarachnoid block), and
the success rate of a satisfactory block is generally
lower than for neuraxial blocks. However the cardiovascular stability and postoperative pain relief these
regional blocks provide make them worthwhile techniques to perform especially in the very sick patient.
This paper reports the use of these blocks in 10 patients
who underwent lower limb amputations at the Korle
Bu Teaching Hospital.

SUMMARY
Objective: To determine whether there are any advantages of using peripheral nerve blocks as an anaesthetic
technique for patients undergoing lower limb amputations.
Methods: Ten cases that had emergency surgery at the
Korle Bu Teaching Hospital were reviewed. Indices
looked at were the effectiveness of the nerve block,
cardiovascular stability during surgery and the duration
of postoperative analgesia provided by the block.
Results: 9 out of 10 cases had an above knee amputation (AKA) and 1 had a below knee amputation
(BKA). 7 of the 10 cases were diabetics. A sciatic
nerve block (SNB) combined with either a 3-in-1 block
or a psoas compartment lumbar plexus block (LPB)
was given to patients undergoing an AKA. A sciatic
nerve block combined with a femoral nerve block was
given to the patient undergoing a BKA. In 7 cases, anaesthesia provided by the block was good and in 3
cases it was fair. The patients were cardiovascularly
stable during surgery. Postoperative pain relief provided by the blocks ranged from 5 hours to 30 hours.
Conclusion: Using peripheral nerve blocks for lower
limb amputations is an effective technique of anaesthesia, providing cardiovascular stability as well as good
postoperative analgesia.

PATIENTS AND METHODS

The 10 patients being reported on here were patients
who were undergoing a below knee or above knee amputation done as an emergency on days that the author
was on call. For patients undergoing an AKA , a number were given a sciatic block combined with a threein-one block and the remainder were given a sciatic
nerve block combined with a psoas compartment lumbar plexus block. The only patient undergoing a BKA
was given a sciatic nerve block (SNB) combined with a
femoral nerve block. The decision on whether to use
the anterior or posterior approach for the sciatic nerve
block and whether to use a 3-in-1 block or LPB depended mainly on whether or not the patient could easily be turned onto their side (the posterior approach for
a SNB and a LPB will need the patient on their side).

Keywords: Sciatic nerve block, three-in-one block,

psoas compartment lumbar plexus block

INTRODUCTION
The need for lower limb amputations (below knee or
above knee amputations) in Ghana is not uncommon.
Patients requiring this procedure as an emergency are
usually either diabetics with uncontrolled sepsis of the
leg or patients with peripheral vascular disease with
gangrene. The patients are often quite ill and general
anaesthesia can be dangerous. Neuraxial (spinal or epidural) anaesthesia, rather than a general anaesthetic is
often used but even this can be problematic as the patients may be septic with unstable cardiovascular systems and spinal/epidural anaesthesia may drop the
blood pressure further. An alternative technique is to
perform a regional block of the affected lower limb

As is normally done for regional techniques the procedure was explained to the patient (who would have
already signed a consent form for surgery) and the procedure done only if the patient agreed to it. A mixture
of lidocaine with adrenaline 5mcg/ml together with
either bupivacaine or ropivacaine (depending on which
one was available) was used. The approach for the sciatic block was either the anterior approach described
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by Chelly et al1 or the posterior approach described by

Labat.2 For each block, the sciatic, 3-in-1, and LPB the
patient was given either 15ml of lidocaine with adrenaline (5mcg/ml) plus 10ml of 0.5% bupivacaine, or
15ml of 0.5% ropivacaine plus 10ml of lidocaine with
adrenaline. The concentration of lidocaine used ranged
between 1-1.5%, depending on the weight of the patient and in order to keep within the safe maximum
dose. For the femoral nerve block (in the patient for a
BKA), a combination of 5ml of 2% lidocaine with
adrenaline (5mcg/ml) plus 5ml 0.5% bupivacaine was
used.

GHANA MEDICAL JOURNAL

procedure, ECG, pulse oximetry and non-invasive

blood pressure were monitored. Resuscitation drugs
and equipment were readily available. As a measure of
the degree of postoperative analgesia provided by the
blocks, the number of hours postoperatively before any
further pain relief was required was determined.

RESULTS
As seen in table 1, the ages of the patients ranged between 55 years and 84 years with a mean of 69.1yrs. 4
were males and 6 were females giving a male to female
ratio of 1:1.5. Out of the 10 patients, 7 were diabetics,
2 had peripheral vascular disease and 1 had a malignant
ulcer of the knee. 5 patients had a SNB combined with
a 3-in-1 block, 4 had a SNB combined with a psoas
compartment LPB and 1 had a SNB combined with a
femoral nerve block. All the patients were on antibiotics. Five patients were on subcutaneous heparin or low
molecular weight heparin as prophylaxis against deep
vein thrombosis (DVT), and one patient was on both
heparin and aspirin.

Stimuplex nerve stimulating needles (Braun) were used

for the blocks. A 150mm needle was used for the anterior approach to the sciatic nerve and a 100mm needle
was used for the posterior approach. A 100mm or
150mm needle was used for the psoas compartment
lumbar plexus block. For the blocks, the current was
set initially at 3-4 mA and gradually decreased as the
nerve was localised. A stimulating current of anything
between 0.3 and 0.7mA was accepted prior to the anaesthetic agent being injected. Prior to and during the
Table 1 Patient data and nerve block given
Patient
KO

Age
65

Sex
F

AS

70

MA

75

EA

67

KA

84

EO

63

IN

74

AP

55

MD

72

SA

66

Diagnosis
Diabetic ulcer
right foot
Gangrene Right
foot
Gangrene Left
leg
Gangrene Right
foot
Gangrene Left
leg
DKA (treated)
Gangrene Left
foot
Gangrene Left
foot
Malignant Ulcer
left Knee
Gangrene Left
foot
Gangrene Right
leg

Co-morbidity
DM/HT

ASA
III

Amputation Type
AKA

PVD/HT

III

AKA

DM/HT/PVD

III

AKA

DM/HT

IV

AKA

PVD

III

AKA

DM

IV

BKA

DM

III

AKA

NIL

III

AKA

DM/HT

III

AKA

DM

III

AKA

Block Used
Sciatic (ant.a)
3-in-1 block
Sciatic (ant.a)
3-in-1 block
Sciatic (ant.a)
3-in-1 block
Sciatic (ant.a)
3-in-1 block
Sciatic (ant.a)
3-in-1 block
Sciatic (post.a)
Femoral block
Sciatic (post.a)
LPB
Sciatic (post.a)
LPB
Sciatic (post.a)
LPB
Sciatic (post.a)
LPB

DM Diabetes Mellitus
HT Hypertension PVD Peripheral vascular disease DKA Diabetic ketoacidosis
LPB Lumbar plexus block AKA Above knee amputation BKA Below knee amputation ant.a anterior approach
post.a posterior approach

The mean duration of surgery was 97.5minutes (range

50mins-210mins). The time interval between the end of
surgery and the time the first dose of analgesic was
needed ranged between 5hrs and 30.5hrs with a mean

of 12.5hrs. Most patients had a low haemoglobin level

ranging from 6.8g/dL to 11.1g/dL with a mean of
8.8g/dL. White cell count was raised in most cases
ranging from 4.4x109/dL to 23.3x109/dL with a mean
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of 16.0x109/dL . Fasting blood sugars done a few hours

prior to surgery were reasonable, ranging between
4.8mmol/L and 12.1mmol/L with a mean of
8.3mmol/L. All the 10 patients were cardiovascularly
stable throughout surgery. The systolic blood pressure
of the patients ranged between 90mmHg and

GHANA MEDICAL JOURNAL

200mmHg with a mean of 139.9mmHg. The diastolic

pressure ranged between 45mmHg and 135mmHg with
a mean of 79.1mmHg. The heart rate of the patients
ranged between 72 beats/min and 125 beats/min with a
mean of 98 beats/min.

Table 2 Results of nerve block

Initial

Onset
Time

Supplementation
of Anaesthesia

*Quality of
Block (sensory)

KO

20 mins

Midazolam 2mg

105 mins

AS

Not Recorded

65 mins

17 hours

MA

25 mins

Entonox
Propofol 40mg
Pethidine 25mg

Good. Complete
block
Fair. Partial block

Time Postop before 1st

analgesia dose
/Comments
30.5 hours

50 mins

7 hours

EA

30 mins

Entonox
Propofol 100mg

Good. Complete
block
Fair. Partial block

50 mins

KA

30 mins

Propofol 100mg
Pethidine 40mg
Midazolam 4mg

Fair. Partial block

150 mins

EO

30 mins

Nil

75 mins

IN

5.5 hours

10.5 hours

30 mins

210 mins

SA

30 mins

Nil

Good. Complete
block
Good.
Almost Complete
block
Good. Complete
block

120 mins

MD

Confused preop
Midazolam 3mg
Fentanyl 30mcg
Entonox
Midazolam 1mg
Fentanyl 50 mcg
Entonox

60 mins

AP

Surgery started
1hr after block
due to power
problems
20 mins

Good. Complete
block
Good. Complete
block

When reviewed after 12

hrs, patient had not
needed any analgesia
and was not in pain
12 hrs. Patient had some
pain in lateral and posterior part of thigh during
surgery
10.5 hours

5 hrs. Small area of sensation post during surgery

15 hours

Duration of
Surgery (mins)

90 mins

* Quality of block assessed by Anaesthetist

A study from the Lagos University Teaching Hospital
(LUTH), covering a three year period4 found that
42.6% of the lower limb amputations carried out at the
hospital were diabetes mellitus(DM) related. Foot ulceration accounted for 25.7% of DM related deaths.4

DISCUSSION
In the West African sub-region, diabetes related lower
limb amputation is responsible for more than half of
non-trauma related amputations.3 Foot ulcers are a major problem in diabetes. The prevalence of foot ulcers
in diabetics ranges from approximately 1% in some
European and North American studies, 3-8% in Sweden, to over 11% in some African countries.3 Diabetics
with foot ulcers are a group of high risk patients with
significant morbidity and mortality. Kengne et al3 reported a mortality rate of 22.2% in diabetics with foot
ulceration admitted to the diabetes unit of the Yaounde
Central hospital.

In the ten cases reported here, 7 of them were diabetics.

Diabetic patients requiring lower limb amputation are
often septic and this compromises their cardiovascular
system. In addition to this, some diabetics have autonomic neuropathy which impairs cardiovascular compensation when they are subjected to physiological
changes such as occur during a general anaesthetic.
Very often spinal anaesthesia (subarachnoid block) or
epidural anaesthesia is given to diabetics undergoing
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Volume 43, Number 1

lower limb amputations, and these have advantages

over general anaesthesia. However since these neuraxial blocks do block sympathetic nerves to varying degree, hypotension can occur, worsening the already
compromised cardiovascular system. Fanelli et al5
found out that even in ASA I&II patients in whom a
unilateral spinal block was performed for lower limb
surgery, the mean arterial pressure decreased by about
15% from the baseline values, whereas in patients who
were given a sciatic-femoral block there was no change
in mean arterial pressure. Also the cardiac index decreased by 15-20% in the group who were given a unilateral spinal block whereas there was no change in the
group given a sciatic-femoral nerve block. In the ten
patients reported here, heart rate, systolic and diastolic
pressures were remarkably stable throughout surgery.

GHANA MEDICAL JOURNAL

in which the lumbar plexus is approached posteriorly.

In two of the patients, sensation was still felt over the
posterior aspect of the thigh. In these cases, presumably the posterior cutaneous nerve of the thigh escaped
the block.
The agents used for the blocks were lidocaine mixed
with either bupivacaine or ropivacaine. The rationale
for using lidocaine was that the onset of the block
would be quicker than using bupivacaine or ropivacaine alone. The addition of bupivacaine or ropivacaine
was to prolong the duration of the block. Ropivacaine
was used when available otherwise bupivacaine was
used. Advantages of ropivacaine over bupivacaine are
that it is less cardiotoxic than bupivacaine and the onset
of action is quicker than bupivacaine.7 Fanelli et al8
when comparing ropivacaine, bupivacaine and mepivacaine for sciatic and femoral nerve blockade found that
the onset of the block was significantly shorter with
ropivacaine compared to bupivacaine, but the duration
of postoperative analgesia was shorter with ropivacaine as compared to bupivacaine.

In the patients presented here, 9 had an AKA and 1 had

a BKA. Those that had an AKA, had a sciatic nerve
block combined with either a 3-in-1 block as described
by Winnie6 or a psoas compartment lumbar plexus
block. The patient who had a BKA had a sciatic block
combined with a femoral nerve block. The lower limb
is supplied by the sciatic nerve together with nerves
from the lumbar plexus. The thigh is supplied by the
femoral nerve, the lateral cutaneous femoral nerve, and
the obturator nerve (all from the lumbar plexus). In
addition, a narrow posterior slip of the thigh is supplied
by the posterior femoral cutaneous nerve (S2 / S3)
which enters the thigh together with the sciatic nerve
but then diverges from the sciatic nerve. The leg below
the knee is supplied by the tibial and peroneal branches
of the sciatic nerve, as well as the saphenous nerve
which is a continuation/branch of the femoral nerve.
Thus for a BKA, a sciatic nerve block together with a
femoral nerve block is adequate whereas for an AKA,
one needs to block the sciatic nerve together with
nerves of the lumbar plexus. One can block the nerves
of the lumbar plexus by using a 3-in-1 block in which
case the volume of local anaesthetic used should be at
least 20ml to enable the solution to spread up the fascial compartment.6 Alternatively, one could do a psoas
compartment lumbar plexus block.

In this report, two of the three patients who were given

ropivacaine had postoperative pain relief for 5 hours
which was shorter than the periods of postoperative
analgesia for the patients who were given bupivacaine.
With the dosages used, none of the patients showed
any signs of local anaesthetic toxicity. Smith and Siggins9 showed that with sciatic nerve blocks, using the
same dosage, a higher concentration (with less volume)
resulted in a block that had a quicker onset time and a
longer duration of action. As seen in Table 2, most of
the patients had several hours of postoperative analgesia which is another advantage of using peripheral
nerve blocks. Coagulation profiles were not done in
any patient, but being septic, some of the patients may
have had deranged coagulation. Some of the patients
were on subcutaneous heparin and one patient was on
aspirin as well as heparin. Inspite of this, none of the
patients had any complication that could be attributed
to bleeding in the vicinity of the block.
An exciting advance that has taken place over the past
few years is ultrasound guidance in regional anaesthesia.10,11 Advantages of this are a high success rate of the
blocks since the nerves are imaged by ultrasound and
one can use lower volumes of the agent and thus higher
concentrations. Complication rates are very low. When
blocking the lower limb using ultrasound guidance, one
can hopefully visualize the posterior cutaneous femoral
nerve and therefore block it, avoiding the situation
which occurred in two of the patients where it appeared
that the nerve escaped being blocked.

In 5 patients, the anterior approach to the sciatic nerve

as described by Chelly and Delauney1 was used. In the
other 5, the posterior approach, described by Labat,
was used. One advantage of the anterior approach is
that the patient does not need to be turned on to the
side, which is desirable if the patient has a painful condition such as a fractured tibia. The 3-in-1 block is
simpler to do than the psoas compartment lumbar
plexus block. However since the 3-in-1 technique relies on the spread of the local anaesthetic agent up the
neurovascular sheath, it is probably a less predictable
block than the psoas compartment lumbar plexus block
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H.K. Baddoo

5.

Fanelli G., Casati A, Aldegheri G, Beccaria P,

Berti M, Leoni A, Torri G Cardiovascular effects
of two different regional anaesthetic techniques for
unilateral leg surgery.Acta Anaesthesiol Scand
1998 ; 42 : 80-84
6. Winnie A.P., Ramamurthy S, Durrani Z The Inguinal Paravascular technique of lumbar plexus
anaesthesia : The 3-in-1 BlockAnesth Analg
1973 ; 52:989-996
7. McClure J.H. Ropivacaine Br J Anaesth. 1996 ;
76:300-307
8. Fanelli G, Casati A, Beccaria P, Aldegheri G, Berti
M, Tarantino F, Torri G A double-blind comparison of ropivacaine, bupivacaine and mepivacaine
during sciatic and femoral nerve blockade.Anesth
Analg 1998 ; 87 ; 597-600
9. Smith B.E. and Siggins D Low volume, high concentration block of the sciatic nerve Anaesthesia
1988 ; 43 : 8-11
10. Geert Jan van Geffen, Mathieu Gielen Ultrasoundguided subgluteal sciatic nerve blocks with stimulating catheters in children : a descriptive study
Anesth Analg 2006 ;103(2) : 328-33
11. Marhofer P, Greher M and Kapral . Ultrasound
guidance in regional anaesthesia Br J Anaesth.
2005 ; 94(1) : 7-17

CONCLUSION
Peripheral nerve blocks can effectively be used for
lower limb amputations, providing cardiovascular stability and good postoperative analgesia. The introduction of ultrasound guided regional anaesthesia is a
promising advance, increasing the success rate and
safety of peripheral nerve blocks.

REFERENCES
1.

2.

3.

4.

Peripheral nerve block in limb amputation

Chelly J.E., Laurent Delauney New anterior approach to the sciatic nerve block Anesthesiology
1999 ; 91 : 1655-60
Casati A. Multiple-Stimulation Technique to block
the Sciatic nerve. In: Chelly JE, ed Peripheral
Nerve Blocks, 2nd Edn. Philadelphia: Lippincott
Williams and Wilkins, 2004:121-22
Kengne A.P, Dzudia A.L., Fezeu L.L, Mbanya
J.C. Impact of secondary foot complications on the
inpatient department of the Diabetes unit of
Yaounde Central Hospital. Lower extremity
wounds 2006;5(1) : 64-68
Ogbera A.O., Fasanmade O, Ohwovoriole A.E.,
Adediran O. An assessment of the Disease Burden
of Foot ulcers in patients with Diabetes Mellitus
attending a teaching hospital in Lagos, Nigeria.
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