Combined sciatic nerve and sacral erector spinae block in a quadriparetic patient for managing grade IV sacral and trochanteric pressure sores

The sciatic nerve, an extensive peripheral nerve emerging from the sacral plexus, plays a crucial role in providing anesthesia and analgesia to lower limb muscles and joints. Sacral erector spinae block (SESP) effectively alleviates back and hip pain in the posterior region. This case report presents a unique approach involving combined sciatic nerve block and SESP for debridement and local flap coverage in a patient with sensorimotor quadriparesis and grade IV sacral and trochanteric pressure sores. Patients with quadriparesis, especially those scheduled for surgery to address pressure sores, pose unique challenges for anesthesia due to their susceptibility to intraoperative and postoperative complications associated with general anesthesia (GA) and at times even central neuraxial block may be a contraindication. In such cases, regional nerve blocks offer a safer alternative. A 26-year-old male presented with sensorimotor quadriparesis following a fall from a height of 20 feet. He developed a stumbling gait and asymmetric weakness, predominantly on the left side of the body. Over the course of 7 months of immobility, the patient experienced weight loss, muscle atrophy, and progressing quadriparesis with grade IV sacral and trochanteric pressure sores. Due to the localized cervical cord lesion, spinal anesthesia was deemed undesirable, and GA raised concerns due to the patient's severe undernourishment, quadriparesis, respiratory muscle weakness, and the potential for postoperative pulmonary complications necessitating an extended stay in the intensive care unit. To mitigate these risks, regional nerve blocks were selected as the preferred anesthetic approach. Preoperatively, the patient received thorough counseling and provided informed written consent. In the operating room, standard American Society of Anesthesiologists monitors were applied, including noninvasive blood pressure, electrocardiography, pulse oximetry, and temperature monitoring. The patient's initial vitals were within normal limit. Under aseptic conditions, the patient received ultrasound-guided sciatic nerve block combined with SESP block. The block was administered using 0.5% bupivacaine (15 mL) and lidocaine with adrenaline (1:200,000, 20 mL), with the addition of dexamethasone (4 mg). Ultrasound guidance enabled precise localization of the sciatic nerve, and a stimulating needle (22-gauge, 60 mm) was used for real-time supervision. After confirming negative aspiration, 10 mL of 0.5% bupivacaine was injected at the level of the S4 median sacral crest, followed by an additional 10 mL at the S2 median sacral crest level. The local anesthetic was carefully applied between the erector spinae muscles and the S4 and S2 median sacral crests in the proper fascial plane [Figure 1a-c]. Thirty minutes' post-block, the patient's pain sensation and motor blockade were assessed, both of which were successfully achieved. Subsequently, the patient was positioned prone and prepared for surgery [Figure 1d and e]. To ensure comfort in the prone position, dexmedetomidine loading (0.7 mcg/kg/min) was administered for 10 minutes, followed by a maintenance dose of 0.4 mcg/kg/hr.Figure 1: (a) Pressure sores on the sacrum and greater trochanter, (b) Ultrasound-guided sciatic nerve block, (c) Ultrasound-guided sacral ESP block, (d) Patient comfortable on prone position, (e) Patient being operated for pressure soresIn patients with high-risk profiles, such as those with quadriparesis undergoing pressure sore surgery, regional nerve blocks offer advantages over general and spinal anesthesia. This approach reduces the risk of pulmonary complications and the need for intensive care unit admission. By employing combined sciatic nerve block and SESP block, we effectively mitigated the risks associated with both spinal and general anesthesia. Ultrasound-guided peripheral nerve blocks provides several advantages over landmark-guided techniques, including improved visualization of target and nearby neural anatomy, as well as vascular structures. While the sacral Erector Spinae Plane block was initially designed to target the posterior branches of the sacral nerves, research indicates that when the sacral Erector Spinae Plane block is administered with a larger volume or modified technique, the injected substance can extend from the sacral foramina to either the nerve roots or the epidural space through the transforaminal pathway.[1] In conclusion, regional blocks can be helpful and minimize complications from the central neuraxial blockade and GA in individuals who are posted for debridement and local flap coverage in patients with sensorimotor quadriparesis a unable to undergo surgery. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.