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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 27  |  Issue : 1  |  Page : 36-40

Prolonged knee pain relief by saphenous block (new technique)


Consultant Pain Management, Apollo Hospitals, Ahmedabad, Gujarat, India

Date of Web Publication10-Jul-2013

Correspondence Address:
Rajeev Harshe
35/1, Sector 2 A, Gandhinagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.114871

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  Abstract 

Pain in the knee joint can be from a variety of reasons. It can be either from the joint itself, it can be myofascial or it can be neuropathy, radicular pain. The myofascial component can be in different forms, namely, collateral ligament pain, bursitis, tendinitis, and so on. This responds well to local injections of steroids. Pain from the joint can be because of osteoarthritis (OA), rheumatoid arthritis or any other variety of arthritis. Among these osteoarthritis is the most common and naturally occurring pain. There are several modalities used for managing pain in the knee joint. They include medicines and physiotherapy, intra-articular steroid injection, intra-articular Hyalgan, Synvisc injection, prolotherapy, genicular nerve block, ablation, intra-articular pulsed radio frequency (PRF) ablation, acupuncture, injection of platelet-rich plasma in the joint, total knee replacement, high tibial osteotomy, arthroscopy and lavage, and so on. All these modalities have their pros and cons. Literature and experience state that the pain relief provided may last for a few months with these modalities except in surgical interventions in advanced OA. The saphenous nerve is termination of femoral nerve and it is essentially sensory nerve. It supplies the medial compartment and some part of the anterior compartment of the knee joint. This nerve has been blocked near the knee joint by way of infiltration by surgeons and anesthetists, for relief of pain after knee surgery, with varying pain relief of postoperative pain. When we block the saphenous in the mid thigh in the sartorial canal, the fluid tends to block the medial branch of the anterior femoral cutaneous nerve also. It is hypothesized that this may give complete medial and anterior knee pain relief and as most of the knee OA patients have medial and anterior knee pain, this may prove useful. Use of ultrasonography helps to locate the nerve better, ensuring perfection. An effort has been made to block this nerve in the sartorial canal with steroid and LA under ultrasonography (USG) guidance and observe the results. Patients have received very good pain relief (95 - 100%) for a substantially long time (up to four years).

Keywords: Knee, osteoarthritis, pain, saphenous, USG


How to cite this article:
Harshe R. Prolonged knee pain relief by saphenous block (new technique). Indian J Pain 2013;27:36-40

How to cite this URL:
Harshe R. Prolonged knee pain relief by saphenous block (new technique). Indian J Pain [serial online] 2013 [cited 2019 Mar 23];27:36-40. Available from: http://www.indianjpain.org/text.asp?2013/27/1/36/114871


  Case Report Top


Case 1

  • Eighty-three-year-old female.
  • Weighing 75 kg with height of 5 ft 1 inch.
  • Pain in both knee joints, more on the left, more on walking, climbing stairs, getting up after sitting. It was 9/10 on VAS.
  • The duration of pain was almost three years gradually increasing in intensity.
  • It was ache without tingling/numbness. The pain was spreading down the leg a little. Morning stiffness was there and walking distance was ten meters only.
  • She had been advised surgery by two knee surgeons. She was reluctant and now she is nearly bed ridden with every movement being in pain.
  • There is a history of hypertension, diabetes, and ischemic heart disease (IHD). All of these were optimized on medication. She was taking frequent nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief apart from other medication. [1],[2],[3],[4],[5]


Clinical examination

Left knee

  • On inspection, mild swollen knee (not hot) with infrapatellar (IP) and suprapatellar (SP) bursa swelling seen.
  • There was tenderness on the superomedial and inferomedial aspect of the patellofemoral junction.
  • There was tenderness on the medial joint line. Semimembranosus (SM) / Semitendinosus (ST) tendons were tender to touch.
  • There was no posterior or lateral tenderness, but it was aching on movement.
  • Passive extension and flexion did give mild crepitus and pain, the range being 90%.
  • Walking and standing was painful with limited extension.
  • No signs of cruciate ligament laxity noted.
  • The right knee was less affected.



  General Top


  • Pulse: 68/minute, BP: 140/78, RS/CVS: Normal, Spine: Normal, Neurology: Normal
  • BT/CT Normal (as per physician's advise, aspirin was stopped for three days)



  Investigations Top


The x-ray revealed radiological grade four degenerative changes in the left knee and radiological grade two changes in the right knee joint [Figure 1] and [Figure 2]; the medial compartment being the most hit in both. There were no loose bodies. The patient was offered the option of a saphenous block.
Figure 1: Grade four arthritis in the left knee joint

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Figure 2: Rt grade two arthritis

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  Method Top


First scanning of the medial aspect of the thigh was done to locate the saphenous nerve, which lies near the femoral vessels. [6] It gave out articular branches on coming out of the sartorial canal, so the Sartorius was located, and scanning was done up and down to locate the right spot before the branching took place. [6]

One 5cc syringe was filled with 1 cc (40 mg) injection triamcinolone and 4 cc 1% preservative-free Xylocaine. It was attached to one 23 number spinal needle. This was passed in the plane to reach the saphenous nerve and after negative aspiration for blood, the content was injected.

The procedure was done in the Emergency Room with monitoring and resuscitation preparation, under total aseptic precautions. Pulse, BP, and Spo2 were monitored throughout and remained normal

The patient was observed for half an hour and then made to walk. She experienced complete pain relief and could walk unaided. The pain score became 1/10 on VAS. She was given Baxin LB (ampicillin, cloxacillin) 500 mg one TDS for three days and ultracet (tramadol, paracetamol) one TDS, for three days. She was called for follow up after seven days. She was explained that pain in the injection site was expected for two days and the patient was discharged.

The patient was explained that this treatment was purely for pain relief and that she should continue taking care of the knee as before, as per the orthopedic surgeon's advise.

The patient was followed up personally for three weeks and then every three months on telephone up to three years. Till this article is written, that is, three years and four months down the line she is pain-free, with good movements. She did a trip abroad unescorted meanwhile.

Case 2

  • Sixty-two-year-old female (mother of a gynecologist)
  • Weighing 70 kg with a height of 5 ft 5 inches
  • Pain in right knee joint, more on walking and climbing stairs. It was 8/10 on VAS.
  • The duration of pain was for almost one year, gradually increasing in intensity.
  • It was an ache without tingling/numbness. Morning stiffness was there and walking distance was three hundred meters.
  • She was taking frequent NSAIDs for pain relief.



  Clinical examination Top


Right knee

  • On inspection mild IP bursa swelling was seen.
  • There was tenderness on the inferomedial aspect of the patellafemoral junction.
  • There was tenderness on the medial joint line.
  • There was no posterior and lateral tenderness.
  • Passive extension and flexion did give pain, the range being 90%
  • No signs of cruciate ligament laxity were noted.
  • The left knee was fairly normal.



  General Top


Pulse: 72/m, BP: 130/70, RS/CVS: Normal, Spine: Normal, Neurology: Normal


  Investigations Top


An x-ray revealed radiological grade two degenerative changes in the right knee. There were no loose bodies. The patient was offered the option of a saphenous block.


  Method Top


The same method was used, as mentioned above, to give the block.

The patient was observed for half-an-hour and then made to walk. She experienced complete pain relief and could walk unaided. The pain score was 0/10. She was given Baxin LB (ampicillin plus cloxacillin) 500 mg one TDS for three days and ultracet (tramadol and paracetamol combination) one TDS for three days. She was called for follow up after seven days. She was explained that pain in the injection site was expected for two days and the patient was discharged.

The patient was explained that this treatment was purely for pain relief and that she should continue taking care of the knee as before, as per orthopedic surgeon's advise.

The patient was followed up personally for three weeks and then every three months on telephone, up to three years. Till this article is written, that is, four years and one month down the line she is pain-free with good movements.

Case 3

  • Twenty-seven-year-old female.
  • Weighing 80 kg with a height of 5 ft.
  • Severe pain in the right knee joint, more on walking and climbing stairs. It was 10/10 on VAS.
  • The duration of pain was three months, gradually increasing in intensity.
  • It was an ache without tingling/numbness. The pain was spreading down the leg a little.
  • She had consulted orthopedic surgeons and investigated with normal reports and conservative treatment, but the pain was incapacitating. She was advised SOS medicines, physiotherapy, active weight reduction, with constant knee brace, and reduction in activities.
  • She had a history of a fall from the scooter and the knee being hit at that time.



  Clinical examination Top


Right knee

  • On inspection, a mild swollen knee.
  • There was tenderness on the superomedial and inferomedial aspect of the patellafemoral junction.
  • There was tenderness on the medial joint line. The SM/ST tendons were tender to touch.
  • There was no posterior and lateral tenderness, but it was aching on movement.
  • Passive extension and flexion did give pain, the range being 80%
  • Walking and standing was painful.
  • No signs of cruciate ligament laxity noted.
  • The left knee was fairly normal.



  General Top


Pulse: 84/m, BP: 102/80, RS/CVS: Normal, Spine: Normal, Neurology: Normal


  Investigations Top


An x-ray revealed a normal knee joint. Magnetic resonance imaging (MRI) of the right knee joint was normal. The patient was offered the option of saphenous block [Figure 3].
Figure 3: Normal knee

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  Method Top


The method used was the same as mentioned in the previous case.

The patient was observed for half-an-hour and then made to walk. She experienced complete pain relief and could walk unaided. The score became 1/10 on VAS. She was given Baxin LB (ampicillin plus cloxacillin) 500 mg one TDS for three days and ultracet (tramadol and paracetamol combination) one TDS for three days. She was called for follow up after seven days. She was explained that pain in the injection site was expected for two days and the patient was discharged.

The patient was explained that this treatment was purely for pain relief and that she should continue taking care of the knee as before as per orthopedic surgeon's advise.

The patient was followed up personally for three weeks and then every three months on telephone, up to three years. Till this article is written, that is, two years and eight months down the line she is pain-free with good movements.


  Discussion Top


Knee joint pain mainly due to Osteoarthritis is the most common form of chronic pain we come across in society. Most of them resort to medicines and physiotherapy. They continue to suffer from pain and take random SOS analgesics, usually NSAIDs.

Very few are undergoing surgery. Cost and fear of surgery are major deterrent factors apart from some being unfit for surgery. To date, unfortunately, pain management is very much underutilized in India. We know that each of the existing methods to treat knee pain have short lasting results due to a number varied reasons. [4]

There is a need to find out some method that is simple, minimally harmful/harmless, minimally invasive, cost-effective, and that gives sufficiently prolonged results, and value for money.

This will not only prepare more patients to use it, but also will give good quality of life to these senior people, who are a neglected lot and suffer a lot due to other comorbidities.

Use of the saphenous nerve block is established for postoperative pain relief after total knee replacement (TKR). [5] People were infiltrating branches on the medial aspect of the knee with partial results.

Ultrasonography is a modality that can help you visualize the nerve, the vessels, and the bone real time. Little training and a trained anesthesiologist can use it for benefit. [7],[8] It helps to accurately place medicine near the nerve. [9],[10] It also, therefore, reduces the quantity of medicine needed. It helps you avoid the vessels and so reduces the chances of complications. [10]

The saphenous nerve is a termination of the femoral nerve and it is essentially a sensory nerve. It supplies the medial aspect of the knee and lower leg. If we inject medicine near it, in the mid thigh, in the sartorial canal [Figure 4], then we tend to block the medial branch of the anterior cutaneous nerve of the thigh also. [11],[12] This ensures complete coverage of the anterior and medial compartment of the knee, ensuring good relief. Here, a small quantity of the medicine is sufficient as the canal is a tight space. [6]

Considering these things, I decided to try and give the block of saphenous before it branches under the Sartorius and near the femoral vessels. [6],[11],[12] To my surprise not only were the initial results good, but there was a prolonged effect, lasting up to four years in some. I have done many, but have been able to follow up a few, who are all very happy and pain-free even after two to four years.
Figure 4: USG saphenous

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This just stimulates us to think about why and how this has happened.

Can we assume that pain in the knee joint seems less of an inflammatory condition and more from hyper sensitized nerves? As only then will you get such a good and prolonged effect, without touching the joint. Of course more studies are required to find out the reason.

The effects may be variable, but properly placed blocks in properly selected patients, may give predictably prolonged relief.

The benefits of the procedure include...

  • As we can avoid RFA we avoid the chances of getting a Charcot joint.
  • The technique is nearly painless.
  • There is no swelling in or around the joint or no flare phenomena, making the procedure easily acceptable and patient friendly.
  • It is done on an OPD basis, so it is hassle-free and less time consuming.
  • The cost of the procedure is very less, so it is widely accepted by people.


The limitations of the procedure include...

  • It is not a curative treatment.
  • It requires an ultrasonography machine with a color Doppler, which makes its use limited to hospitals.
  • There are chances of failure if there is use of an improper technique, improper selection of a patient, general debility, avoiding ambulation of patient, lack of proper training of the doctor, and other factors.



  Conclusion Top


  • This technique of giving a saphenous block under the Sartorius in a higher position, that is, mid thigh, has given good and prolonged results in few patients.
  • Now, there is need to do multicentric, double blind, placebo-controlled trials in medical schools, to evaluate this technique, its merits and demerits.
  • If this is done, osteoarthritis patients will get an economic, scientific, and long-lasting option for surgery if they wish to.


 
  References Top

1.Choi WJ, Hwang SJ, Song JG, Leem JG, Kang YU, Park PH, et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: A double-blind randomized controlled trial. Pain 2011;152:481-7.  Back to cited text no. 1
    
2.Sampson S, Reed M, Silvers H, Meng M, Mandelbaum B. Injection of platelet-rich plasma in patients with primary and secondary kneeosteoarthritis: A pilot study. Am J Phys Med Rehabil 2010;89:961-9.  Back to cited text no. 2
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3.Yavuz U, Sökücü S, Albayrak A, Oztürk K. Efficacy comparisons of the intraarticular steroidal agents in the patients with knee osteoarthritis. Rheumatol Int 2012;32:3391-6.  Back to cited text no. 3
    
4.Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: A systematic review and meta-analysis. Arthritis Rheum 2009;61:1704-11.  Back to cited text no. 4
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5.Andersen HL, Gyrn J, Møller L, Christensen B, Zaric D. Continuous saphenous nerve block as supplement to single-dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med 2013;38:106-11.  Back to cited text no. 5
    
6.Tsai PB, Karnwal A, Kakazu C, Tokhner V, Julka IS. Efficacy of an ultrasound-guided subsartorial approach to saphenous nerve block: A case series. Can J Anaesth 2010;57:683-8.   Back to cited text no. 6
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7.Lefort MR, Henneberg S, Bille AB, Classen V, Afshari A. The use of ultrasound for nerve block in children seems beneficial. Ugeskr Laeger 2011;173:2257-61.  Back to cited text no. 7
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8.Wadhwa A, Kandadai SK, Tongpresert S, Obal D, Gebhard RE. Ultrasound guidance for deep peripheral nerve blocks: A brief review. Anesthesiol Res Pract 2011;2011:262070.  Back to cited text no. 8
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9.Lefort MR, Henneberg S, Bille AB, Classen V, Afshari A. The use of ultrasound for nerve block in children seems beneficial. Ugeskr Laeger 2011;173:2257-61.  Back to cited text no. 9
[PUBMED]    
10.Thomas LC, Graham SK, Osteen KD, Porter HS, Nossaman BD. Comparison of ultrasound and nerve stimulation techniques for interscalene brachial plexus block for shoulder surgery in a residency training environment: A randomized, controlled, observer-blinded trial. Ochsner J 2011 Fall;11:246-52.  Back to cited text no. 10
    
11.Kapoor R, Adhikary SD, Siefring C, McQuillan PM. The saphenous nerve and its relationship to the nerve to the vastus medialis in and around the adductor canal: An anatomical study. Acta Anaesthesiol Scand 2012;56:365-7.  Back to cited text no. 11
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12.Saranteas T, Anagnostis G, Paraskeuopoulos T, Koulalis D, Kokkalis Z, Nakou M, et al. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenousnerve block. Reg Anesth Pain Med 2011;36:399-402.  Back to cited text no. 12
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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