Comparing the sciatic nerve block quality of anterior and posterior approaches: A randomised trial

doi:10.21203/rs.2.14391/v2

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Comparing the sciatic nerve block quality of anterior and posterior approaches: A randomised trial

https://doi.org/10.21203/rs.2.14391/v2

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published 13 Dec, 2019

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Background: The co-administration of sciatic nerve and femoral nerve blocks may provide anaesthesia and analgesia in patients undergoing lower extremity surgeries. Several approaches to sciatic nerve block have been described, including anterior and posterior approaches. Methods: Our study included 58 patients, randomly assigned to receive either an anterior (Group A , n = 29) or posterior (Group P, n = 29) approach. After the blocks were performed, we determined sensory and motor block start and end times, first fentanyl requirement time after block and before operation starts, first fentanyl requirement time after the operation starts, the mean fentanyl dose administered per patient after block and before operation starts, the mean fentanyl dose administered per patient after the operation starts, the time to first diclofenac sodium administration, and the total dose of diclofenac sodium required. The date of trial registration was retrospectively registered in 11.07.2018 Results: Comparison of the two groups revealed that Group P exhibited significantly shorter times to starting the sensory block (12.88±4.87 min for Group A, 7.70±2.05 min for Goup P) p=0.01 and first fentanyl requirement time after block and before operation starts (00.00±00.00 min for Group A, 4.05±7.47 min for Group P) p=<0.01 and a significantly higher first fentanyl requirement time after operation starts (31.20±27.79 µg for Group A, 44.03±23.78 µg for Group P) and a significantly higher the mean fentanyl dose administered per patient after block and before operation starts (00.00±00.00 min for Group A, 16.24±57.13 min for Group P) p=0.01 and a significantly lower the mean fentanyl dose administered per patient after operation starts (147.75±122.30 µg for Group A, 11.51±12.87 µg Group P). Patient satisfaction (p=<0.01), anesthesia quality (p=0.006), and surgical quality (p=0.047) were significantly higher in Group P. Conclusions: Sciatic nerve block can be performed with anterior and posterior approach in patients who will be operated due to malleolar fracture. However, analgesia should be performed before starting the patient in the posterior approach and after the operation in the anterior approach.

Anesthesiology & Pain Medicine

anterior sciatic nerve block

posterior sciatic nerve block

block quality

The co-administration of sciatic nerve and femoral nerve blocks provides anaesthesia or analgesia in patients undergoing lower extremity surgeries.^1-3 Sciatic nerve blocks can be applied using different approaches. The anterior sciatic nerve block is one such approach.⁴ Anterior sciatic nerve blocks can be performed while the patient is in the supine position, at the same time and from the same region as a femoral nerve block, and turning the patient to one side is not required. After the tourniquet is applied, without moving the patient, the patient can be transferred to the operating room. However, the sciatic nerve is localized deeply and behind the femur,^5,6 which makes the application of the block difficult; consequently, it is considered an advanced nerve block. Posterior sciatic nerve block is another approach.⁴ The advantages of this approach include the availability of imaging with ultrasonography (USG) and the fact that performing this type of nerve block is technically easier. One disadvantage is that patients with lower limb fractures will typically experience pain until the block is achieved because the patients must be turned sideways to allow the fractured limb to remain on top.

USG has been used during peripheral nerve block applications as well as classical techniques and generally enhances success during peripheral nerve blocks.^4,7 USG has been successfully used in both anterior and posterior sciatic nerve blocks as well as femoral nerve blocks.⁴ Past studies have indicated that the concurrent use of USG and a nerve stimulator increases block success and quality.^8-10

The primary outcome of our study was to compare the mean time to onset of sensory block in sciatic nerve block with anterior and posterior approach. Secondary results, first fentanyl requirement time after block and before operation starts, first fentanyl requirement time after operation starts, the mean fentanyl dose administered per patient after block and before operation starts, the mean fentanyl dose administered per patient after operation starts, time of onset of motor and sensory block and duration of sciatic and femoral blocks, time to first diclofenac sodium, total dose of diclofenac sodium administered in the first 24 hours, postoperative visual analog scale (VAS), patient satisfaction, anesthesia quality from the point of view of anesthesia and surgical quality from the point of view of the surgeon.

We know that the patient feels pain before starting the block when he gives lateral position to posterior sciatic nerve block especially in medial and lateral malleolar fractures. This pain is felt by the patient after the block is performed and the patient's VAS value is evaluated high after the block. This leads to the early addition of additional analgesics. We think that the quality of anterior and posterior sciatic nerve block is comparable.

In the present study, we aimed to compare the quality of sciatic nerve blocks performed with anterior and posterior approaches in patients undergoing lower extremity surgeries.

Patients:

The local ethical board committee approved this study with an ethical approval report dated 18.03.2013 and numbered 2013/125. This study was conducted between 18.03.2013-24.06.2016 in the operating room of Republic of Turkey Health science Univercity Bagcilar Training and Research Hospital. This study has been prepared in accordance with the Principles of the Helsinki declaration. We obtained written informed consent from each patient. This study was computer-randomized in terms of anterior or posterior sciatic nerve block, single-blinded, and prospectively planned. At the beginning of the study, 80 patients were randomized and failed blocks were continued with general anesthesia. These patients were excluded from the study before registering in failed blocks and proceeding to the analysis stage. After the block was performed, the anesthesiologist who was following the patient underwent general anesthesia without knowing whether anterior or posterior sciatic nerve block was performed in failed blocks. A single-blinded anaesthesiologist performed all posterior or anterior sciatic nerve and femoral nerve blocks and left the operating room after the nerve block was completed and the patient was repositioned. Another anaesthesiologist followed the patient without knowing what approach had been previously used. Our study complies with consort rules. Consort checklist submitted as an attachment.

Inclusion criteria: Patients of both sexes who were aged between 18 and 65 years, had lateral and/or medial malleolus fractures and of the American Society of Anesthesiologists (ASA) class I-II.

Exclusion criteria: Patients with vascular disease, cardiac disease. Metabolic (Diabetes mellitus)-renal-hepatic disease. Neuropathic pain in lower extremity. Pregnancy. Hemodynamic instability. Drug use that is likely to cause metabolic acid-base imbalance. History for steroid use and allergy. Contraindications to regional anaesthesia. Alcohol drug addiction. Those who did not graduate from primary school were excluded from the study. Failed block, sciatic nerve was not visualized in patients, patients with delirium.

Procedure:

The variables of interest included patients’ age; gender; height; weight; operation time; tourniquet time; ASA classification; First fentanyl requirement time before operation and after blockade; First fentanyl requirement time after operation; mean fentanyl dose administered per patient before operation and after blockade; Mean fentanyl dose administered per patient after operation; motor and sensory block start and end times after sciatic and femoral block’s time to first diclofenac sodium administration; total dose of diclofenac sodium administered in 24 hours; visual analog scale (VAS) values; patient satisfaction; anaesthetic quality from the point of view of the anaesthesiologist; and surgical quality from the point of view of the surgeon.

Patient satisfaction: 0: failed, 1: weak, 2: moderate, 3: good, 4: excellent.^11,12

Anaesthesia quality (anaesthesiologist) and surgical quality (surgeon): 1: Failed; general anaesthesia was required, 2: Moderate; complainant, complementary analgesic was needed, 3: Good; little complainant, no need for complementary analgesia, 4: Excellent; patients do not complain.¹¹

The patients were informed about VAS one day before. The patients having no premedication. The patients were taken to the regional block room. Routine monitoring included; electrocardiogram, and noninvasive arterial blood pressure, and peripheral pulse oximeter monitoring. Sciatic nerve blocks using an anterior approach were performed using the Stimuplex® A needle (21G 0.80-150), which was positioned at 30° and isolated, in conjunction with a block nerve stimulator (Stimuplex HNS nerve stimulator; BRAUN, Germany) and ultrasound (Diagnostic ultrasound system, Model SDU 450 XL Class-1 type B; Shimadzu Corporation, Japan). A total of 40 mL of a local anesthetic solution, comprising 15 mL of 0.5% isobaric bupivacaine and 5 mL of 2% lidocaine and 20 mL isotonic sodium chloride, was prepared.

In both approaches, nerve stimulation was performed with a frequency of 2 Hz and with a 1-mA current, and the stimulus intensity was gradually reduced to 0.4 mA as long as a response was obtained.

Femoral nerve block: The nerve was visualized with concurrent USG, and the needle was oriented to the nerve. After the contraction of the vastus medialis, vastus intermedialis, and vastus lateralis muscles were visualized, a local anesthetic mixture of 20 mL was injected, and dissemination of the local anesthetic solution was imaged by USG (linear probe) (Figure 2).

Anterior sciatic nerve block: The sciatic nerve was imaged by USG (convex probe) along the needle route, and the needle was advanced to the nerve. When plantar flexion, dorsal flexion, and eversion of the foot were observed, 20 mL of local anesthetic mixture was administered and the local anesthetic spread was simultaneously imaged by USG (Figure 3).

Posterior sciatic nerve block: The USG probe was placed between the greater trochanter and the coccyx at the entry point of the needle, and the needle was advanced by imaging the nerve. When the plantar flexion, dorsal flexion, and eversion of the foot were observed, 20 mL of local anesthetic mixture was administered and the local anesthetic spread was simultaneously imaged by USG (Figure 4).

After the blocks were completed, the motor block was assessed by monitoring the movement of the ankle joint and knee and the sensory block was assessed using application of cold saline bag every minute; the block start times were recorded. When the patient was not receiving any cold stimulation on the sciatic and femoral stimulation areas, it was recorded as the start time of the full femoral-sciatic sensory block. Once the knee joint could not be moved, the time was recorded as the start time of the full femoral motor block. When the ankle joint was unable to move, it was recorded as the start time of the full sciatic motor block. After the block was fully achieved, a tourniquet was applied to the extremity to be operated and was inflated. Patients underwent surgery 30 min after the block was provided. One μg kg-1 fentanyl was injected intravenously in pain if the VAS value was 5 or more. Mean fentanyl dose administered per patient before operation and after blockade; Mean fentanyl dose administered per patient after operation; First fentanyl requirement time before operation and after blockade; First fentanyl requirement time after operation were recorded.

The time to first diclofenac sodium administration and the total dose of diclofenac sodium administered within 24 hours of the postoperative period were recorded. The first postoperative dose of diclofenac sodium was administered when a patient had VAS values of 5 or more.

Statistical analysis:

All data were evaluated using SPSS 11.5 for Windows.

Calculation of sample size: Before initiating the study, the required number of participants was determined according to the results of a pilot study that included 10 patients in each group. In this earlier pilot study, the mean time of sciatic nerve sensory block onset ± standard deviation (SD) was 8.88 ± 4.87 min for Group A (anterior approach to sciatic nerve block + femoral nerve block) and 4.70 ± 2.05 min for Group P (posterior approach to sciatic nerve block + femoral nerve block). The sample size was calculated as 29 (n = 29) for Group A and 29 (n = 29) for Group P, with α = 5% and 90% power. Fifty-eight patients were enrolled in the present study.

The normality distribution of the data was assessed by the Shapiro-wilks test. Mean ± SD values for the parametric tests and medians (minimum–maximum) for the nonparametric tests were used. Categorical data were presented as %n. Independent samples t-test was used for binary comparison of group data, and the chi-square test was used for between-group comparisons of categorical data. P values <0.05 were considered statistically significant.

Despite local anaesthetic administration, nerve blocks were not achieved in eight of the patients in Group A, and these patients were excluded from the study. In Group A, the sciatic nerve was not visualized in two patients and muscle response was not obtained with stimulation; these patients were excluded from the study. In addition, three patients in Group A were excluded from the study because patients with pain, despite the presence of adequate block and high-dose fentanyl administration.

Despite local anaesthetic administration, in four patients in Group P, nerve blocks were not achieved, and these patients were excluded from the study. Four of the patients in Group P were excluded from the study because patient with pain, despite sufficient block formation and high-dose fentanyl administration. Additionally, one patient in Group P was also excluded from the study because delirium developed during the block. No complications were observed in the groups during the intraoperative and postoperative periods.

Participant data pertaining to age, height, weight, ASA, tourniquet duration, and surgical duration are given in Table 1. There was no statistically significant difference between Groups A and P with respect to these data.

The sciatic nerve sensory block start and end times and femoral nerve sensory block start and end times of the participants are presented in Table 2. There was a significant difference between Groups A and P in terms of the sciatic nerve sensory block start time, and the sciatic nerve block start time was significantly lower in Group P than Group A. There was no statistically significant difference between the groups in terms of the sciatic nerve sensory block end time and femoral nerve sensory block start and end times.

The sciatic nerve and femoral nerve motor block start and end times for the participants are given in Table 3. There were no statistically significant between-group differences for start and end times of sciatic and femoral nerve motor blocks.

Group comparisons of patient satisfaction, anesthesia quality, and surgical quality are given in Table 4. There was a statistically significant difference between Groups A and P in terms of patient satisfaction, with patient satisfaction being significantly greater in Group P than Group A. There was a statistically significant between-group difference in anesthesia quality, with Group P performing significantly better than Group A. There was a statistically significant between-group difference in surgical quality, with better surgical quality for Group P than Group A.

Mean fentanyl dose administered per patient before operation and after blockade, mean fentanyl dose administered per patient after operation, First fentanyl requirement time before operation and after blockade and First fentanyl requirement time after operation, the total dose of diclofenac sodium administered in the postoperative period, and the time to first diclofenac sodium administration are given in Table 5. There was a statistically significant between-group difference in mean fentanyl dose administered per patient before operation and after blockade required, with the mean fentanyl dose administered per patient before operation and after blockade to Group P significantly higher than that administered to Group A. There was a statistically significant between-group difference in mean fentanyl dose administered per patient after operation required, with the mean fentanyl dose administered per patient after operation to Group P significantly lower than that administered to Group A. There was a statistically significant between-group difference in the first fentanyl requirement time before operation and after blockade administration, with a significantly shorter time observed in Group P than Group A. There was a statistically significant between-group difference in the first fentanyl requirement time after operation administration, with a significantly shorter time observed in Group A than Group P. There was no statistically significant between-group difference in the total dose of diclofenac sodium administered during the postoperative 24-h period and the time to first diclofenac sodium administration.

In the present study, we performed USG-guided sciatic nerve blocks with two different approaches by using a nerve stimulator to minimize possible complications related to applied block technique. There are several approaches for sciatic nerve block, but if a patient is planned to undergo lower limb surgery and tourniquet application is required, anterior or posterior (lumbar plexus block) femoral nerve block must be performed. During the anterior approach, the sciatic nerve is deeper than that observed during the posterior approach. However, during the anterior approach, imaging of the sciatic nerve with USG is as possible as it is with other approaches.⁴ In addition, there are publications reporting that sensory and motor block quality during the anterior approach is at least as good as that observed during the posterior approach.⁴

In our study, we sought to determine if the anterior and posterior approaches differed in terms of block quality. A statistically significant difference in the anterior and posterior approach was observed when the sensory block start times after the sciatic nerve block was completed, and the sensory block was earlier during the posterior approach (7.70 ± 2.05 min) than the anterior approach (12.88 ± 4.87 min). However, there was no statistically significant difference in sensory block end times. A previous study¹³ found that the block start time was 9.42 ± 1.08 min using the anterior approach and 7.75 ± 0.97 using the posterior approach. The block start time for the posterior approach was significantly lower than that for the anterior approach (P = 0.001) in that study. The results of the abovementioned study are compatible with the results of our study.

We found no statistically significant difference between the anterior and posterior approaches in terms of motor block start and end times. When comparing patient satisfaction was compared, 20 of 29 patients scaled their satisfaction as “grade 4,” in Group P indicating that patient satisfaction was significantly higher following the posterior approach than the anterior approach (Table 4). The anesthetist who evaluated the quality of anesthesia graded the quality as “grade 4” in 20 of 29 patients, which showed that the anesthetic quality of the posterior approach was significantly higher than that of the anterior approach. The surgeon who assessed the surgical quality graded satisfaction as “grade 4” for 20 of 29 patients in Group P, which showed that the surgical quality was statistically higher in the posterior approach than the anterior approach. In one study¹³, patient and anesthesiologist satisfaction after anterior and posterior applications were compared, but no statistical difference was found between the two methods, but in this study, the patients were asked whether they were satisfied with the procedure and asked whether they were good or bad in the quality of anesthesia. We evaluated patient satisfaction with 5-valued anesthesiologist satisfaction with 4-valued questionnaire. In our study, the patients, anesthesiologists and surgeons in Group P were statistically significantly more satisfied in terms of anesthetist satisfaction, patient satisfaction and surgeon satisfaction. We attributed this to the better quality of the block despite the fact that patients in Group P had pain and early fentanyl needs due to position. The mean fentanyl dose administered per patient before operation and after blockade was significantly higher with the posterior approach than the anterior approach. The mean fentanyl dose administered per patient after operation was significantly lower with the posterior approach than the anterior approach. This could be explained by the higher quality of the sensory block in the posterior approach or diminished tourniquet pain. However, in the posterior approach, first fentanyl requirement time before operation and after blockade was significantly shorter than that observed with the anterior approach. However, in the posterior approach, first fentanyl requirement time after operation was significantly higher than that observed with the anterior approach. This is due to the pain associated with repositioning of the patients’ fractured extremity. Patients suffering from pain due to fracture were positioned laterally in order to place the fractured limb upwards; therefore, fentanyl administration was required earlier during the posterior approach while the block is expected to be completed. In one study¹³, analgesic needs of the patients in the anterior and posterior approaches were compared within 24 hours after the end of the operation and no statistically significant difference was found between the two groups. In our study, in accordance with this study, there was no statistically significant difference between the groups in terms of time of first analgesic requirement and total analgesic amount within 24 hours after the end of the operation.

The sciatic nerves of two patients were not imaged with USG during the anterior approach. During the anterior approach, the sciatic nerve location is significantly deeper than it is during the posterior approach.⁴ Ota et al. reported that the sciatic nerve of two patients could not be visualized during sciatic block performed with the anterior approach.⁴ We found that there was no difference between the two approaches in terms of sensory and motor block initiation, and it has been stated previously that either of the two approaches can be used depending on preference in minor knee surgery.⁴ In contrast, sensory block of the posterior femoral cutaneous nerve, which runs parallel to the sciatic nerve in the gluteal region, is rarely achieved via the anterior approach. However, this is not considered a disadvantage during knee surgery, where a tourniquet is used.⁴ In that study, most of the patients could not tolerate the tourniquet pain and fentanyl requirements were similar in the study groups.⁴ In another study, posterior femoral cutaneous nerve block did not have any effect on tourniquet pain.¹⁴ In our study, patients experienced increased tourniquet pain associated with the anterior approach and the total dose of fentanyl administered was significantly higher during the anterior approach.

Sciatic nerve block can be performed with anterior and posterior approach in patients who will be operated due to malleolar fracture. However, analgesia should be performed before starting the patient in the posterior approach and after the operation in the anterior approach.

ASA: American Society of Anesthesiologists

VAS: Visual analog scale

USG: Ultrasonography

SPSS: Statistical Package for the Social Sciences

1.Ethics committee: Republic of turkey, health sciences university, Bagcilar training and research hospital Ethics committee for clinical research

Consent to participate: We obtained written informed consent from each patient.

2.Consent for publication: Not Applicable

3.Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

4.Competing interests: The authors declare no competing interests.

5.Funding: Support was provided solely from institutional and/or departmental sources. National Institutes of Health (NIH)

6.Author contribution:

AY: Design, work, analiysis, writing, editing, revision

BB: writing, editing, revision

7.Acknowledgements: Not Applicable

10.Author contribution:

Abdulkadir Yektaş: Design, work, analiysis, writing, editing, revision

Bedih Balkan: writing, editing, revision

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Amin WA, Abou Seada MO, Saeed MF, Mohammed SF, Abdel-Haleem TM, Shabaan EA: Continuous sciatic nerve block: comparative study between the parasacral, lateral, and anterior approaches for lower limb surgery. Middle East J Anesthesiol 2010;20:695-702.
Ota J, Sakura S, Hara K, Saito Y: Ultrasound-guided Anterior approach to sciatic nerve block: A comparation with the posterior approach. Anesth Analg 2009;108:660-5.
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Uz A, Apaydin N, Cinar SO, Apan A, Comert B, Tubbs RS et al: A novel approach sciatic nerve block: cadaveric feasibility study. Surg Radiol Anat 2010;32:873-8.
Schnabel A, Middendorf B, Boschin MG, Gottschalk A, Van Aken H, Zahn PK et al: Differences of analgesic efficacy and complication rates between ultrasound and nervestimulator guided peripheral nerve catheters: Database analysis on patient relevant target parameters. Anesthesist 2014;63:825-31.
McLeod M, McLeod G: A systematic review and meta-analysis of ultrasound versus electrical stimulation for peripheral nerve location and blockade. Anesthesia 2015;70:1084-91.
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Hara K, Sakura S, Yokohowa N: The role of electrical stimulation in ultrasound-guided subgluteal sciatic nerve block: a retrospective study on how response pattern and minimal evoked current affect the resultant blockade. J Anesth 2014;28:524-31.
Cebeci Z, Baran I, Ozgun S, Yalvaç M, Utebey G, Yazıcıoğlu D et al. Combined femoral-sciatic nerve block with bupivacaıne or levobupivacaine vs unilateral spinal anesthesia for arthroscopic knee surgery. JARSS Anestezi Dergisi 2016;24(3):159-166.
Singh DR, Nag K, Nagella AB, Hemanth Kumar VR, Charles AJ. Efficacy of Dexmedetomidine Infusion for Procedural Comfort and Intraoperative Sedation inPatients Undergoing Surgeries with Subarachnoid Block: A Randomized Double blind Clinical Trial. Anesth Essays Res 2017;11(2):294-299.
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Table 1: Comparison of demographic characteristics, tourniquet duration, surgical duration, American Society of Anesthesiologists and gender distribution of the groups.

(mean±SD) or (n)

		Group A (n=29)	Group P (n=29)	p
Age (year)		37.95±12.69	38.95±8.68	0.839
Height (cm)		171.80±14.98	172.30±7.65	0.848
Weight (kg)		78.85±15.22	76.05±11.11	0.511
Tourniquet duration (min)		76.70±32.57	65.55±23.59	0.223
Surgery duration (min)		81.85±30.47	66.35±24.59	0.085
ASA	I (n)	21	22	0.500
ASA	II (n)	8	7	0.500
Gender	Female (n)	22	16	0.083
Gender	Male (n)	7	13	0.083

ASA: American Society of Anesthesiologists

Table 2: Comparison of sensorial block start and end times after sciatic and femoral nerve block. (mean±SD)

	Group A (n=29)	Group P (n=29)	p
Sensory block start time for sciatic nerve (min)	12.88±4.87	7.70±2.05	*0.01
Sensory block end time for sciatic nerve (min)	188.50±69.01	201.85±43.81	0.564
Sensory block start time for femoral nerve (min)	10.39±3.39	9.90±5.49	0.09
Sensory block end time for femoral nerve (min)	146.65±78.67	124.50±17.85	0.074

*Statistically significant

Table 3: Comparison of motor block start and end times after sciatic and femoral nerve block.

(mean±SD)

	Group A (n=29)	Group P (n=29)	p
Motor block start time for sciatic nerve (min)	13.55±4.75	10.40±2.13	0.072
Motor block end time for sciatic nerve (min)	115±63.83	109.50±42.17	0.750
Motor block start time for femoral nerve (min)	11.61±4.48	10.16±3.91	0.063
Motor block end time for femoral nerve (min)	99.70±63.83	71.50±18.07	0.061

Table 4: Comparison of patient satisfaction, anesthesia quality and surgical quality in groups.

(n)

					p
		2	3	4	p
Patient satisfaction	Group A (n=29)	16	9	4	*<0.01
Patient satisfaction	Group P (n=29)	4	5	20	*<0.01
Anesthetic quality	Group A (n=29)	13	7	9	*0.005
Anesthetic quality	Group P (n=29)	3	6	20	*0.005
Surgical quality	Group A (n=29)	8	8	13	*0.026
Surgical quality	Group P (n=29)	3	3	23	*0.026

*Statistically significant

Patient satisfaction: 2: moderate, 3: good, 4: excellent

Table 5: Comparison of mean fentanyl dose administered per patient before operation and after blockade, mean fentanyl dose administered per patient after operation, First fentanyl requirement time before operation and after blockade, First fentanyl requirement time after operation, total diclofenac sodium amount and first diclofenac sodium requirement times in the postoperative first 24-hour periods in the groups. (mean±SD)

	Group A (n=29)	Group P (n=29)	p
Mean fentanyl dose administered per patient before operation and after blockade (µg)	00.00±00.00	16.24±57.13	*<0.01
First fentanyl requirement time before operation and after blockade (min)	00.00±00.00	4.05±7.47	*<0.01
Mean fentanyl dose administered per patient after operation (µg)	147.75±122.30	11.51±12.87	*<0.01
First fentanyl requirement time after operation (min)	31.20±27.79	44.03±23.78	*<0.01
Total amount of diclofenac sodium administered within 24 hours (mg)	86.25±50.31	71.25±66.52	0.426
First diclofenac sodium requirement time (min)	332.15±246.50	293.75±277.00	0.646

*Statistically significant

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Comparing the sciatic nerve block quality of anterior and posterior approaches: A randomised trial

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