What type of nerve block is recommended for big toe surgery?

Nerve Block for Big Toe Surgery

For big toe surgery, a digital nerve block (either V-block or H-block technique) using long-acting local anesthetic (bupivacaine 0.25%, levobupivacaine 0.25%, or ropivacaine 0.2%) is the recommended anesthetic approach, as regional anesthesia provides excellent surgical anesthesia and postoperative pain relief while avoiding the complications associated with general anesthesia. 1, 2

Primary Nerve Block Technique

Digital nerve blocks are the standard approach for big toe surgery:

• V-block technique demonstrates superior efficacy compared to H-block, producing better neuromuscular blockade in 7.2% more cases at 10 minutes and 12.8% more cases at 20 minutes after injection 3
• Both V-block and H-block techniques are safe and effective options for ingrown toenail surgery and other big toe procedures 3
• Local infiltration and nerve blocks provide excellent anesthesia and pain relief for day surgery procedures involving the foot 1

Recommended Local Anesthetic Agents

Use long-acting local anesthetics for optimal surgical anesthesia and postoperative pain control:

• Bupivacaine 0.25% at maximum dose of 1 mL/kg (2.5 mg/kg) for wound infiltration and peripheral nerve block 1
• Levobupivacaine 0.25% at maximum dose of 1 mL/kg (2.5 mg/kg) 1
• Ropivacaine 0.2% at maximum dose of 1.5 mL/kg (3 mg/kg) 1

Alternative Regional Techniques for More Extensive Foot Surgery

For procedures beyond isolated big toe surgery, consider proximal nerve blocks:

• Popliteal sciatic nerve block is highly effective for foot and ankle surgery, with continuous infusion techniques (bupivacaine 0.25% at 5 mL/h) reducing postoperative pain by >50% and opioid use by >60% 4
• The minimum effective volume for ultrasound-guided popliteal sciatic nerve block is 6.14 mL of ropivacaine 0.75%, representing a significant reduction compared to traditional techniques 5
• Ankle blocks targeting specific nerves (tibial, deep peroneal, superficial peroneal, sural, saphenous) can be used for forefoot procedures 2

Multimodal Analgesia Framework

Combine regional anesthesia with systemic analgesics:

• Administer prophylactic oral NSAIDs preoperatively if not contraindicated, as long-acting NSAIDs minimize postoperative pain without the morbidity of opioids 1
• Start oral analgesics before the local anesthesia begins to wear off and continue on a regular basis rather than as-needed 1
• Reserve opioids for breakthrough pain only, avoiding indiscriminate use particularly of morphine to minimize nausea and vomiting 1

Critical Safety Considerations

Patients can be safely discharged with residual sensory or motor blockade provided:

• The limb is protected and appropriate support is available at home 1
• The expected duration of blockade is explained to the patient 1
• Written instructions are provided regarding conduct until normal power and sensation returns 1
• Proprioception in the big toe has returned before attempting ambulation (this is specifically mentioned as a criterion after neuraxial blocks but applies to safe mobilization generally) 1

Common Pitfalls to Avoid

EMLA cream application prior to digital nerve block does not reduce pain during injection and provides no clinical benefit, as topical anesthesia may not reach the digital nerves despite their superficial location 6

Avoid general anesthesia when possible, as it has higher morbidity and complication rates compared to regional anesthesia for foot and ankle surgery 2

Do not use multiple-dose vials of bupivacaine for caudal or epidural anesthesia due to safety concerns 7