Ultrasonographic anatomy of the brachial plexus and major nerves of the canine thoracic limb.

A technique for ultrasonography of the brachial plexus and major nerves of the canine thoracic limb is described based on examination of five canine cadavers and three healthy dogs. The ventral branches of the spinal nerves that contribute to the brachial plexus are identifiable at their exit from the intervertebral foramina. These nerves may be followed distally, cranial to the first rib, until they form the brachial plexus. The musculocutaneous, ulnar, and median nerves are identified on the medial aspect of mid-humerus and followed proximally to the axillary region and distally to the elbow. The radial nerve, formed by multiple nerve components, is seen on the mediocaudal aspect of the humerus. Nerves appear as hypoechoic tubular structures with an internal echo-texture of discontinuous hyperechoic bands, surrounded by a thin rim of highly echogenic tissue. Improved understanding of the ultrasonographic anatomy of the brachial plexus and its main branches supports clinical use of this modality.

Evaluation of a continuous epidural analgesia program for postoperative pain in children.

A continuous epidural analgesia (CEA) program was developed for pediatric patients cared for outside of a critical care environment. Stable patients can be successfully monitored in the inpatient areas provided sufficient education and support is offered to allow for safe administration, monitoring, and evaluation of patient outcomes. The CEA program was developed in collaboration with the departments of nursing, anesthesiology, and pharmacy and was introduced on a 1-year trial basis on the surgical patient service unit. A retrospective record review was conducted of patients offered CEA over the first 2 years of the program to determine the safety and efficacy of the program. This article describes the development, implementation, and evaluation of the CEA program for surgical patients in a tertiary pediatric hospital. The safety and efficacy of the program as well as the benefits, challenges, and lessons learned are discussed.

Sources of porcine longissimus dorsi muscle (LDM) innervation as revealed by retrograde neuronal tract-tracing.

The aim of the present study was to establish the origin of the motor, autonomic and sensory innervation of the L1-L2 segment of the porcine longissimus dorsi muscle (LDM), in order to provide morphological basis for further studies focusing on this neural pathway under experimental conditions, e.g. phototerapy and/or lateral electrical surface stimulation. To reach the goal of the study, multiple injections of the fluorescent neuronal tracer Fast Blue (FB) were made into the LDM region between the spinal processes of the vertebrae L1 and L2. The spinal cord (Th13-S1 segments) as well as the sensory and autonomic ganglia of interest, i.e., dorsal root (DRG) and sympathetic chain ganglia from corresponding spinal cord levels were collected three weeks later. FB-positive (FB+) motoneurons were observed exclusively within the nucleus ventromedialis at L1 and L2 spinal cord level, forming the most ventro-medially arranged cell column within this nucleus. Primary sensory and sympathetic chain neurons were found in appropriate ipsilateral ganglia at Th15-L3 levels. The vast majority of retrogradely traced neurons (virtually all motoneurons, approximately 76% of sensory and 99.4% of sympathetic chain ganglia neurons) was found at the L1 and L2 levels. The morphometric evaluation of FB-labeled DRG neurons showed that the majority of them (approximately 66%) belonged to the class of small-diameter perikarya (10-30 microm in diameter), whereas those of medium size (30-80 microm in diameter) and of large diameter (more than 80 microm) constituted 22.6% and 11.5% of all DRG neurons, respectively. The results of the present study demonstrated that the nerve terminals supplying porcine LDM originated from different levels of the spinal cord, dorsal root and sympathetic chain ganglia. Thus, the study has revealed sources and morphological characteristic of somatic, autonomic and spinal afferent neurons supplying porcine LDM, simultaneously pointing out the characteristic features of their distribution pattern.

Partial sensory and motor deficit of ipsilateral lower limb after continuous interscalene brachial plexus block.

We describe a partial sensory and motor block of the ipsilateral lower limb after interscalene infusion. After and injection of 20 mL of ropivacaine through the needle, the catheter was advanced 5 cm, and an infusion of ropivacaine 0.2% 5 mL/h commenced. Six hours later, the patient reported a left sensory and motor hemisyndrome, which resolved after the infusion was discontinued. Cervical computed tomography showed the tip of the catheter close to the intervertebral foramen at the C7-T1 level and several intravertebral paramedullar air bubbles. We conclude that the neurological symptoms were caused by an injection of local anesthetic via an interscalene catheter placed in proximity to the epidural space. To avoid this complication, we recommend advancing the catheter no more than 2-3 cm and performing frequent neurological evaluation of patients.

Sensory and motor function of the esophagus: lessons from ultrasound imaging.

Catheter-based high-frequency intraluminal ultrasound imaging is a powerful tool to study esophageal sensory and motor function and dysfunction in vivo in humans. It can be combined with manometry, pH, and impedance measurement techniques to determine the relationships between different physiologic parameters. High-frequency intraluminal ultrasound imaging has provided a number of important insights regarding the longitudinal muscle function of the esophagus. On the basis of the ultrasound images and intraluminal pressure recordings, it seems that there is synchrony in the timing and the amplitude of contraction between the circular and longitudinal muscle layers. A sustained contraction of the longitudinal muscle layer is temporally related to esophageal chest pain and heartburn. The biomechanics of the esophageal wall and its relationship to sensory and motor function can be studied in humans in vivo by using high-frequency intraluminal ultrasound much more precisely than has previously been possible. Achalasia, diffuse esophageal spasm, and nutcracker esophagus are associated with hypertrophy of circular and longitudinal muscle layers. Finally, high-frequency intraluminal ultrasound imaging is the only technique that can detect reflux-related distention of the esophagus and its role in esophageal symptoms. Future approaches to display and quantify ultrasound image data are discussed. The principles of high-frequency intraluminal ultrasound described here are also applicable to study of the motor and sensory function of the other regions of the gastrointestinal tract.

Intradermal injections of bradykinin or histamine cause a flare-like vasodilatation in monkey. Evidence from laser Doppler studies.

The spreading cutaneous vasodilatation (flare) that follows a cutaneous injury is readily visible in humans but cannot be visualized in monkey. To determine if monkeys exhibit this neurally mediated reaction, cutaneous blood flow changes after intradermal injections of bradykinin and of histamine were monitored in the hairy skin of pentobarbital anesthetized monkeys. Using a laser Doppler device, recordings of cutaneous blood flow were made at distances of 15 and 25 mm from the injection of 50 microliters of saline, bradykinin (10(-3) M) and histamine (10(-3) M). These sites were beyond the radius of the wheal caused by bradykinin (6.3 mm) or histamine (6.8 mm). At both recording sites, both drugs caused an increase in blood flow that was significantly larger than that caused by the injection of the same volume of saline. These results provide evidence that although a flare is not visible in monkey skin, a flare-like vasodilatation does occur over an area of at least 50 mm diameter.